City Creek Post Acute

In the surveyor’s words

From the most serious findings on record at City Creek Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 30, 2026

  Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 43 sampled residents, one resident sustained a third-degree burn to his left wrist from spilling a prepackaged soup prepared and served by facility staff. Resident identifier: 3.It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents, F689, at a scope and severity of G. […]

• Actual harm, isolatedF600May 4, 2022

  Based on interview and record review it was determined, for 2 of 23 sample residents, that each resident did not have the right to be free from abuse. Specifically, a resident was threatened by a roommate and there was no investigation to rule out abuse. Resident identifier: 33 and 89. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated her roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. […]

• Actual harm, isolatedF684May 4, 2022

  Based on interview and record review it was determined, for 1 of 23 sample residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. Specifically, a resident was not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 38's medical record was reviewed on 5/4/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The urine analysis and culture were not located in resident 38's medical record. […]

• No harm, potential for more than minimal, patternF812Mar 30, 2026

  Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a Bluetooth speaker was stored on a shelf used to store items used in food preparation and a male staff member with a beard was observed to be preparing food without wearing a beardnet. Findings included:On 3/23/26 at 8:02am an initial observation was conducted of the facility kitchen. There was a Bluetooth speaker sitting on a shelf used to store hotel pans used for meal preparation.On 3/25/25 at 11:31am a follow up observation was conducted of the facility kitchen. [NAME] 1 was observed to have a beard. [NAME] 1 was not wearing a beard net while preparing enchiladas that were to be served to residents at lunch. […]

• No harm, potential for more than minimal, patternF880Mar 30, 2026

  Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 43 sampled residents, staff did not wear personal protective equipment (PPE) when residents were on Enhanced Barrier Precautions (EBP) and hand hygiene was not performed during wound care. Resident identifiers: 14, 73, and 74.Findings included:1. […]