Holladay Healthcare Center

In the surveyor’s words

From the most serious findings on record at Holladay Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 24, 2025

  Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine temperatures were not meeting the required temperature for sanitation. Findings include: On 3/17/25 at 9:34 AM, the dish machine temperature log was reviewed. The washing temperature and the sanitizer were documented for each meal for March 2025. On 3/17/25 for the breakfast meal had a temperature of 120 degrees Fahrenheit and the sanitizer was 200 parts per million (PPM). Dietary Aide (DA) 1 was observed to be changing the sanitizer solution. DA 1 was observed to check the sanitizer and it was 0 PPM. An interview was immediately conducted with the Dietary Manager (DM). […]

• No harm, potential for more than minimal, patternF638Mar 24, 2025

  Based on interview and record review, the facility did not assess a resident using the quarterly review instrument no less frequently than once every 3 months. Specifically, 4 of 37 sampled residents, quarterly Minimum Data Set (MDS) assessments were completed greater than 3 months apart. Resident identifiers: 9, 10, 39 and 63. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, major depressive disorder, and hypertension. Resident 10's quarterly MDS had an assessment reference date (ARD) of 1/11/25 and was completed on 3/17/25. The previous quarterly MDS was completed on 10/24/25. 2. […]

• No harm, potential for more than minimal, patternF804Mar 24, 2025

  Based on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and served at a safe and appetizing temperature. Specifically, for 8 out of 37 sampled resident, residents complained of food quality, a test tray not attractive or palatable and resident council minutes revealed complaints of food quality. Resident identifiers: 23, 33, 37, 50, 60, 124, 126 and 286. Findings include: 1. On 3/20/25 at 2:06 PM, an interview was conducted with resident 23. Resident 23 stated that the food was not good. Resident 23 stated that she completed the meal request forms, but the food delivered was often not what she ordered. Resident 23 stated that she was attempting to eat less carbohydrates, but had been served lots of pasta and rice. […]

• No harm, potential for more than minimal, patternF880Mar 24, 2025

  Based on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not performed between residents who were being assisted with eating or performed when delivering lunch trays between multiple resident rooms. Resident identifiers: 25, 34, 35 and 43. Findings include: On 3/17/25 at 12:16 PM, lunch service was observed in the 2nd floor dining room. Certified Nursing Assistants (CNA) 1 and 2 were observed to sit at a table with residents 25, 34, 35 and 43, no hand hygiene (HH) was used prior to sitting down. […]

• No harm, potential for more than minimal, patternF609Sep 8, 2023

  Based on interviews, record review, and facility policy and document review, the facility failed to report allegations of physical and sexual abuse timely to the state survey agency for 4 (Residents #34, #292, #77, and #242) of 5 residents reviewed for abuse and/or neglect. Findings included: A review of the facility's policy titled, Abuse: Prevention of and Prohibition Against, last revised/reviewed in October 2022, revealed, H. Reporting / Response 1. All allegations of abuse, neglect, misappropriation of property, or exploitation should be reported immediately to the Administrator. 2. […]