Holladay Healthcare Center
4782 South Holladay Boulevard · Salt Lake City, UT · 84117 · 8012777002
120 certified beds For profit - Limited Liability company Chain: The Ensign Group
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The composite number cleared 74 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.62 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.63 | 0.55–0.75 |
| Weekend hours / resident-day | 3.29 | ≈ weekday level |
| Nursing turnover / year | 44% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (25 in the current record)
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Potential for harm · D March 24, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected May 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · E March 24, 2025
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected May 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 24, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected May 10, 2025 · Quality of Life and Care
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Potential for harm · D March 24, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 10, 2025 · Pharmacy Service
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Potential for harm · D March 24, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected May 10, 2025 · Pharmacy Service
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Potential for harm · E March 24, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected May 10, 2025 · Nutrition and Dietary
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Potential for harm · F March 24, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 10, 2025 · Nutrition and Dietary
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Potential for harm · E March 24, 2025
Provide and implement an infection prevention and control program.
Corrected May 10, 2025 · Infection Control
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Potential for harm · D March 24, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 10, 2025 · Quality of Life and Care
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Potential for harm · D March 24, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 10, 2025 · Quality of Life and Care
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Potential for harm · D March 24, 2025 · found via complaint
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected May 10, 2025 · Nursing and Physician Services
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Potential for harm · D September 8, 2023
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected October 9, 2023 · Resident Rights
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Potential for harm · D September 8, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Corrected October 9, 2023 · Quality of Life and Care
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Potential for harm · D September 8, 2023 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected October 9, 2023 · Resident Assessment and Care Planning
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Potential for harm · E September 8, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected October 9, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E September 8, 2023 · found via complaint
Respond appropriately to all alleged violations.
Corrected October 9, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 8, 2023 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected October 9, 2023 · Pharmacy Service
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Potential for harm · D September 8, 2023 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected October 9, 2023 · Pharmacy Service
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Potential for harm · D December 16, 2021
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected February 7, 2022 · Resident Rights
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Potential for harm · D December 16, 2021
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 7, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 16, 2021
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected February 7, 2022 · Quality of Life and Care
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Potential for harm · D December 16, 2021
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected February 7, 2022 · Pharmacy Service
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Potential for harm · E December 16, 2021
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected February 7, 2022 · Nutrition and Dietary
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Potential for harm · D December 16, 2021
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected February 7, 2022 · Nutrition and Dietary
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Potential for harm · E December 16, 2021
Provide and implement an infection prevention and control program.
Corrected February 7, 2022 · Infection Control
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 465109 · certified since February 13, 1987. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.