Pine Creek Rehabilitation And Nursing

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

an interview was conducted with the ADM. The ADM stated that he was not the ADM when the incident with resident 38 had occurred. The ADM stated he called the prior ADM and was told that he had not been completely in the loop regarding that incident. The ADM stated that the prior ADM spoke with corporate staff and was told to pay resident 38 back the money that was taken. The ADM stated that was all the prior ADM could say. The ADM stated that yes he would have called local law enforcement and reported the allegation. The ADM stated that he would investigate the allegation by speaking with the individual and the resident. The ADM stated that he would have assessed how the resident was doing. The ADM stated that

he would have completed the typical investigation stuff and he would have asked for the money back from

the individual that took it. The ADM stated that he had a curriculum of training that he presented at the all staff monthly meetings. The ADM stated that abuse was presented twice a year. The ADM stated if there was a unique case he would bring abuse up again. The ADM stated there was no training that he could find regarding the incident with resident 38.

Event ID:

Facility ID:

46A064

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

46A064

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Creek Rehabilitation and Nursing

876 West 700 South Salt Lake City, UT 84104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility did not ensure all alleged violations involving abuse, including misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, to Adult Protective Services (APS) and local law enforcement. Specifically, for 1 out of 23 sampled residents, an allegation of misappropriation of resident property was not reported to law enforcement and the report to APS was reported 17 days after the allegation. Resident identifier: 38.

Findings included: Resident 38 was admitted to the facility on [DATE REDACTED] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease, generalized anxiety disorder, and adjustment disorder with mixed disturbance of emotions and conduct. Resident 38's medical record was reviewed. The facility Incident Report Form was reviewed. On 3/4/25 at 1:37 PM, resident 38 reported that she had learned that the (Nursing Assistant) NA was having some struggles financially and resident 38 offered to give the NA $100.00 to help. After multiple attempts resident 38 finally forced the funds in the NA's pocket and the NA accepted the funds. After a few days resident 38 texted the NA asking for the $100.00 back so resident 38 could pay for some personal storage expenses. The NA did not respond to resident 38 and resident 38 reported the issue to two different staff members to ask for help. The alleged perpetrator statement dated 3/4/25 at 1:00 PM, documented that the NA was talking to resident 38 about her financial situation and talking about life. After resident 38 found out that she was struggling a little bit, resident 38 offered her $100.00 to help get her by. The NA reported that she did not accept the money at first but after

she kept pressing and put the money in her pocket she kept the money. The NA reported that she did not know it was not allowed. The employee was terminated and the facility verified the allegation. The APS report included with the facility investigation was submitted on 3/21/25 at 1:51 PM. The facility Alleged Resident Abuse/Neglect Investigation Checklist documented Notification of Police was not applicable. On 10/8/25 at 11:22 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she did not currently work at the facility but she was the RA when she did. The RA stated that she was informed that resident 38 let a NA borrow $100.00, and the NA had not paid it back. The RA stated that resident 38 had no changes in behavior. The RA stated that she notified the Administrator (ADM) and Director of Nursing once she became aware of the incident. The RA stated that she did not help with investigating incidents. The RA stated that abuse training was provided to staff twice a year and the training included signs and symptoms of abuse, who to report allegations to, and the time frame of reporting. On 10/8/25 at 1:22 PM, an interview was conducted with the ADM. The ADM stated that he was not the ADM when the incident with resident 38 had occurred. The ADM stated he called the prior ADM and was told that he had not been completely in the loop regarding that incident. The ADM stated that the prior ADM spoke with corporate staff and was told to pay resident 38 back the money that was taken. The ADM stated that was all

the prior ADM could say. The ADM stated that yes he would have called local law enforcement and reported

the allegation. The ADM stated that he would investigate the allegation by speaking with the individual and

the resident. The ADM stated that he would have assessed how the resident was doing. The ADM stated that he would have completed the typical investigation stuff and he would have asked for the money back from the individual that took it. The ADM stated that he had a curriculum of training that he presented at the all staff monthly meetings. The ADM stated that abuse was presented twice a year. The ADM stated if there was a unique case he would bring abuse up again. The ADM stated there was no training that he could find regarding the incident with resident 38.

Event ID:

Facility ID:

46A064

If continuation sheet