City Creek Post Acute
165 South 1000 East · Salt Lake City, UT · 84102 · 8013225521
108 certified beds Government - Hospital district Chain: The Ensign Group
Why this verdict
- Staffing levels are well below research benchmarks for safe care.
- 3 citations involved actual harm to residents.
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 1 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (19 in the current record)
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Actual harm · G March 30, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 22, 2026 · Quality of Life and Care
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Potential for harm · E January 29, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 16, 2024 · Quality of Life and Care
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Potential for harm · D January 29, 2024 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected February 16, 2024 · Quality of Life and Care
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Actual harm · G May 4, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 3, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G May 4, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 3, 2022 · Quality of Life and Care
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Potential for harm · D May 4, 2022
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected July 3, 2022 · Resident Rights
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Potential for harm · D May 4, 2022
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected July 3, 2022 · Resident Rights
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Potential for harm · D May 4, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 3, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 4, 2022
Respond appropriately to all alleged violations.
Corrected July 3, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 4, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 3, 2022 · Quality of Life and Care
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Potential for harm · D May 4, 2022
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.
Corrected July 3, 2022 · Pharmacy Service
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Potential for harm · D May 4, 2022
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected July 3, 2022 · Administration
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Potential for harm · D May 4, 2022
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected July 3, 2022 · Administration
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Potential for harm · E May 4, 2022
Provide and implement an infection prevention and control program.
Corrected July 3, 2022 · Infection Control
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Potential for harm · E May 4, 2022
Perform COVID19 testing on residents and staff.
Corrected July 3, 2022 · Infection Control
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Potential for harm · E May 4, 2022
Ensure staff are vaccinated for COVID-19
Corrected July 3, 2022 · Infection Control
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Potential for harm · D November 7, 2019
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected December 18, 2019 · Resident Rights
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Potential for harm · D November 7, 2019
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 18, 2019 · Pharmacy Service
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Potential for harm · D November 7, 2019
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 18, 2019 · Resident Assessment and Care Planning
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 465072 · certified since December 15, 1979. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.