Pine Creek Rehabilitation and Nursing
876 West 700 South, Salt Lake City, UT 84104 · Salt Lake County · 34 certified beds · avg 29 residents/day · certified since Dec 1, 1991
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Oct 3, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 26, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 3, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 1, 2023 (Past Non-Compliance)
▲ Actual harm, one-off · Oct 3, 2024 · F-0740
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 26, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (41)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Oct 9, 2025 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Oct 9, 2025 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Oct 9, 2025 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Oct 9, 2025 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Oct 9, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 9, 2025 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
| Oct 3, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 3, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 3, 2024 | ▲ G · Actual harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not keep complete, dated laboratory records in residents' files. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not keep signed and dated reports of x-rays and other diagnostic tests in residents' records. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not make sure that paid feeding assistants — staff hired to help residents eat and drink — had the training they need. |
| Mar 2, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 2, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Mar 2, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Mar 2, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 2, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 2, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 2, 2023 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (28 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | E |
| 2024 | 28 | 3 | J ▲ |
| 2025 | 6 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $56,121, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Oct 3, 2024 | Fine | $56,121 |
| Oct 3, 2024 | Payment Denial | 5 days from Nov 21, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.45 | 3.87 | 3.95 | bottom 38% in Utah; bottom 34% in the U.S. |
| Registered Nurse hours | 0.92 | 1.17 | 0.69 | bottom 40% in Utah; top 20% in the U.S. |
| Weekend total nurse staffing | 3.14 | 3.39 | 3.50 | top 48% in Utah; bottom 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.64 | 0.88 | 0.48 | bottom 39% in Utah; top 20% in the U.S. |
| Total nursing staff turnover (%) | 80.0 | 50.7 | 45.8 | bottom 1% in Utah; bottom 2% in the U.S. |
| RN turnover (%) | 80.0 | 40.6 | 42.9 | bottom 2% in Utah; bottom 6% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.81, RN 0.75, weekend 2.55. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What mental health services do you provide on-site, and who delivers them?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Midtown Manor | 1.0 mi | Salt Lake City, UT | ★☆☆☆☆ | 2/5 | |
| Maple Ridge Rehabilitation and Nursing | 2.1 mi | Salt Lake City, UT | ★☆☆☆☆ | 2/5 | abuse |
| St Joseph Villa | 2.4 mi | Salt Lake City, UT | ★★★☆☆ | 3/5 | |
| City Creek Post Acute | 2.7 mi | Salt Lake City, UT | ★★★☆☆ | 3/5 | |
| Monument Healthcare South Salt Lake | 3.0 mi | Salt Lake City, UT | ★☆☆☆☆ | 1/5 | SFF |
| Alpine Meadow Rehabilitation and Nursing | 3.1 mi | West Valley City, UT | ★★★☆☆ | 2/5 | |
| Meadow Brook Rehabilitation and Nursing | 3.3 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Little Cottonwood Rehabilitation and Nursing | 3.6 mi | South Salt Lake, UT | ★★★★★ | 5/5 | |
| William E Christofferson Salt Lake Veterans Home | 4.2 mi | Salt Lake City, UT | ★★★★★ | 4/5 | |
| Millcreek Rehabilitation and Nursing | 4.3 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 46A064.