| Spring Creek Healthcare Center | |
| 4600 South Highland Drive, Salt Lake City, Utah 84117 | |
| (801) 272-1892 | |
| Name | Spring Creek Healthcare Center |
|---|---|
| Location | 4600 South Highland Drive, Salt Lake City, Utah |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 92 |
| Occupancy Rate | 86.2% |
| Medicare ID (CCN) | 465049 |
| Legal Business Name | Beaver Valley Hospital |
| Ownership Type | For Profit - Limited Liability Company |
| Chain | Cascades Healthcare (19 nursing homes) |
| Chain Average Overall Rating | 1.9 out of 5 |
| NPI Number | 1598990699 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Beaver Valley Hospital |
| Doing Business As | Spring Creek Healthcare Center |
| Address | 4600 S. Highland Drive, Salt Lake City, UT 84117 |
| Phone Number | 801-272-1892 |
| NPI Number | 1548218050 |
| Match | Possible same name, address or phone number |
| Organization Name | Evergreen at Holladay, L.L.C. |
| Doing Business As | Evergreen Canyons Health and Rehabilitation Center |
| Address | 4600 South Highland Dr, Salt Lake City, UT 84117 |
| Phone Number | 801-272-1892 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 3.49 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.97 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.32 | 0.86 |
| Nurse aide hours per resident per day | 2.2 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.13 | 3.42 |
| RN hours per resident per day on the weekend | 0.81 | 0.48 |
| Physical therapist hours per resident per day | 0.01 | 0.07 |
| Total nursing staff turnover | 76.8% | 45.8% |
| Registered nurse turnover | 80% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 1 |
| Total Amount of Fines in Dollars | $53,472 |
| Number of Payment Denials | 1 |
| Total Number of Penalties | 2 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Feb 3, 2025 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, pattern | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | 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. F0622, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Ensure services provided by the nursing facility meet professional standards of quality. F0658, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. F0693, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. F0694, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. F0756, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Feb 3, 2025 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Mar 27, 2025 |
| Jan 11, 2024 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection, Complaint inspection | Actual harm, isolated | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, widespread | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Standard inspection | Potential for harm, pattern | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. F0801, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Standard inspection | Potential for harm, pattern | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Implement a program that monitors antibiotic use. F0881, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Keep signed and dated reports of x-rays and other diagnostic services in the residents record. F0779, Administration, Standard inspection | Potential for harm, isolated | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. F0805, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. F0806, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Feb 12, 2024 |
| Jan 11, 2024 | Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. F0811, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Feb 12, 2024 |
| Apr 13, 2022 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Immediate jeopardy, pattern | Corrected by Jun 23, 2022 |
| Apr 13, 2022 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Immediate jeopardy, pattern | Corrected by Jun 23, 2022 |
| Apr 13, 2022 | Respond appropriately to all alleged violations. F0610, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Immediate jeopardy, pattern | Corrected by Jun 23, 2022 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 1.55 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.27 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 1.02 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 84.13 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.66 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.34 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.56 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.74 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.33 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.17 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.91 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 1.82 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.11 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 24.11 | 15.38 |
Holladay Healthcare Center Location: 4782 South Holladay Boulevard, Salt Lake City, Utah 84117 Phone: (801) 277-7002 |
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Meadow Brook Rehabilitation and Nursing Location: 433 East 2700 South, Salt Lake City, Utah 84115 Phone: (801) 487-2248 |
Millcreek Rehabilitation and Nursing Location: 3520 South Highland Drive, Salt Lake City, Utah 84106 Phone: (801) 484-7638 |