Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at City Creek Post Acute during CMS and state inspections, most recent first.
A resident with cognitive and mobility impairments, identified as a fall risk and requiring two-person assistance for transfers, was left unsupervised and without access to a call light after returning to his room. The resident attempted to transfer from his wheelchair to bed without help, resulting in a fall that caused an abrasion and foot pain. Staff and policy reviews confirmed that required safety interventions, including a reachable call light and adequate supervision, were not provided.
A resident with intact cognition was physically abused by another resident, who also had intact cognition, in an LTC facility. The incident involved one resident slapping another due to perceived loud behavior. Witnesses confirmed the event, and the facility's policy on abuse prevention was not upheld, leading to a deficiency in resident protection.
The facility was found deficient in food safety and hygiene practices. Water pitchers were stored uncovered, exposing them to contamination. Food items lacked proper labeling with received, opened, and use-by dates. Additionally, a dietary aide's hair was not fully covered by a hair net during food preparation, violating the facility's hygiene policy.
A long-term care facility failed to maintain infection prevention and control procedures for nine residents. Unlabeled basins, unsanitizable wheelchair armrests, and improper use of PPEs were observed. Staff acknowledged these issues, and the facility lacked documentation for labeling and infection control protocols.
A resident with difficulty swallowing was left unsupervised during breakfast, despite needing close monitoring to prevent choking or aspiration. Staff confirmed the need for supervision, and facility policy required interventions to reduce accident risks, which were not followed.
A resident's urinary catheter was removed, but LNs continued to document catheter care in the TAR, leading to inaccurate records. The resident confirmed the catheter removal, and the DON acknowledged the documentation error, which contradicted the facility's policy on accurate record-keeping.
Two residents experienced issues with food preferences and allergies not being accommodated. One resident, with diabetes and other conditions, was served disliked foods, leading to weight loss. Another resident, with allergies to seafood, was repeatedly served fish despite clear documentation of their allergies. Staff interviews revealed that meal tickets were meant to ensure dietary accuracy, but these protocols were not followed.
A resident with congestive heart failure, atrial fibrillation, and hypertension was unable to call for assistance due to a malfunctioning call light, resulting in unmet care needs. The resident was found in a soiled incontinence brief, and a CNA confirmed the call light was not working. The DON stated that all residents should have a working call light or an alternative means to call for help.
A resident with epilepsy and hemiplegia did not receive necessary care to maintain mobility due to unresolved issues with his wheelchair straps, which were not addressed by staff. Despite a physician's order for daily wheelchair use, the resident remained in bed for 12 days. Staff failed to communicate the problem effectively, and the facility's policies on assistive devices were not followed.
Failure to Provide Adequate Supervision and Accessible Call Light Leads to Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including encephalopathy, dementia, gait and mobility abnormalities, and cognitive communication deficit, was left unsupervised and without access to a call light after returning to his room from the nurses' station. The resident required substantial to maximal assistance for transfers and was identified as a fall risk, with care plans specifying the need for a two-person assist and a reachable call light at all times. Despite these documented needs, the resident was able to wheel himself back to his room unaccompanied, and the call light was not within his reach. As a result of these lapses, the resident attempted to transfer himself from his wheelchair to his bed without assistance, leading to a fall. The fall was unwitnessed, and the resident sustained an abrasion to the top of his left hand and reported bilateral foot pain. Observations and interviews confirmed that the call light was out of reach at the time of the incident, and staff acknowledged that the call light should have been accessible and that the resident required close monitoring and assistance for transfers. Facility policies reviewed indicated that residents confined to a chair or bed should have the call light within easy reach, and that interventions should be tailored to individual fall risks. Multiple staff interviews corroborated that the resident was a known fall risk and typically required close supervision, yet these interventions were not consistently implemented, directly contributing to the resident's fall and resulting injuries.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 1, who was admitted with a diagnosis of Diabetes Mellitus and had intact cognition, was slapped by Resident 2. Resident 2, who had diagnoses including congestive heart failure, alcohol dependence, and chronic pain syndrome, also had intact cognition. The incident occurred when Resident 2 slapped Resident 1 due to the latter's consistently loud behavior, as noted in Resident 2's progress notes. A witness confirmed seeing Resident 2 get up and slap Resident 1 across the face. Interviews conducted with staff and residents further corroborated the incident. A janitor witnessed the event and intervened, while Resident 1 described the slap as feeling like being hit with a baseball mitt. Resident 2 admitted to the action, describing it as a reaction to perceived aggression from Resident 1. The facility's policy on abuse prevention clearly states that residents have the right to be free from abuse by anyone, including other residents. However, the facility's failure to prevent this incident resulted in a deficiency in protecting residents from abuse.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Water pitchers and accompanying cups were stored upright and uncovered, exposing them to potential contamination from dust and splatter. This was confirmed by multiple staff members, including a dietary aide and the dietary manager, who acknowledged that the pitchers should be stored with lids facing down to prevent contamination. Additionally, the facility did not provide a policy and procedure document for storing water pitchers when requested. Further deficiencies were noted in the labeling and dating of food items. Observations revealed that certain food items, such as a bag of French fries and a bag of meatballs, were not labeled with received, opened, or use-by dates. This was corroborated by staff, including the dietary manager, who confirmed that all food should be labeled with these dates. The facility's policy on labeling and dating foods, which requires all food items to be labeled and dated, was not followed. Additionally, during a meal observation, a dietary aide was seen with a hair net that did not fully cover her hair, which was confirmed by the dietary manager and the registered dietician. The facility's policy on employee hygiene mandates that hair nets or caps must cover all hair to prevent contamination, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control procedures for nine residents. Unlabeled basins were found in the bathrooms of two residents, which were confirmed by a CNA who acknowledged that they should have been labeled. The Director of Nurses (DON) stated that all patient equipment should be labeled with the name, room number, or both, but the facility could not provide a policy and procedure for labeling resident equipment. Three residents had wheelchairs with armrests in disrepair, making them unable to be sanitized. The Rehab Director confirmed the disrepair and stated that maintenance would replace them. The Maintenance Assistant explained that wheelchairs are cleaned monthly, but the damaged armrests had not been repaired. The Infection Preventionist noted that sanitizing the armrests would be difficult if the upholstery was damaged. The facility's logbook documentation indicated that wheelchairs should be inspected for damage, but repairs for the affected residents were not documented. Two Licensed Nurses entered an enhanced standard precautions room without PPEs to provide care to a resident, and another LN entered a transmission-based precautions room without PPEs to pick up equipment. Both instances were acknowledged by the staff involved, who admitted they should have worn gowns and gloves. Additionally, a resident's nebulizer was found on the floor instead of being stored in an anti-microbial bag, and another resident's anti-microbial bag was undated and unlabeled. The DON confirmed the expectation to follow infection control protocols, but the facility was unable to provide a policy and procedure upon request.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, identified as Resident 40, who was at risk of choking or aspirating fluids due to difficulty swallowing. Resident 40 was admitted to the facility with a diagnosis that included difficulty swallowing, and specific orders were in place to ensure safe eating practices. These orders included close supervision during meals, sitting upright, taking small sips and bites, and ensuring oral cavity clearance. Despite these precautions, Resident 40 was left unsupervised during breakfast, consuming over 90 percent of his meal without any staff monitoring. Interviews with staff, including a Certified Nursing Assistant (CNA 8), a Licensed Vocational Nurse (LN 6), and a Speech Language Pathologist (SLP), confirmed that Resident 40 required close monitoring during meals to prevent choking or aspiration. The SLP had previously assessed that Resident 40 could tolerate a mechanical soft diet with supervision, emphasizing the risk of aspiration due to impulsive eating behavior. The facility's policy on safety and supervision of residents, dated April 2021, outlined the need for implementing and monitoring interventions to reduce accident risks, which were not adhered to in this instance.
Inaccurate Documentation of Urinary Catheter Care
Penalty
Summary
The facility failed to ensure accurate medical records for a resident when a urinary catheter was discontinued, yet licensed nurses continued to document monitoring and care for the catheter. This discrepancy was identified for one of 30 sampled residents, referred to as Resident 48, who was admitted with conditions including diabetes mellitus, a right femur fracture, and urinary bladder dysfunction. Despite the catheter being removed on 10/9/24, documentation in the Treatment Administration Record (TAR) indicated ongoing catheter care from 10/10/24 to 10/15/24. Observations and interviews revealed that the resident confirmed the catheter removal, and the Director of Nursing acknowledged the inaccurate documentation. The facility's policy on charting and documentation mandates that all services and changes in a resident's condition be accurately recorded, which was not adhered to in this case. This failure resulted in inaccurate documentation and increased the potential for miscommunication among healthcare providers.
Failure to Accommodate Food Preferences and Allergies
Penalty
Summary
The facility failed to accommodate the food preferences and allergies of two residents, leading to potential risks for both individuals. Resident 48, who was admitted with conditions including diabetes mellitus, a right femur fracture, and urinary bladder dysfunction, expressed dissatisfaction with the meals provided. Despite having documented food dislikes such as cream of wheat and pork sausage, Resident 48 was served these items, resulting in a weight loss of about 12 pounds since admission. The resident also reported that their preference for hot oatmeal was not consistently honored, and there was a lack of communication from the dietitian regarding their food preferences. Resident 80, admitted with diagnoses including hypoxemia, post-traumatic stress disorder, morbid obesity, and acid reflux disease, experienced issues with the management of their food allergies. The resident's care plan noted significant allergies to seafood, among other items, yet they were repeatedly served fish, which they were allergic to and disliked. This oversight occurred despite the presence of meal tickets that were supposed to indicate allergies and preferences. The resident expressed frustration over the repeated serving of seafood, which they had clearly communicated as an allergy and a dislike. Interviews with facility staff, including a Certified Nursing Assistant and the Dietary Manager, revealed that meal tickets were intended to ensure dietary orders were accurate and preferences were respected. However, the failure to adhere to these protocols resulted in the residents receiving meals that did not align with their documented preferences and allergies. The facility's policy stated that food preferences should be adhered to within reason, but this was not effectively implemented for the two residents in question.
Failure to Ensure Working Call Light for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, leading to unmet care needs. Resident 62, who was admitted with diagnoses including congestive heart failure, atrial fibrillation, and hypertension, was observed in her bed attempting to use her call light, which was not functioning. She expressed distress over her soiled incontinence brief and the lack of response from staff. A Certified Nursing Assistant confirmed the malfunctioning call light, acknowledging that it should be operational as the resident required assistance. The Director of Nursing later stated that all residents should have a working call light or an alternative means to call for help. The facility's policy on answering call lights emphasized the importance of ensuring that call lights are plugged in and functioning at all times.
Failure to Address Wheelchair Concerns and Physician's Orders
Penalty
Summary
The facility failed to provide necessary treatment, services, and equipment to maintain or improve the mobility of a resident diagnosed with epilepsy, hemiplegia, and major depressive disorder. The resident, who was dependent on staff for transfers and mobility, had a physician's order to be up in a wheelchair daily. However, the resident's concerns about his personal wheelchair not working due to faulty straps were not addressed. The resident expressed that he did not feel safe using the wheelchair without the straps, leading to him not being up in his wheelchair for 12 days. The staff, including a CNA and a licensed nurse, were aware of the wheelchair issue but did not take appropriate action to resolve it. The maintenance assistant checked the wheelchair but could not fix the straps and failed to notify management or log the issue. The rehabilitation director was not informed of the problem and thus did not evaluate the resident's concern. The director of nursing and the administrator were also unaware of the issue, indicating a breakdown in communication and procedure adherence. The facility's policies on activities of daily living and assistive devices were not followed, contributing to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgewood Post Acute | 1.7 mi | ★★★★★ | 2 | 0 |
| Bruceville Terrace - D/p Snf Of Methodist Hospital | 2.2 mi | ★★★★★ | 18 | 0 |
| Double Tree Post Acute Care Center | 2.7 mi | ★★★★★ | 22 | 0 |
| Capital Post Acute | 2.8 mi | ★★★★★ | 28 | 0 |
| University Post-acute Rehab | 4.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.