Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 1
Date: Nov 12, 2025
Visit Reason
The inspection was conducted to investigate a deficiency related to the facility's failure to ensure each resident received food prepared in a form designed to meet individual needs, following an incident where a resident choked and passed away after being served a sandwich contrary to their diet order.
Findings
The facility failed to provide food in the correct texture for one resident with a soft and bite-sized diet, resulting in choking and death. The facility implemented corrective actions including staff education, limiting sandwich access in the memory care unit, and improving access to diet orders prior to the survey.
Deficiencies (1)
F 0805: The facility failed to ensure each resident received food prepared in a form designed to meet individual needs. A resident on a soft and bite-sized diet was served a sandwich, which led to choking and death.
Report Facts
Residents affected: 1
Date of incident: Oct 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Provided the resident a sandwich and performed Heimlich maneuver |
| DON | Director of Nursing | Educated staff on diet textures and oversaw corrective actions |
| ADMIN | Administrator | Involved in investigation and corrective action planning |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements for the William E Christofferson Salt Lake Veterans Home.
Findings
The facility was found to have multiple deficiencies including failure to reasonably accommodate resident needs, inadequate notification to the Ombudsman about discharges, insufficient supervision leading to a resident fall, improper food service hygiene practices, and breaches in infection prevention during medication administration.
Deficiencies (5)
F 0558: The facility failed to reasonably accommodate the needs and preferences of resident 50 by not providing individualized accommodations to keep the resident's telephone and radio within reach.
F 0623: The facility did not provide timely notification to the resident representative and Ombudsman before transfer or discharge, specifically failing to send discharge notices for resident 30.
F 0689: The facility did not ensure adequate supervision and assistance to prevent accidents, resulting in resident 6 sustaining a fall while left unattended despite requiring two-person assistance for transfers.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, as food service staff were observed not wearing hair restraints.
F 0880: The facility failed to implement an infection prevention and control program, as a staff member was observed touching resident medications with bare hands during administration for residents 62 and 70.
Report Facts
Residents sampled: 23
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed touching resident medications with bare hands during medication administration |
| RN 1 | Registered Nurse | Interviewed regarding proper hand hygiene and medication handling practices |
| Director of Nursing | Director of Nursing | Provided statements regarding shelving for resident 50, fall interventions, and infection control policies |
| Maintenance Manager | Maintenance Manager | Interviewed about shelving and wall conditions in resident 50's room |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed about fall response and resident supervision |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed about resident 50's needs and assistance with transfers for resident 6 |
| Dietary Manager | Dietary Manager | Interviewed about hair covering policies in the kitchen |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 9, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey to assess compliance with regulatory standards related to housekeeping, food service safety, and quality assessment and assurance.
Findings
The facility was found deficient in maintaining a sanitary and comfortable environment due to missing seat cushions on chairs in the Memory Care Unit. Food safety violations were noted with open and expired food items in the walk-in refrigerator and freezer. Additionally, the Quality Assessment and Assurance committee failed to develop and implement appropriate corrective plans for previously identified deficiencies.
Deficiencies (3)
F584: The facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Four chairs on the Memory Care Unit were missing seat cushions for about a month.
F812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. Food items in the walk-in freezer were open to air, and items in the refrigerator were past their use-by dates.
F0867: The facility did not ensure the Quality Assessment and Assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies, including repeated non-compliance with F584 and F812.
Report Facts
Date of survey completion: Jun 9, 2022
Number of chairs missing cushions: 4
Number of past use-by dates noted: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding missing seat cushions on Memory Care Unit chairs |
| ST 1 | Speech Therapist | Interviewed regarding missing seat cushions on Memory Care Unit chairs |
| HM | Housekeeping Manager | Interviewed regarding removal and cleaning of seat cushions |
| DA 1 | Dietary Aide | Interviewed regarding food storage and date checking practices |
| DM | Dietary Manager | Interviewed regarding food safety practices and removal of expired food items |
| Administrator | Interviewed regarding expectations for furniture cleaning and QAA committee activities |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 19, 2019
Visit Reason
Routine inspection of William E Christofferson Salt Lake Veterans Home to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including medication errors, failure to timely report abuse and injuries, inadequate care planning, unsafe environment, improper medication storage, and food safety violations. Several residents experienced medication administration errors, falls, and abuse incidents that were not properly managed or reported.
Deficiencies (13)
F 0554: Facility allowed residents to self-administer drugs without proper clinical evaluation and physician orders, as evidenced by resident 74 self-administering Flonase without evaluation or order.
F 0580: Facility failed to notify physicians timely of significant treatment changes including medication refusals and substitutions for residents 29, 40, and 41, resulting in lack of physician oversight.
F 0584: Facility did not maintain a safe, clean, and homelike environment; wheelchairs for residents 14, 22, 29, and 37 were soiled or damaged.
F 0600: Facility failed to protect residents from abuse and neglect, allowing resident 11 to have multiple resident-to-resident altercations with physical contact without adequate prevention or supervision.
F 0609: Facility did not timely report suspected abuse and injuries of unknown origin to proper authorities, including delayed reporting of resident 51's injury and multiple resident-to-resident altercations involving resident 11.
F 0656: Facility failed to develop and implement comprehensive care plans for residents 9 and 66, including lack of specific oxygen interventions and failure to update care plan after falls.
F 0676: Facility did not provide adequate care to prevent decline in activities of daily living; residents 9 and 11 had long, soiled nails and resident 9 experienced injury during nail care.
F 0689: Facility failed to maintain a safe environment and provide adequate supervision to prevent falls for residents 9 and 68; interventions were not updated after multiple falls.
F 0695: Facility did not provide safe and appropriate respiratory care for resident 66, who was observed without oxygen despite low pulse oxygen saturation levels.
F 0759: Facility had a medication error rate exceeding 5%, including wrong dose, wrong medication, and failure to follow physician orders for residents 29, 40, and 41.
F 0760: Facility did not ensure residents were free from significant medication errors; residents 29, 40, and 41 had insulin administration errors and failure to take apical pulse as ordered.
F 0761: Facility failed to ensure safe and secure storage and labeling of drugs; expired medications were administered to resident 9 and medications lacked proper labeling.
F 0812: Facility did not store, prepare, distribute, and serve food in accordance with professional standards; staff were observed without hairnets, improper glove use, reusing uncleaned plate domes, and cross contamination in dining room.
Report Facts
Medication error rate: 10.87
Fall risk score: 19
Fall risk score: 16
Fall risk score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed medication administration and interviewed about medication and resident care |
| LPN 2 | Licensed Practical Nurse | Interviewed about medication administration and resident care |
| RN 1 | Registered Nurse | Observed medication administration and interviewed about medication and resident care |
| DON | Director of Nursing | Interviewed about facility policies, medication errors, abuse reporting, and resident care |
| ADON 1 | Assistant Director of Nursing | Interviewed about medication administration and resident care |
| Pharmacist 1 | Interviewed about medication substitutions and medication contents | |
| CNA 2 | Certified Nursing Assistant | Interviewed about resident care and behaviors |
| CNA 3 | Certified Nursing Assistant | Interviewed about resident behaviors and care |
| Administrator | Interviewed about resident care, staffing, and abuse reporting | |
| Dietary Manager | Interviewed about food service and kitchen hygiene | |
| MD 1 | Medical Director | Interviewed about medication administration and resident care |
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