William E Christofferson Salt Lake Veterans Home

In the surveyor’s words

From the most serious findings on record at William E Christofferson Salt Lake Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF805Nov 12, 2025

  Based on interview and record review, for 1 of 3 sampled residents, the facility failed to ensure each resident received food prepared in a form designed to meet individual needs. Specifically, a resident had a diet order for soft and bite-sized texture and was served a sandwich for a snack which resulted in the resident choking and passing away. Resident identifier: 1.It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, S483.60(d)(3) Food prepared in a form designed to meet individual needs, F805, at a scope and severity of G. […]

• No harm, potential for more than minimal, widespreadF812Mar 19, 2026

  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 dishmachine washing temperature was not meeting manufacturer requirements and sanitizer solution was not at required levels for sanitizing. In addition, there were soiled areas in the kitchen. Findings included: 1. On 3/16/26 at 9:21 AM, an initial kitchen tour of the kitchen was conducted. The following was observed: Dietary Aide (DA) 1 stated the sanitizer solution located by the 3 compartment sink was made at 8:30 AM. DA 1 stated the sanitizer was quats ammonia and needed to be between 250-260 Parts Per Million (PPM). DA 1 was observed to test the solution and stated it was at 500 PPM. […]

• No harm, potential for more than minimal, patternF812Jun 9, 2022

  Based on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air, and food items in the walk-in refrigerator were past the manufacturers use-by date. Findings included: On [DATE] at 9:06 AM, an initial walk-through of the kitchen area was conducted. In the walk-in refrigerator, a container of sour cream with an open date of [DATE], and a use-by date of [DATE], was observed. A container of cottage cheese was also observed with a use-by date of [DATE]. On [DATE] at 9:15 AM, an observation was made of the walk-in freezer. A box of frozen doughnut-holes were observed open to air. […]

• No harm, potential for more than minimal, patternF886Oct 18, 2021

  Based on interview and record review it was determined, for 5 of 5 sampled facility staff members, that the facility did not ensure that testing of all facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on the county positivity rate, was not completed two times a week. Staff identifiers: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5. Findings include: On 10/18/21, a list of staff that were unvaccinated were provided. Staff 1, Staff 2, Staff 3, Staff 4 and Staff 5 were indicated as unvaccinated. According to the Center for Disease Control and Prevention (CDC) the community transmission was red for the weeks of 9/20/21, 9/27/21, 10/4/21, 10/12/21 and 10/18/21. […]

• No harm, potential for more than minimal, isolatedF773Mar 19, 2026

  Based on interview and record review, for 2 of 32 sampled residents, the facility did not obtain laboratory services only when ordered by a physician. Specifically, a resident had a Complete Blood Count (CBC) with differential and Vitamin D, 25-Hydroxy drawn without a physician's order. Resident identifier 5. Findings included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia, abnormal findings of blood chemistry, post traumatic stress disorder and major depressive disorder. Resident 5's medical record was reviewed 3/19/26. Resident 5 had laboratory results for Vitamin D, 25-Hydroxy and CBC with differential on 12/8/25. There were no physician's orders for the laboratory draws. […]