Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holladay Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that the dish machine consistently met required sanitation standards, as observed through multiple cycles with wash and rinse temperatures below 120°F and inconsistent sanitizer levels. Staff continued to use and store dishes as clean despite these deficiencies, and documentation did not clearly specify compliance with professional food safety standards.
Four residents with complex medical conditions did not have their quarterly MDS assessments completed within the required three-month interval. The MDS coordinator confirmed that assessments were submitted late due to falling behind and prioritizing current over overdue assessments.
Several residents reported that meals were consistently cold, bland, and did not match their menu selections or dietary preferences. Direct observation confirmed that food was served at improper temperatures and lacked seasoning. Resident council minutes documented ongoing complaints about food quality, temperature, and presentation, indicating a persistent failure to provide palatable and appetizing meals.
Staff were observed assisting multiple residents with eating and delivering meal trays without performing hand hygiene between resident interactions or between handling trays. This failure to follow infection control protocols was confirmed by interviews with nursing leadership, who stated that hand hygiene was expected between each resident and tray delivery.
A resident with multiple chronic conditions did not receive a comprehensive MDS assessment within the required 12-month period. The MDS coordinator confirmed the delay, stating that overdue assessments were sometimes deprioritized in favor of current ones.
A resident with multiple chronic conditions was provided oxygen therapy without an active physician's order, and staff did not follow standardized procedures for changing oxygen tubing and humidifier. Staff relied on the resident or equipment settings to determine oxygen needs, and there was no documentation of scheduled equipment changes. The facility also failed to address the resident's request for a smaller portable oxygen tank.
A resident with complex cardiac and renal conditions was administered metoprolol on multiple occasions despite physician orders to hold the medication for systolic blood pressure below 100. Nursing staff did not adhere to the specified parameters, resulting in the administration of the drug when it was not indicated.
An opened Lantus insulin pen, labeled with an open date beyond the recommended 28-day period, was found in the medication cart and available for use for a resident with multiple health conditions. Nursing staff confirmed that insulin should be discarded after 28 days, but the expired medication was not removed as required.
A resident with impaired mobility and a physician's order for podus boots to prevent pressure ulcers did not consistently have the boots applied as required. Despite documentation indicating the intervention was in place, direct observations showed the boot was not on the resident's foot during several checks, and the resident expressed concern about the lack of action. Staff reported that orders were communicated via shift reports and electronic alerts, but the intervention was not reliably implemented.
A resident with severe dementia and behavioral issues was exposed to accident hazards when tools and an unsecured toilet were left in her accessible bathroom during repairs, despite her known wandering and impulsive behavior. Staff confirmed the presence of these hazards and acknowledged the resident could access the area. Additionally, a staff member was observed carrying unsecured oxygen tanks through the hallway, contrary to safety protocols.
A nurse aide was employed full-time for about eight months without completing the required state-approved training and competency evaluation program. The aide was hired and worked beyond the four-month limit without certification, and facility leadership could not provide a clear explanation for this lapse, citing possible confusion over a staffing waiver.
Failure to Maintain Proper Dish Machine Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically related to dish machine sanitation. Observations and record reviews revealed that the dish machine was not consistently reaching the required temperatures for proper sanitation. On multiple occasions, the wash and rinse cycles of the dish machine were documented at temperatures below the minimum standard of 120 degrees Fahrenheit. Additionally, the sanitizer solution was found to be at 0 parts per million (PPM) during one observation, despite logs indicating 200 PPM. Staff were observed placing dishes, utensils, and kitchenware away as clean after cycles that did not meet the required temperature or sanitizer levels. Interviews with dietary staff and the dietary manager confirmed awareness of the required temperature and sanitizer standards, but also revealed that the dish machine was used even when these standards were not met. The dish machine logs for several months showed inconsistent documentation, with no clear specification of which temperature was being recorded. The dietary manager acknowledged that water temperatures were lower when the laundry was in use and confirmed that the dish machine was not always operating at the required sanitation levels.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that each resident’s assessment was updated at least once every three months, as required. Specifically, four residents with various diagnoses, including multiple sclerosis, major depressive disorder, hypertension, type 2 diabetes mellitus, fibromyalgia, spinal stenosis, Alzheimer's disease, heart failure, nontraumatic subdural hemorrhage, and vascular dementia, had quarterly Minimum Data Set (MDS) assessments completed more than three months apart. The assessment reference dates (ARD) and completion dates for these residents showed that the required quarterly reviews were not performed within the mandated timeframe. During an interview, the MDS coordinator acknowledged that the MDS assessments for these residents were completed late. The coordinator explained that when she fell behind on her workload, she prioritized current assessments over those that were already overdue, resulting in the late completion of the required quarterly MDS assessments for the affected residents.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for 8 out of 37 sampled residents. Multiple residents reported that their meals were consistently cold, bland, and did not match their menu selections or dietary preferences. Specific complaints included being served unwanted carbohydrates, cold eggs, and food that was not seasoned or appealing. Some residents stated they avoided eating due to the poor quality and temperature of the food, and one resident relied on family to bring meals. Resident council meeting minutes over several months documented ongoing concerns about food temperature, presentation, and the facility not honoring residents' menu choices or dietary dislikes. Direct observation of a test tray revealed that food items such as rice and peas were served at temperatures below recommended hot holding standards and were bland and unseasoned. The meat was tough and also lacked flavor, while the dessert was palatable. The Dietary Manager acknowledged a recent change in tray plating and service but was not aware of significant complaints about cold food. The Administrator confirmed that food complaints had been recurring and noted changes in food service organization and equipment, but issues with food temperature and accuracy of meal orders persisted as evidenced by resident feedback and council minutes.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple instances where staff did not perform hand hygiene between resident interactions during meal service. Certified Nursing Assistants (CNAs) were observed assisting several residents with eating, including putting on clothing protectors, touching utensils, feeding, and wiping mouths, without using hand sanitizer or washing hands between each resident. Additionally, CNAs and other staff members were seen delivering and setting up meal trays for different residents in various rooms without performing hand hygiene between handling trays, touching room surfaces, and interacting with residents. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that staff were expected to sanitize their hands between feeding residents and passing meal trays, but this was not observed in practice. The deficiency was identified through direct observation of staff actions during lunch service and was corroborated by staff interviews, indicating a lack of adherence to established infection control protocols designed to prevent the transmission of communicable diseases and infections among residents.
Late Completion of Annual MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment for a resident at least every 12 months as required. Specifically, one resident, who was admitted with diagnoses including biomechanical lesions of the thoracic region, heart failure, and chronic kidney disease, did not have their annual Minimum Data Set (MDS) assessment completed within the required timeframe. The assessment reference date was set, but the MDS was not completed until over 13 months after the previous annual assessment. During an interview, the MDS coordinator acknowledged the delay, explaining that when behind on assessments, priority was given to current MDSs due, resulting in some assessments being completed late.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with a history of osteomyelitis, type 2 diabetes, foot ulcer, and chronic obstructive pulmonary disease was observed using an oxygen concentrator without an active physician's order for oxygen therapy. The resident's care plan indicated oxygen should be administered as ordered by a physician, but the only order found in the medical record was discontinued prior to the current stay. Staff interviews confirmed that there were no current orders for oxygen use or for changing the tubing and humidifier, and the tubing and humidifier on the resident's equipment were not dated. Multiple staff members, including nursing assistants and registered nurses, reported relying on the resident or the oxygen concentrator settings to determine oxygen needs, rather than following a physician's order. Staff also described inconsistent practices regarding the changing of tubing and humidifier water, with changes occurring when equipment appeared dirty or as needed, rather than according to a set schedule or order. The facility did not provide smaller portable oxygen tanks requested by the resident, and management was unaware of the request. The lack of physician orders and standardized procedures for respiratory care led to the deficiency.
Failure to Follow Medication Parameters for Antihypertensive Administration
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including acute idiopathic pericarditis, supraventricular tachycardia, single subsegmental thrombotic pulmonary embolism, chronic kidney disease, and thyrotoxicosis, received metoprolol tartrate outside of the physician-ordered parameters. The medication order specified that metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 100 or if the pulse was less than 50. Despite these parameters, nursing staff administered metoprolol on several occasions when the resident's SBP was documented below 100. Specifically, the medication was given on at least six documented dates when the resident's SBP ranged from 92 to 98, all below the ordered threshold. Interviews with the Assistant Director of Nursing and the Clinical Resource Nurse confirmed that staff were expected to follow medication order parameters, but these expectations were not met in this case, resulting in the administration of an unnecessary drug as defined by regulatory standards.
Expired Insulin Pen Not Discarded After 28 Days
Penalty
Summary
A deficiency was identified when an opened Lantus insulin pen, labeled with an open date exceeding the recommended 28-day usage period, was found in the medication cart for one resident. The insulin pen had been opened for 34 days, which is 6 days past the professional standard for safe use. The insulin was available for use despite being past the acceptable timeframe for administration. Interviews with nursing staff confirmed that insulin should be labeled with the date it is opened and discarded after 28 days. Both LPNs and the Assistant Director of Nursing acknowledged that the insulin should have been disposed of once it reached the 28-day mark, but it remained in the medication cart and was not discarded as required. The resident involved had a medical history including acute diastolic congestive heart failure, paroxysmal atrial fibrillation, and type 2 diabetes mellitus.
Failure to Consistently Apply Physician-Ordered Podus Boots for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, weakness, and impaired mobility, did not consistently receive a physician-ordered intervention to prevent pressure ulcers. The resident had a history of skin breakdown risk and was ordered to have podus boots applied every shift as a preventative measure for a developing area of redness on the left lateral ankle. Despite this order, observations on multiple occasions revealed that the podus boot was not applied to the resident's left foot while the resident was in bed, and the boot was found in the corner of the room instead. Documentation in the Treatment Administration Record indicated the boot was in place, but direct observation contradicted this record. Interviews with the resident, who was cognitively intact, confirmed awareness of the need for the boot and concern that the intervention was not being implemented. Staff interviews revealed that communication about the podus boot order was provided during shift reports and through alerts in the electronic medical record, and that nurses were expected to verify the application of the boots. However, the failure to ensure the podus boot was consistently applied as ordered resulted in the resident not receiving the necessary treatment and services to prevent pressure ulcer development.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment. A resident with dementia, behavioral disturbances, and a BIMS score indicating severe cognitive impairment was found to have tools left in her bathroom while the toilet was unsecured and out of use for several days. Multiple staff interviews confirmed that the bathroom contained tools, an open hole in the floor, and the toilet lying on the ground, while the resident, known for wandering and impulsive behavior, remained in the room. The bathroom was not able to be locked, and the resident was physically able to access the area with these hazards present. Staff and family interviews indicated that the resident's bathroom was blocked off with caution tape, but the resident continued to stay in the room and was taken to the shower room for toileting needs. The maintenance director acknowledged possibly leaving tools in the bathroom and confirmed that the resident could have accessed the area while repairs were ongoing. Staff also reported that the resident was eventually placed on one-to-one supervision due to her confusion and wandering, but at the time of the incident, she was able to enter the hazardous bathroom environment. Additionally, a staff member was observed carrying unsecured oxygen tanks through the hallway, rather than using a dolly as required. Interviews with clinical staff confirmed that oxygen tanks should not be carried by hand due to the risk of dropping them. These actions demonstrate a failure to maintain a safe environment and provide adequate supervision to prevent accidents for residents, particularly those with cognitive impairments.
Nurse Aide Employed Beyond Four Months Without Certification
Penalty
Summary
A nurse aide was employed on a full-time basis for approximately eight months without completing a state-approved training and competency evaluation program, as required for individuals working in such roles for more than four months. Review of the employee record showed the nurse aide was hired on February 9, 2024, but did not receive nurse aide certification until October 8, 2024, indicating a period of employment beyond four months without proper certification. During an interview, the Regional Nurse Consultant was unable to explain why the nurse aide remained employed without certification and suggested there may have been confusion regarding a staffing waiver.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Creek Healthcare Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Highland Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Millcreek | 2.2 mi | ★★★★★ | 10 | 0 |
| Mt. Olympus Rehabilitation Center | 2.4 mi | ★★★★★ | 2 | 2 |
| Monument Healthcare Canyon Rim | 2.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.