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Health Inspection Summary

Pine Creek Rehabilitation and Nursing

876 West 700 South

Salt Lake City, UT 84104

(801) 355-9649

Deficiency Category	Inspection Date: 10/3/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 3/2/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 8/18/21 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	4	0	0
Quality of Life and Care Deficiencies	3	1	0
Infection Control Deficiencies	3	2	2
Resident Assessment and Care Planning Deficiencies	2	1	1
Nursing and Physician Services Deficiencies	1	0	0
Resident Rights Deficiencies	4	2	1
Nutrition and Dietary Deficiencies	1	0	0
Pharmacy Service Deficiencies	5	1	0
Environmental Deficiencies	0	0	1
Administration Deficiencies	5	0	0

Detailed result for inspection on 10/3/24

Date of last standard health inspection:	10/3/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	10/3/24Read the full report (PDF)
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:	28
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
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some
Respond appropriately to all alleged violations.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	10/3/24	11/26/24	3 - Actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	10/3/24	11/26/24	4 - Immediate jeopardy to resident health or safety	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	10/3/24	10/3/24	4 - Immediate jeopardy to resident health or safety	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Implement a program that monitors antibiotic use.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that paid feeding assistants have the training they need.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Ensure each resident’s drug regimen must be free from unnecessary drugs.	10/3/24	11/26/24	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.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Ensure medication error rates are not 5 percent or greater.	10/3/24	11/26/24	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.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep complete, dated laboratory records in the resident's record.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Provide timely, quality laboratory services/tests to meet the needs of residents.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few

Detailed result for inspection on 3/2/23

Date of last standard health inspection:	3/2/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	No complaint inspections
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:	7
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 Date	Date 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.	3/2/23	4/6/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement policies and procedures for flu and pneumonia vaccinations.	3/2/23	4/6/23	2 - Minimal harm or potential for actual harm	Few
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	3/2/23	4/6/23	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	3/2/23	4/6/23	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 Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	3/2/23	4/6/23	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	3/2/23	4/6/23	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date 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.	3/2/23	4/6/23	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.

Detailed result for inspection on 8/18/21

Date of last standard health inspection:	8/18/21Read 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	5/26/22Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	5
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
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	8/18/21	10/6/21	2 - Minimal harm or potential for actual harm	Some
Develop and implement policies and procedures for flu and pneumonia vaccinations.	8/18/21	10/6/21	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date 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.	8/18/21	10/6/21	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 Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.	8/18/21	10/6/21	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.	8/18/21	10/6/21	2 - Minimal harm or potential for actual harm	Many

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 Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Some
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	10/3/24	11/26/24	4 - Immediate jeopardy to resident health or safety	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	10/3/24	10/3/24	4 - Immediate jeopardy to resident health or safety	Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	10/3/24	11/26/24	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.

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