Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 William E Christofferson Salt Lake Veterans Home during CMS and state inspections, most recent first.
Kitchen sanitation and dishmachine temperature deficiencies: A dietary aide used sanitizer that tested outside the expected range and later another staff member found it at 0 PPM, while soiled areas were observed on the shelf above the trayline, ceiling, and piping behind cooking equipment. Staff also handled raw meat and then touched cutting boards without hand hygiene, and the dishmachine washing cycle repeatedly measured below the stated minimum while clean dishes were being put away.
Laboratory tests were obtained for a resident without a physician order. The resident, who had dementia, abnormal blood chemistry findings, PTSD, and major depressive disorder, had CBC and Vitamin D, 25-Hydroxy results in the chart with no corresponding order. The DON stated she could not find an order for the tests and believed the nurse miscalculated the 6-month timing for routine labs.
Missing Lab Results in Medical Records: The facility failed to keep lab reports accurately maintained and readily available in the medical record for two residents. One resident had ordered anemia-related labs, including ferritin, serum iron, transferrin, and TIBC, that were not found in the chart, and another resident had a TSH order with reflux to free T4 where the T4 was present but the TSH result was missing. The DON stated some results had to be manually printed from an external portal and scanned into the record, and that the missing TSH should have been in the chart.
A resident with severe cognitive impairment and a physician-ordered soft and bite-sized diet was given a ham and cheese sandwich that did not meet the required texture, leading to choking and death. Staff provided the inappropriate snack despite documented swallowing difficulties and care plan instructions, and there was a lack of clear communication and knowledge among staff regarding diet orders and safe food options for residents with modified diets.
Kitchen sanitation and dishmachine temperature deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety because the dishmachine washing temperature was below the manufacturer-required level and sanitizer solution levels were not consistently at the required range. During the kitchen observation, a dietary aide stated the sanitizer by the 3-compartment sink had been made earlier that morning and was supposed to be between 250 and 260 PPM, but the aide tested it at 500 PPM and then used it to wipe the trayline. A sign by the sanitizer solution stated it should test between 150 and 400 PPM, while a later test by another staff member showed the solution at 0 PPM. A sanitation bucket log for March 2026 showed staff documented 300 to 400 PPM, and the log also stated sanitizer should be 200 to 300 PPM and changed every 4 hours. The kitchen was also observed to have soiled areas, including dust on piping behind the stove, fryer, and oven, food splatter on the ceiling over the trayline, and a soiled shelf above the trayline where food was served from below. In addition, a dietary aide was observed touching raw meat with gloves, removing the gloves, and then touching cutting boards without hand hygiene. The dishmachine washing cycle was repeatedly observed at 145, 140, and 145 degrees Fahrenheit while clean dishes, trays, and plate bases were being put away, even though staff stated the washing cycle needed to be above 150 degrees Fahrenheit and the rinse above 180 degrees Fahrenheit. The dietary manager stated the dishmachine needed to run 2 to 3 times to reach the required temperatures and acknowledged that the shelf above the trayline was not on the cleaning list and that the pipes behind the fryer, ovens, and stove needed to be cleaned.
Laboratory tests were obtained without a physician order
Penalty
Summary
Laboratory services were obtained for Resident 5 without a physician's order. Resident 5 was admitted with diagnoses including dementia, abnormal findings of blood chemistry, post traumatic stress disorder, and major depressive disorder. The resident's record showed laboratory results for Vitamin D, 25-Hydroxy and CBC with differential on 12/8/25, but there were no physician's orders for those blood draws. The record also showed a physician's order dated 7/8/26 for CBC, CMP, and Vitamin D level every 6 months starting on the 8th for 1 day for routine labs, and another Vitamin D, 25-Hydroxy and CBC with manual differential completed on 1/8/26. The DON stated during interview that she could not find an order for the 12/8/25 CBC and Vitamin D, 25-Hydroxy and believed the nurse calculated 6 months from July 2025 as 12/8/25 instead of 1/8/26.
Missing Lab Results in Medical Records
Penalty
Summary
The facility failed to ensure that laboratory reports were accurately maintained and readily available in the medical record for 2 of 32 sampled residents. For Resident 3, who was admitted and later readmitted with diagnoses including hypo-osmolality, hyponatremia, and anxiety, a physician order dated 12/28/25 required additional labs for 12/29/25, including ferritin level, serum iron, transferrin, and TIBC for anemia. Those laboratory tests dated 12/29/25 were not located in Resident 3's medical record during review from 3/16/26 through 3/19/26. For Resident 4, who was admitted with diagnoses including vascular dementia, depression, PTSD, constipation, and prediabetes, a physician order dated 1/26/26 revealed a TSH with reflux to free T4. The record showed the T4 was completed on 1/26/26, but there were no TSH results in the medical record. During interview on 3/19/26, the DON stated the TSH had been completed but was not in the record and needed to be manually printed from an external portal and scanned into the medical record; the DON stated the TSH results should have been in the medical record.
Failure to Provide Diet-Appropriate Food Results in Resident Choking Death
Penalty
Summary
A resident with a history of dysphagia, severe cognitive impairment, and multiple comorbidities was admitted with a physician's order for a soft and bite-sized (IDDSI Level 6) diet. The resident's care plan and speech therapy recommendations specified the need for close supervision during meals, encouragement of small bites, and avoidance of foods not consistent with the prescribed diet texture. Despite these documented requirements, the resident was provided a half ham and cheese sandwich as a snack, which did not meet the soft and bite-sized texture criteria and included regular bread, a known choking risk for individuals on this diet. While consuming the sandwich, the resident began to cough and exhibited signs of choking. Staff attempted to assist by performing a mouth sweep and the Heimlich maneuver, but the resident's condition deteriorated, leading to unresponsiveness. Emergency services were called, and CPR was initiated, but the resident could not be revived and was pronounced deceased. Witness statements and nursing notes confirmed that the sandwich provided was not appropriate for the resident's ordered diet and that the resident had a known history of coughing and choking with food, particularly when not closely supervised or when consuming inappropriate textures. Interviews with staff revealed that sandwiches were previously available in the memory care unit's snack refrigerator and that there was a lack of clear, accessible information regarding residents' diet orders at the time of the incident. Staff knowledge of diet textures and the specific requirements for soft and bite-sized diets was inconsistent, and there was no standardized process in place to ensure that only appropriate foods were provided to residents with modified diets. The failure to provide food in a form designed to meet the resident's individual needs directly resulted in the choking incident and subsequent death.
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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) |
|---|---|---|---|---|
| City Creek Post Acute | 1.6 mi | ★★★★★ | 6 | 0 |
| Maple Ridge Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Cottonwood Creek | 2.1 mi | ★★★★★ | 0 | 0 |
| St Joseph Villa | 3.2 mi | ★★★★★ | 0 | 0 |
| Millcreek Rehabilitation And Nursing | 3.2 mi | ★★★★★ | 3 | 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.