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, isolatedF697Aug 28, 2023

  Based on interview and record review, the facility failed to adequately address the pain of one of three sampled residents (Resident 1), when Licensed Nurse (LN 1) and LN 2 failed to assess, reassess, evaluate and treat Resident 1's symptoms. This failure resulted in Resident 1 unnecessarily experiencing 10/10 (most pain imaginable) pain for five and one-half hours. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in the spring of 2023 with diagnoses which included fracture (break in the bone) of the carpal bone in both wrists (small bone in the wrist) head laceration (deep cut or tear in the skin), and pain right wrist. […]

• Actual harm, isolatedF684Dec 21, 2022

  Based on observation, interview, and record review, the facility failed to ensure treatment and care in accordance with professional standards of care when one of three sampled residents (Resident 1) was lifted back to bed by Certified Nursing Assistant 3 (CNA 3) after a fall, prior to being assessed by a Licensed Nurse (LN). This failure resulted in Resident 1 needing to be moved to a higher level of care due to a fractured sternum (broken breastbone). Findings: During a record review, it was noted that Resident 1 was admitted to the facility in the summer of 2022, with diagnoses that included unspecified fracture of left femur (thigh bone), generalized muscle weakness, epilepsy (a disorder in the brain causing abnormal nerve and muscle activity), schizoaffective disorder (a combination… […]

• Actual harm, isolatedF600Jan 28, 2022

  Based on observation, interview, and record review, the facilty neglected Resident 1 when they failed to ensure adequate diagnostic imaging and evaluation were completed, for one of three sampled residents (Resident 1) when a femur (thigh bone) fracture remained undiagnosed for twenty-two days. This failure resulted in Resident 1 experiencing moderate to severe pain for twenty-two days. Findings: Resident 1 was admitted to the facility in the middle of 2021 for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's, Brief Interview for Mental Status (BIMS, an assessment tool) dated 6/16/21, the BIMS indicated, a score of 9, on a scale of 0-15, indicating moderately impaired cognition (ability to think and process information). […]

• No harm, potential for more than minimal, widespreadF801Jul 24, 2026

  Based on observation, interview and record review, the facility failed to ensure the Contracted (35-hour/week) Registered Dietitian (RD) effectively monitored the dietetic service operations and provided frequently consultation to the Dietary Manager (DM). This failure had the potential to result in compromising the nutritional status of residents through the potential transmission of food borne illness, inappropriate preparation of diet textures, and incorrect plating of physician ordered diets and nourishment. There was a total of 90 out of 95 residents receiving meals from the facility kitchen.Findings:During the annual recertification survey from 7/21/26 to 7/23/26, multiple issues surrounding the delivery of dietetic services were identified:1. […]

• No harm, potential for more than minimal, widespreadF812Jul 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when:Dietary Staff did not practice properly for the storing and handling the thawing process of the health shakes (frozen nutritional supplement drinks pack individually in cartons, which provide additional calories and nutrients)Found kitchenware was stacked wet and stored away in the clean and ready-to-use areaThe blade of can opener was not well maintainedTwo of five cutting boards were not clean and stored away in the clean and ready-to-use cutting board rackTwo different sizes Teflon coating cooking pans were not well maintainedOne [NAME] with facial hair was not covered with facial hair… […]