Holladay Healthcare Center

Name: Holladay Healthcare Center
Address: 4782 South Holladay Boulevard, Salt Lake City, UT, 84117, US
Telephone: 8012777002

4782 South Holladay Boulevard, Salt Lake City, UT 84117 · Salt Lake County · 120 certified beds · avg 80 residents/day · certified since Feb 13, 1987

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.47

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (25)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Mar 24, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 24, 2025	E · Potential for harm, repeated	The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Mar 24, 2025	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Mar 24, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 24, 2025	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Mar 24, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Mar 24, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 24, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 24, 2025	D · Potential for harm, one-off	The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. · from a complaint
Mar 24, 2025	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Mar 24, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Sep 8, 2023	E · Potential for harm, repeated	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Sep 8, 2023	E · Potential for harm, repeated	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Sep 8, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Sep 8, 2023	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Dec 16, 2021	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Dec 16, 2021	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 16, 2021	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Dec 16, 2021	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Dec 16, 2021	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Dec 16, 2021	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Dec 16, 2021	D · Potential for harm, one-off	The facility did not properly run its feeding assistant program — assessing which residents are appropriate for it, following each resident's care plan, and making sure feeding assistants are trained and supervised. Feeding assistants are trained helpers who assist residents at mealtimes.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 11).

Year	Citations	Worst severity that year
2021	7	E
2023	7	E
2025	11	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Utah avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.47	3.87	3.95	bottom 41% in Utah; bottom 35% in the U.S.
Registered Nurse hours	0.65	1.17	0.69	bottom 8% in Utah; top 42% in the U.S.
Weekend total nurse staffing	3.07	3.39	3.50	bottom 44% in Utah; bottom 35% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.64	0.88	0.48	bottom 38% in Utah; top 20% in the U.S.
Total nursing staff turnover (%)	43.8	50.7	45.8	top 31% in Utah; top 47% in the U.S.
RN turnover (%)	25.0	40.6	42.9	top 22% in Utah; top 20% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.59, RN 0.67, weekend 3.18. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	02/01/2007
Caretrust GP LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Caretrust Reit INC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Cottonwood Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Ctr Partnership LP	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Moss, Tyler	Individual	Corporate Officer	NOT APPLICABLE	05/01/2016
Olympus Health, INC.	Organization	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Olympus Health, INC.	Organization	ADP of the SNF	NOT APPLICABLE	09/16/2025
Wallace, Mark	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Wallace, Mark	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
Workman, David	Individual	Operational/Managerial Control	NOT APPLICABLE	09/20/2024
Workman, David	Individual	ADP of the SNF	NOT APPLICABLE	09/20/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you track that every resident's quarterly assessment happens on time?"
"Could I join residents for a meal to see the food quality and temperature for myself?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"How soon after admission is a full assessment completed, and how are the findings shared with the family?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Spring Creek Healthcare Center	1.1 mi	Salt Lake City, UT	★★☆☆☆	2/5
Highland Care Center	1.4 mi	Holladay, UT	★★★★★	4/5
Monument Healthcare Cottonwood Creek	2.1 mi	Salt Lake City, UT	★★★☆☆	2/5
Monument Healthcare Millcreek	2.2 mi	Salt Lake City, UT	★★★★☆	3/5
Mt. Olympus Rehabilitation Center	2.4 mi	Salt Lake City, UT	★★☆☆☆	1/5
Monument Healthcare Canyon Rim	2.4 mi	Millcreek, UT	★★★☆☆	3/5
Rocky Mountain Care - Cottage on Vine	3.0 mi	Murray, UT	★★★☆☆	2/5
Monument Healthcare Murray Creek	3.0 mi	Millcreek, UT	★★☆☆☆	1/5	abuse
Paramount Health and Rehabilitation	3.4 mi	Salt Lake City, UT	★★★☆☆	2/5
Millcreek Rehabilitation and Nursing	3.5 mi	Salt Lake City, UT	★★☆☆☆	1/5	abuse
Aspen Ridge Transitional Rehab	3.5 mi	Murray, UT	★★★★★	5/5
Aspen Ridge West Transitional Rehab	4.2 mi	Murray, UT	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Salt Lake City →

Facility data as of CMS processing date 2026-08-01. CCN 465109.

The Care File

Visit checklist — Holladay Healthcare Center

4782 South Holladay Boulevard, Salt Lake City, UT 84117 · 8012777002

Health inspection rating 2/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you track that every resident's quarterly assessment happens on time?"
☐ "Could I join residents for a meal to see the food quality and temperature for myself?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 465109 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)