Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
Food was not stored, prepared, distributed, and served in accordance with professional standards. A Bluetooth speaker was observed on a shelf used for meal prep items, and an LPN with a beard was observed preparing enchiladas for residents' lunch without a beard net.
Infection prevention and control was deficient when staff did not consistently use PPE for residents on EBP and did not perform hand hygiene during wound care. A resident with a stage 3 pressure wound had wound care performed without gowns by the NP and UM despite EBP signage and PPE being present. Another resident on EBP for a surgical wound received direct care from an OT wearing gloves but no gown, and a third resident’s wound care included multiple glove changes without hand hygiene between dirty and clean steps.
A resident was transferred to the hospital after becoming unarousable, but the medical record did not document what information was sent to the receiving provider. RN staff stated that transfer packets typically include a face sheet, bed hold copy, and med list, and the DON said transfer documentation should also include the provider order, hospital transfer agreement, POLST, and transfer sheet; however, none of that transfer documentation was found in the resident’s record.
Bed Rail Used Without Entrapment Assessment: A resident with multiple diagnoses, including CVA-related hemiplegia, seizures, and weakness, had bilateral upper side rails in place and reported that her hand was caught in the side bar after she fell off the bed. The resident’s record did not contain a documented entrapment assessment for the bed rail, and staff interviews indicated that the mobility assessment did not address positioning bars or entrapment, while therapy’s evaluation was not entered into the chart.
Food Preferences Not Followed on Meal Ticket: A resident with severe malnutrition, cachexia, and GI issues did not receive the meal preferences documented on the meal ticket. The resident stated the kitchen did not follow meal instructions and that he could not digest leafy greens, while the observed breakfast tray lacked requested items such as cheese omelets and yogurt and included food that was not served as preferred. The DM confirmed the resident’s double portions, extra gravy/sauces, and specific breakfast preferences, and also stated that cooked vegetables should have been substituted for lettuce, but a side salad was served instead.
Burn Injury from Hot Soup Due to Inadequate Supervision and Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who sustained a burn injury from hot food. One resident with end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and an above-knee amputation of the left leg requested that staff heat a prepackaged ramen soup. Facility staff heated the soup in a microwave located in the nutrition station behind the nurse’s station according to the package directions and then returned the hot soup to the resident. After receiving the heated soup, the resident, who used a motorized wheelchair and was described as very independent, turned in his power wheelchair, causing the ramen to spill and the hot liquid to burn the palmar side of his left wrist. A progress note documented that the resident received a burn to his left wrist after spilling the hot soup, that the wound was assessed, wound care was provided, and new orders were placed following consultation with a wound provider. The resident reportedly tolerated treatment well and denied pain or other concerns at that time. Subsequent documentation by a wound provider classified the burn on the resident’s left wrist as a third-degree burn. Staff interviews revealed that, prior to this incident, staff heated residents’ food according to package directions and determined whether it was safe to return based on touch, without using thermometers to verify temperature. A CNA reported that the resident often asked CNAs to heat food and insisted on carrying it himself, and that staff declined to heat his food when he refused to allow them to carry it due to safety concerns. An LPN and the DON both confirmed that thermometers were not available for use before the burn occurred and that staff relied on touch to judge food temperature.
Food Service Safety Lapses in Kitchen
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen observation, a Bluetooth speaker was found sitting on a shelf used to store hotel pans used for meal preparation. During a follow-up kitchen observation, a male staff member with a beard was observed preparing enchiladas for residents' lunch without wearing a beard net. In interview, the Dietary Manager stated that she would purchase beard nets for the male staff member and move the Bluetooth speaker to an area of the kitchen not used for food preparation.
Infection Prevention and Control Program Deficiency
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors found that for 3 of 43 sampled residents, staff did not consistently wear PPE for residents on Enhanced Barrier Precautions (EBP), and hand hygiene was not performed during wound care. Resident 14 had diagnoses including encephalopathy and was documented with a stage 3 pressure wound on the left buttock. EBP signage and a PPE cart were observed outside the room, and a wound care observation showed the NP and UM performing wound care without donning gowns. The NP used alcohol-based hand rub before putting on gloves, but neither the NP nor the UM wore gowns during the wound care. During interview, the NP stated she would wear a gown if the resident was on precautions but was not sure what precautions were required for residents on EBP. Resident 74 had an order for EBP for a surgical wound, with PPE required for high resident contact care activities. During observation, OT 1 assisted the resident with dressing adjustment, repositioning, and transfer from bed to wheelchair while wearing gloves but no gown; a PPE cart was not located outside the room. Resident 73 had EBP for a Foley catheter and wound care orders for the right foot. During wound care observation, RN 1 wore a gown and gloves but did not perform hand hygiene when changing gloves between dirty and clean steps on multiple occasions. RN 1 stated hand hygiene should be performed when moving from dirty to clean areas and said she forgot to do so because she was nervous. The UM stated that during wound care, staff should doff gloves, perform hand hygiene, and don clean gloves when moving from dirty to clean areas.
Missing Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility did not ensure that when a resident was transferred to the hospital, the resident’s medical record documented what information was sent to the receiving provider, including the required transfer documentation. For one sampled resident, the record did not contain a hospital transfer sheet or any documentation showing what information accompanied the resident during the transfer. Resident 9 was admitted with diagnoses including calculus of bile duct, UTI, pneumonia, type 2 DM, SIRS, HTN, chronic pancreatitis, emphysema, dysphagia, obstructive reflux uropathy, history of malignant neoplasm of prostate, anemia, BPH, and generalized anxiety disorder. A nursing progress note documented that the resident was not arousable with verbal stimuli or sternal rub, had vital signs recorded, and was sent to the hospital with the son notified. RN 1 stated that when residents are transferred, staff send a face sheet, bed hold copy, and medication list, and that it should be documented in a progress note what was sent. The DON stated that transfer documentation should include an order from the provider, a hospital transfer agreement, bed hold information, a face sheet, medication list, POLST, and a transfer sheet with the reason for transfer, but the resident’s record did not show what information was sent on the transfer.
Bed Rail Used Without Entrapment Assessment
Penalty
Summary
A bed rail was used for Resident 65 without a documented assessment of the resident’s risk for entrapment prior to installation. Resident 65 was admitted with diagnoses including secondary malignant neoplasm of the brain, malignant neoplasm of the left breast, disorders of bone density, hemiplegia and hemiparesis following a cerebrovascular accident, seizures, weakness, thyrotoxicosis, adjustment disorder with anxiety, and depressed mood. During interview, Resident 65 stated that she fell off the bed and her hand was caught in the side bar, and her representative stated that the incident had been reported but he could not recall to whom. The resident was observed with a sling on the left arm and left hand, and the bed had bilateral upper side rails with a gap between the mattress frame and the side rail; the rails were not stationary and shifted when touched. Resident 65 later stated that her hand got caught in the side rail approximately two weeks earlier. Record review showed no assessment of the side rail for entrapment in the medical record. CNA 1 stated that Resident 65 required a two-person assist for transfers and bed mobility. LPN 1 stated that the resident had been evaluated for entrapment with bedrails on admission, but the functional abilities assessment completed on 3/5/26 assessed mobility status and did not assess positioning bars or entrapment. The RNC stated that therapy evaluated the resident for the bedrail but no assessment was entered in the medical record, and the DON stated that the resident should have been assessed for the bedrail as well.
Food Preferences Not Followed on Meal Ticket
Penalty
Summary
The facility did not ensure that each resident received food that accommodated resident allergies, intolerances, and preferences. For 1 of 43 sampled residents, Resident 8 did not receive the food preferences documented on the meal ticket. Resident 8 was admitted and re-admitted with diagnoses including severe protein-calorie malnutrition, cachexia, hypokalemia, hypotension, acute kidney failure, hypomagnesemia, depression, and pain. During interview, Resident 8 stated the kitchen never followed the instructions for his meals, that he could not digest leafy green vegetables, and that he had to order food out often because he could not eat a lot of what the facility provided. The resident also stated that the breakfast tray observed during the interview had eggs that were not hot and an English muffin that was not toasted or warm. The meal ticket for Resident 8 documented special instructions for double portions with extra gravy/sauces and likes including double portions, cold cereal, yogurt, two omelets with salsa, and two tortillas, with no dislikes documented. The nutrition records documented double portions and that the resident requested extra sauces, gravies, or butter with meals, and that he remained selective with meal preferences offered. The Dietary Manager stated that food preferences were printed on meal tickets and that Resident 8 preferred double portions, extra gravy and sauces, and specific breakfast items including cold cereal, two omelets with cheese, two yogurts, and two tortillas. The Dietary Manager also stated that Resident 8 should have received substitutions such as cooked vegetables instead of lettuce, but the resident did not receive cheese omelets or yogurt on the observed breakfast tray and received a side salad instead of cooked vegetables on another meal.
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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 Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare Cottonwood Creek | 0.5 mi | ★★★★★ | 0 | 0 |
| Maple Ridge Rehabilitation And Nursing | 0.5 mi | ★★★★★ | 0 | 0 |
| William E Christofferson Salt Lake Veterans Home | 1.6 mi | ★★★★★ | 7 | 0 |
| St Joseph Villa | 2.5 mi | ★★★★★ | 0 | 0 |
| Pine Creek Rehabilitation And Nursing | 2.7 mi | ★★★★★ | 8 | 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.