Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sandy Health And Rehab during CMS and state inspections, most recent first.
Multiple residents and staff reported persistent foul odors and visible cleanliness issues in a shower room, including strong urine and sewage smells, soiled linens, and stained furniture. Observations confirmed broken tiles, mold, and a non-functioning toilet in other shower rooms. Staff interviews revealed inconsistent reporting and unclear responsibilities for maintenance and housekeeping, resulting in ongoing disrepair and an environment that was not safe, clean, or homelike.
Multiple residents reported that food was often cold, bland, unappetizing, and nutritionally inadequate, with observations confirming improper food temperatures and unattractive presentation. Resident council minutes and grievance forms documented ongoing dissatisfaction with food quality, and interviews with dietary staff and administration revealed a lack of awareness and oversight regarding these issues.
Dietary staff failed to follow sanitary food handling practices by touching multiple unclean surfaces and then handling plates and food with the same gloves, as well as chopping food on a cutting board that was not cleaned between uses. Both the cook and dietary manager acknowledged these lapses, confirming that food was prepared and served in a manner not consistent with professional standards.
Several residents with chronic medical conditions were not properly offered or administered influenza and COVID-19 vaccines, despite signed consents indicating acceptance. Documentation was missing for both the offer and administration of vaccines, as confirmed by facility leadership.
Two residents were unable to access their personal funds on weekends because only the Business Office Manager, who worked weekdays, could distribute money. Staff confirmed that no one was available to provide funds outside of business hours, and delays in obtaining cash from the corporate office further limited access.
A resident with multiple diagnoses returned from the hospital with sutures on the bridge of the nose and instructions for removal in 7 days. Facility staff failed to remove the sutures within the specified timeframe, and the resident was observed with the sutures still in place and tugging at them. Staff interviews revealed confusion about the correct removal period, and the DON confirmed the removal was overdue.
A resident with multiple chronic conditions did not have required serum phenytoin and phenobarbital lab results documented in the electronic medical record, despite pharmacy recommendations and physician approval for these labs. Staff interviews revealed that while diagnostic results were supposed to be scanned and uploaded promptly, the necessary laboratory reports were missing from the resident's chart.
A resident receiving antibiotics for pneumonia did not have a signed and dated chest x-ray report filed in their clinical record, despite staff confirming that such a report should have been present to support the diagnosis and treatment.
A resident with multiple documented food allergies, including peas, was served a meal containing peas despite clear indications on her meal ticket and care plan. The resident reported receiving foods she was allergic to on a recurring basis, and observation confirmed the presence of an allergen on her tray. The deficiency persisted even after previous complaints and staff education.
Several shower and bathing areas lacked working call lights or had missing cords, preventing residents from summoning staff assistance. Multiple residents and CNAs confirmed the call lights were non-functional or inaccessible, and maintenance staff noted cords should be floor-length but were absent. The administrator acknowledged the system's age and frequent failures, with staff compensating by checking on residents more often or remaining present during showers.
Two residents with cognitive impairments and a history of wandering eloped from a facility due to inadequate supervision and safety measures. One resident sustained severe burns after leaving without staff knowledge, while another was found outside the facility twice despite having a wander guard. The facility's safety systems were insufficient to prevent these incidents.
Two residents in an LTC facility did not receive appropriate wound care and documentation. One resident with a toe injury experienced a delay in treatment and lack of monitoring, while another resident with burns had no documented wound measurements. The facility failed to adhere to professional standards and care plans, leading to deficiencies in care.
The facility failed to maintain a sanitary environment in resident shower rooms, as black spots were observed on the baseboard near the shower entrance. Staff interviews revealed inconsistencies in cleaning responsibilities, with CNAs and housekeeping having different understandings of their roles. The Administrator identified the spots as potential mold or moisture, indicating a need for a deep clean.
A resident on hospice services with multiple diagnoses, including a brain bleed, was found on the floor with a laceration above the right eye. The facility failed to thoroughly investigate the incident, lacking interviews with key staff and detailed documentation of the resident's condition and preventive measures. Inconsistencies in records and inadequate assessment of the resident's fall risk contributed to the deficiency.
Two residents did not receive prescribed antibiotics due to transcription errors and failure to order from the pharmacy. One resident with a toe injury and another with severe burns were affected. The DON acknowledged the oversight and lack of a 24-hour chart check.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in its shower rooms, as evidenced by multiple resident and staff interviews and direct observations. Several residents reported refusing to use the 100-hall shower room due to persistent unpleasant odors described as similar to soiled diapers, sewage, or urine. Staff corroborated these complaints, noting that the odor was strong and that some residents would not use the shower room because of it. Observations confirmed the presence of a strong urine and sewage-like odor, soiled linens in unlabeled garbage cans, a fabric chair with brown and white stains, and shower chairs with brown substances on the seat area. Large garbage cans, one without a liner and half full of briefs and trash, contributed to the odor, and the trash was not being emptied regularly according to staff interviews. In addition to odor issues, the physical condition of the shower rooms was found to be in disrepair. The south 300 hallway shower room had missing and broken tiles at the base of a divider wall, and the Maintenance Director acknowledged that the open gap between tiles could allow humidity to penetrate the wall, potentially causing further damage. Mold was observed around a sprinkler head and in a corner with a large water spot, and the toilet in the 200-hall shower room was out of order due to a broken main pipe and was covered with a plastic sheet. These maintenance issues were confirmed by the Maintenance Director, who stated that repairs were needed but had not been requested until a recent resident complaint. Communication and reporting of these issues were inconsistent. While some CNAs reported entering complaints into the maintenance system, others were unsure if the system was being utilized. The Assistant Director of Nursing was unaware of any complaints regarding the odor, and there was confusion among staff about responsibilities for emptying trash and reporting maintenance needs. Housekeeping staff stated that shower rooms were cleaned daily with disinfectant, odor control, and floor cleaner, but persistent odors and cleanliness issues remained. The Administrator was aware of the ongoing odor problem and noted that a plumber had previously worked on the issue, but the problem persisted intermittently.
Failure to Provide Palatable, Attractive, and Safe-Temperature Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for a significant number of residents. Multiple residents reported that the food was often cold, bland, unappetizing, and sometimes unidentifiable. Several residents described the food as processed, lacking in variety, and not meeting their nutritional needs, with some specifically noting insufficient protein and small portion sizes. Observations confirmed that salads were not kept at the required temperature, with temperatures recorded well above the safe threshold prior to serving. Additionally, test trays revealed that hot foods were bland and cold foods, such as milk and salad, were served at improper temperatures. Resident council minutes and grievance forms documented ongoing complaints about food quality, including issues with food temperature, lack of adherence to meal tickets, and dissatisfaction with the taste and nutritional content of meals. Residents also reported receiving food items they disliked or were not supposed to have, and some noted that requests for snacks or alternative items were not accommodated. These complaints were consistent over several months, indicating a pattern of unresolved issues related to food service. Interviews with dietary staff and facility administration revealed a lack of awareness regarding the extent of the food quality and temperature issues. The Dietary Manager acknowledged that salads should have been kept refrigerated until use and recognized that improper handling led to elevated temperatures. The Administrator was unaware of the temperature problems and only generally aware of resident dissatisfaction with the food. These findings demonstrate that the facility did not ensure food was consistently palatable, attractive, and served at safe temperatures, as required.
Unsanitary Food Handling and Surface Cleaning Deficiencies
Penalty
Summary
During a lunch service tray line, multiple instances of unsanitary food handling practices were observed among dietary staff. One dietary aide donned gloves and then touched various surfaces, including a thermometer, sink, and refrigerator handle, before touching the face of plates with the same gloved hand. A cook was also seen wearing gloves while touching oven doors, sink handles, and a spatula handle, then touching the face of plates prior to plating food for residents. Additionally, the cook slid plates across a white cutting board and used the same board to chop carrots without cleaning it before or after use. The chopped carrots were then plated and served to residents. Another staff member repositioned food on plates with gloved hands after touching multiple surfaces, including plates, covers, fridge door, cart, and sink handles, without performing hand hygiene or changing gloves before handling the food. Interviews with the cook and the dietary manager confirmed that staff should not touch the face of plates or food with dirty gloves and that gloves should be changed between tasks. Both acknowledged that the white cutting board, used for chopping food for mechanically soft diets, was not cleaned prior to use, despite being used to move plates along the tray line. The dietary manager admitted that this practice was inappropriate as the surface was dirty at the time food was prepared on it.
Failure to Offer and Administer Required Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly offered and administered influenza, pneumococcal, and COVID-19 vaccines as required. Specifically, two residents had signed consent forms indicating their acceptance of the 2024/2025 COVID-19 booster, but there was no documentation that the booster was administered to them. Additionally, one resident did not have any documentation showing that they were offered the influenza or COVID-19 booster vaccines for the 2024/2025 season. These findings were based on interviews and record reviews conducted by surveyors. The residents involved had various medical conditions, including epilepsy, chronic systolic heart failure, and Alzheimer's disease. The facility's process included obtaining vaccination consents during admission and pre-ordering vaccines, but the records reviewed did not show that the required vaccines were offered or administered as indicated by the residents' consents. The Regional Nurse Consultant confirmed the lack of documentation and administration for the affected residents.
Residents Denied Timely Access to Personal Funds
Penalty
Summary
The facility failed to provide two residents with ready and reasonable access to their personal funds, despite having been authorized to manage these funds. One resident reported being unable to access her money on weekends because no staff member with access to the funds was available outside of weekday business hours. She was told she would have to wait until Monday to obtain her money. Another resident had previously filed a grievance stating that there was no one available to distribute money on weekends, and the business office confirmed that funds were only accessible during the week. Interviews with facility staff, including the Business Office Manager and the Administrator, confirmed that residents could not access their funds on weekends. The Business Office Manager stated he was solely responsible for distributing funds and only worked Monday through Friday. The Administrator acknowledged gaps in the process, including times when no staff were available to distribute funds and instances when there was no cash available due to delays in obtaining money from the corporate office. These actions and inactions resulted in residents not having reasonable access to their personal funds as required.
Delay in Suture Removal Following Hospital Discharge
Penalty
Summary
A resident with a history of Alzheimer's disease, generalized anxiety disorder, lack of coordination, and major depressive disorder was admitted to the facility following a fall that resulted in a fractured nose and knee. Upon return from the hospital, the resident had sutures placed on the bridge of her nose and a brace on her left leg, with hospital discharge instructions specifying that the sutures should be removed in 7 days. Observations made more than two weeks after the incident revealed that the sutures were still present, with scabs forming over them, and the resident was seen tugging at the sutures. Interviews with facility staff indicated a lack of clarity regarding the appropriate timeframe for suture removal. One LPN believed the sutures should remain for 14-21 days, while the Director of Nursing confirmed that the sutures should have been removed on the date specified in the hospital discharge instructions. The delay in suture removal demonstrated that the resident did not receive care in accordance with professional standards of practice, the comprehensive care plan, or the resident's preferences and goals.
Failure to Maintain Complete Laboratory Records in Resident Chart
Penalty
Summary
A deficiency was identified when the facility failed to maintain complete, dated laboratory records in a resident's clinical record. Specifically, for one resident with multiple complex diagnoses, including benign neoplasm of the brain, chronic respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, and epilepsy, laboratory results for serum phenytoin and phenobarbital were not found in the electronic medical record. The pharmacy had recommended these labs due to the resident's medication regimen, and the attending physician had agreed to the orders. However, a review of the resident's chart revealed that no such lab results were present for the past six months, and there were no routine orders in place for these labs to be drawn. Interviews with facility staff revealed that diagnostic results were sent to medical records to be scanned and uploaded into the electronic medical record. The DON stated that this process typically took about a week, while the medical records staff indicated that she aimed to upload records the same day she received them and then destroyed the originals. Despite these procedures, the required laboratory reports for the resident were not located in the electronic medical record, resulting in incomplete documentation.
Missing Signed and Dated Chest X-ray Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated chest x-ray report in the clinical record of a resident who was being treated for pneumonia. The resident, who had a history of chronic respiratory failure with hypoxia, transient cerebral ischemic attack, and chronic obstructive pulmonary disease, was admitted with these diagnoses and subsequently received two different antibiotics for infectious pneumonitis and pneumonia. Documentation in the medical record included orders for Amoxicillin-Potassium Clavulanate and Doxycycline, as well as nursing notes referencing the treatment for pneumonia. Despite the clinical indications and treatment for pneumonia, a review of the resident's medical record revealed that the chest x-ray report, which would have confirmed the diagnosis, was not present in the file. Interviews with nursing staff and the regional nurse consultant confirmed that a chest x-ray would have been ordered to support the diagnosis, but the report was not located in the record at the time of review. The absence of a signed and dated radiological report in the resident's clinical record constituted the deficiency.
Failure to Accommodate Documented Food Allergies
Penalty
Summary
A deficiency occurred when a resident with documented allergies, including peas, was served fried rice containing peas. The resident reported that she is allergic to peas due to an enzyme deficiency that causes her stomach upset, and stated that she is served foods she is allergic to at least once a week. Observation confirmed the presence of peas on her lunch tray, and the meal ticket clearly listed peas as an allergy and as a strong dislike. The resident's medical record and care plan both documented her allergies, including peas, and her history of multiple medical conditions such as IBS, GERD, obesity, and eating disorders. Despite these documented allergies and clear instructions on the meal ticket, the resident continued to receive foods containing her allergens. A previous grievance report indicated that the resident had complained about being served her allergens, and staff had been educated on the issue. However, the deficiency persisted, as evidenced by the recent incident where the resident was again served peas. The Dietary Manager acknowledged that allergies are highlighted on meal tickets and that multiple staff are supposed to check trays, but was unable to explain how the error occurred.
Non-Functioning Call Light System in Shower and Bathing Areas
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area, as required. Observations revealed that in the 200 and north 300-hall shower rooms, at least one call light was not operational, and there were no cords attached to the call lights in the 100, 200, and north 300-hall shower rooms. Multiple residents and staff confirmed that the call lights either did not work or were missing cords, making it impossible for residents to call for assistance if needed. In one instance, a resident reported concern about being unable to summon help if she became stuck in the shower. Another resident stated that the call light in the 200-hall shower room had not worked since repairs were made, and staff had to remain present during his showers due to the non-functioning system. Further observations showed that in some shower rooms, the call light switches were present but lacked cords, and in at least one case, activating the call light did not result in any visible signal in the hallway. Staff interviews confirmed awareness of the issue, with maintenance staff noting that cords should be long enough to reach residents on the floor, and CNAs describing the need to check on residents frequently due to the lack of a working call system. The facility administrator acknowledged that the call light system was old and prone to frequent bulb outages, and that audits of the system had only recently begun.
Inadequate Supervision and Safety Measures Lead to Resident Elopements
Penalty
Summary
The facility failed to ensure a safe environment for residents, leading to two significant incidents involving elopement and inadequate supervision. Resident 26, who had a history of wandering and was identified as a high elopement risk, managed to leave the facility without staff knowledge. Despite having a wander guard, the resident was able to remove it and elope, resulting in severe burns after falling on hot pavement. The resident's medical history included cognitive impairments and a history of wandering, which were not adequately addressed by the facility's safety measures. In another incident, Resident 10, who was admitted with conditions such as Wernicke's encephalopathy and alcohol abuse, also eloped from the facility. The resident was found outside the facility on two occasions, despite having a wander guard. The facility's records indicated that the resident was confused and exhibited wandering behaviors, yet the safety measures in place were insufficient to prevent the elopements. The facility's doors did not have a comprehensive wander guard system, and the alarms were either not functioning or not responded to by staff. Both incidents highlight the facility's failure to maintain a secure environment and provide adequate supervision for residents at risk of elopement. The lack of effective monitoring and the inability to ensure that safety devices were properly used and maintained contributed to these deficiencies. The facility's response to these incidents, including the submission of investigations to the State Survey Agency, confirmed the occurrences but did not prevent the initial failures in resident safety.
Deficiencies in Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the residents' care plans for two residents. Resident 15, who was admitted with multiple diagnoses including congestive heart failure and difficulty walking, suffered a laceration and dislocation of the right fifth toe after an incident involving a wheelchair. Despite hospital discharge instructions to buddy tape the toes and monitor the wound, the facility did not document the completion of dressing changes or monitoring for infection. Additionally, there was a four-day delay in implementing the ordered Medihoney treatment for the wound, and the resident's toe was noted to be discolored and detached. Resident 26, who had a history of hemiplegia, epilepsy, and burns, did not have documented measurements for their burn wounds on the back and buttocks. The resident sustained second and third-degree burns after an incident involving methamphetamine use and prolonged exposure to hot pavement. Although the facility had a wound nurse and NP to assess wounds weekly, the NP was unable to obtain accurate measurements due to the nature of the burns. The lack of documented measurements hindered the ability to track wound healing and make necessary adjustments to the care plan. The Director of Nursing acknowledged the importance of wound measurements for assessing healing and adjusting care but confirmed that measurements were not consistently documented for Resident 26. This oversight in documentation and treatment implementation for both residents indicates a failure to adhere to professional standards and the residents' comprehensive care plans, resulting in deficiencies in the care provided.
Inadequate Cleaning Practices in Resident Shower Rooms
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in the resident shower rooms, as evidenced by the presence of black spots on the lower corner baseboard near the shower entrance. Observations made on the 200-hall resident shower room revealed these black spots, which were identified by the Administrator as potentially being mold or moisture spots requiring a deep clean. This deficiency was noted during an observation conducted on August 13, 2024. Interviews with facility staff revealed inconsistencies in the cleaning responsibilities and practices for the shower rooms. Housekeeping staff indicated that certified nursing assistants (CNAs) were responsible for cleaning the resident shower rooms, while housekeeping only cleaned resident rooms and common areas. A CNA stated that housekeeping cleaned the showers once a week, and CNAs were responsible for cleaning up after resident showers, including sanitizing shower chairs. The Assistant Director of Nursing confirmed that housekeeping disinfected shower floors and toilets, but the presence of black spots suggested inadequate cleaning practices.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was admitted on hospice services with multiple diagnoses, including traumatic subdural hemorrhage and chronic obstructive pulmonary disease. The incident occurred when the resident was found on the floor with a laceration above the right eye. The staff did not conduct a comprehensive investigation to determine the circumstances leading to the fall, such as the resident's condition prior to the fall, the position of the bed, or whether routine checks were being performed. The report highlights that the resident was a high fall risk due to increased weakness and disorientation, as noted in hospice documentation. Despite this, there was no evidence that the facility had adequately assessed or documented the resident's risk factors or preventive measures in place at the time of the incident. The facility's records did not include interviews with the CNA who discovered the resident or detailed information about the resident's condition before the fall. Additionally, there were inconsistencies in the documentation regarding the resident's primary diagnosis and the use of the term "terminal agitation" after the fall. The nurse involved in the incident later stated that they would not have used the term "terminal agitation" and believed that routine checks were being conducted, although they were unsure of the specifics. This lack of thorough investigation and documentation contributed to the deficiency identified by the surveyors.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident 15, who was admitted with multiple diagnoses including congestive heart failure and difficulty swallowing, suffered a laceration and dislocation of the right fifth toe after an incident involving his wheelchair. The emergency department prescribed Cephalexin to prevent infection, but the medication was neither transcribed onto the medication administration records (MARs) nor ordered from the pharmacy, resulting in the resident not receiving the prescribed antibiotics. Resident 26, who was readmitted with severe burns and other complex medical conditions, also did not receive prescribed antibiotics. An order for Keflex was issued to treat the burns, but it was not transcribed into the electronic medical record. Despite an interdisciplinary review identifying this oversight, the antibiotics were not administered in a timely manner. The Director of Nursing acknowledged the failure to implement the order and the lack of a 24-hour chart check to ensure new orders were followed.
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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 Sandy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehenge Of South Jordan | 2.8 mi | — | 0 | 0 |
| Cascades At Riverwalk | 2.9 mi | — | 20 | 0 |
| Aspen Ridge Transitional Rehab | 3.2 mi | — | 1 | 0 |
| Rocky Mountain Care - Cottage On Vine | 4.1 mi | — | 1 | 0 |
| Monument Healthcare Taylorsville | 4.3 mi | — | 1 | 0 |
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