MISSION AT HILLSIDE REHABILITATION CENTER

Nursing Home Inspector

1216 EAST 1300 SOUTH
SALT LAKE CITY, UT 84105
Salt Lake County
Phone: 801-487-5865
Provider Number: 465128
Last Inspection: 05/10/2017

About the Nursing Home

Number of Beds: 121
Number of Residents: 57
Beds Available: 64
Percent Occupancy: 47%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

38

Facility
38

County
29

UT
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

38

2017
56

2016
11

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/10/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 6/30/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/30/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Pattern : Minimal 4 6/30/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 6/30/2017
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 6/30/2017
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 6/30/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 6/30/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 6/30/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/30/2017
 
Failed To: Provide or obtain laboratory services only when ordered by the attending physician. Isolated : Minimal 3 6/30/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 6/30/2017
 

2/18/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 3/28/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 3/28/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 3/28/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 3/28/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 3/28/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/28/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 3/28/2016
 
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Isolated : Minimal 3 3/28/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 3/28/2016
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 3/28/2016
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 3/28/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 3/28/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 3/28/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 3/28/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 3/28/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 3/28/2016
 

12/3/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 1/15/2015
 
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 1/15/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 1/15/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

12/21/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 10/25/2016
 

3/10/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 4/24/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg UT State Avg
Number of Residents 57 59.19 54.00
Registered Nurses 1.07 1.41 1.35
Licensed Practical / Vocational Nurses 0.27 0.51 0.58
Certified Nursing Assistants 2.14 2.57 2.62
Total Staff Hours 3.48 4.49 4.55

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% UT State Avg%
of high risk long-stay residents with pressure ulcers 3 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 95 96
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 91 93 94
of long-stay residents experiencing one or more falls with major injury 1 2 3
of long-stay residents who have depressive symptoms 1 8 7
of long-stay residents who lose too much weight 6 4 5
of long-stay residents who received an antianxiety or hypnotic medication 13 27 28
of long-stay residents who received an antipsychotic medication 14 16 16
of long-stay residents who self-report moderate to severe pain 12 10 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 24 18 17
of long-stay residents whose need for help with daily activities has increased 20 14 13
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 12 4 4
of low risk long-stay residents who lose control of their bowels or bladder 58 52 48
of short-stay residents assessed and appropriately given the pneumococcal vaccine 86 87 90
of short-stay residents who had an outpatient emergency department visit 12 10 11
of short-stay residents who made improvements in function 63 55 62
of short-stay residents who newly received an antipsychotic medication 3 1 1
of short-stay residents who self-report moderate to severe pain 21 17 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88 87 87
of short-stay residents who were rehospitalized after a nursing home admission 28 16 15
of short-stay residents who were successfully discharged to the community 55 60 64
of short-stay residents with pressure ulcers that are new or worsened 0 0 0