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Health Inspection Summary
Highland Care Center
4285 South Highland Drive
Holladay, UT 84124
(801) 278-2839
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Deficiency Category
Inspection Date:
6/11/24
Complaint Reporting Period:
4/1/24 - 3/31/25
Inspection Date:
3/16/22
Complaint Reporting Period:
4/1/23 - 3/31/24
Inspection Date:
11/7/19
Complaint Reporting Period:
4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies000
Quality of Life and Care Deficiencies022
Infection Control Deficiencies020
Resident Assessment and Care Planning Deficiencies112
Nursing and Physician Services Deficiencies000
Resident Rights Deficiencies010
Nutrition and Dietary Deficiencies121
Pharmacy Service Deficiencies215
Environmental Deficiencies000
Administration Deficiencies110

Detailed result for inspection on 6/11/24
Date of last standard health inspection:6/11/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25
No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:5
Average number of Health Deficiencies in Utah:9
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

6/11/247/31/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

6/11/247/31/24
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident’s drug regimen must be free from unnecessary drugs.

6/11/247/31/24
2 - Minimal harm or potential for actual harm
Few

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.

6/11/247/31/24
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

6/11/247/31/24
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 3/16/22
Date of last standard health inspection:3/16/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:10
Average number of Health Deficiencies in Utah:9.7
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide care and assistance to perform activities of daily living for any resident who is unable.

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

1/2/241/25/24
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement policies and procedures for flu and pneumonia vaccinations.

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Many
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Few

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

1/2/241/25/24
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident’s drug regimen must be free from unnecessary drugs.

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

3/16/224/29/22
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 11/7/19
Date of last standard health inspection:11/7/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23
No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:10
Average number of Health Deficiencies in Utah:9.1
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Some

Provide activities to meet all resident's needs.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives an accurate assessment.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Some
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Some

Ensure medication error rates are not 5 percent or greater.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Few

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.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Few

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.

11/7/1912/20/19
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide enough food/fluids to maintain a resident's health.

1/2/241/25/24
2 - Minimal harm or potential for actual harm
Some

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

1/2/241/25/24
2 - Minimal harm or potential for actual harm
Many
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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