PINE CREEK REHABILITATION AND NURSING

Nursing Home Inspector

876 WEST 700 SOUTH
SALT LAKE CITY, UT 84104
Salt Lake County
Phone: 801-355-9649
Provider Number: 46A064
Last Inspection: 02/23/2017

About the Nursing Home

Number of Beds: 34
Number of Residents: 34
Beds Available: 0
Percent Occupancy: 100%
Insurance Accepted: 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

 

102

Facility
38

County
29

UT
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

102

2017
12

2015
3

2014

Medicare Ratings

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

 

Details by Inspection Date

2/23/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
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 4/7/2017
 
Failed To: Permit residents to remain in the facility and not be transferred or discharged without adequate reason. Isolated : Immediate 5 4/7/2017
 
Failed To: Help and prepare each resident for a safe and easy discharge or transfer from the nursing home. Isolated : Immediate 5 4/7/2017
 
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Pattern : Immediate 6 4/7/2017
 
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. Pattern : Immediate 6 4/7/2017
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Immediate 6 4/7/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 4/7/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 4/7/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 4/7/2017
 
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. Pattern : Minimal 4 6/15/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 4/7/2017
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 6/15/2017
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated : Minimal 3 4/7/2017
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 4/7/2017
 
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 4/7/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 4/7/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/7/2017
 
Failed To: Provide bedrooms that don't allow residents to see each other when privacy is needed. Pattern : Minimal 4 4/7/2017
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Actual 5 4/7/2017
 
Failed To: Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. Pattern : Minimal 4 4/7/2017
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Pattern : Minimal 4 4/7/2017
 
Failed To: Keep complete, dated laboratory records in the resident's file. Isolated : Minimal 3 4/7/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 4/7/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Actual 5 4/7/2017
 

12/1/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
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 12/31/2015
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 12/31/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 12/31/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 12/31/2015
 

9/30/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 10/27/2014
 

Complaint Investigation Deficiencies

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

3/31/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 5/30/2015
 
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. Pattern : Minimal 4 5/30/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg UT State Avg
Number of Residents 34 59.19 54.00
Registered Nurses 0.33 1.41 1.35
Licensed Practical / Vocational Nurses 0.17 0.51 0.58
Certified Nursing Assistants 2.29 2.57 2.62
Total Staff Hours 2.79 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 0 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 92 95 96
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 92 93 94
of long-stay residents experiencing one or more falls with major injury 13 2 3
of long-stay residents who have depressive symptoms 8 8 7
of long-stay residents who lose too much weight 0 4 5
of long-stay residents who received an antianxiety or hypnotic medication 44 27 28
of long-stay residents who received an antipsychotic medication 38 16 16
of long-stay residents who self-report moderate to severe pain 22 10 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 25 18 17
of long-stay residents whose need for help with daily activities has increased 23 14 13
of long-stay residents with a catheter inserted and left in their bladder 0 1 2
of long-stay residents with a urinary tract infection 0 4 4
of low risk long-stay residents who lose control of their bowels or bladder 48 52 48