City Creek Post Acute
165 South 1000 East, Salt Lake City, UT 84102 · Salt Lake County · 108 certified beds · avg 69 residents/day · certified since Dec 15, 1979 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 30, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 22, 2026 (Past Non-Compliance)
▲ Actual harm, one-off · May 4, 2022 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 3, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 4, 2022 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 3, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (21)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 30, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 30, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 30, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 30, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Mar 30, 2026 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Mar 30, 2026 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 29, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| May 4, 2022 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| May 4, 2022 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 4, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 4, 2022 | E · Potential for harm, repeated | The facility did not perform required COVID-19 testing on residents and staff. |
| May 4, 2022 | E · Potential for harm, repeated | The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| May 4, 2022 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 13 | 2 | G ▲ |
| 2024 | 2 | 0 | E |
| 2026 | 6 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 0.00 | 3.87 | 3.95 | — |
| Registered Nurse hours | 0.00 | 1.17 | 0.69 | — |
| Weekend total nurse staffing | 0.00 | 3.39 | 3.50 | — |
| Weekend RN hours (not acuity-adjusted) | 0.00 | 0.88 | 0.48 | — |
| Total nursing staff turnover (%) | 0.0 | 50.7 | 45.8 | — |
| RN turnover (%) | 0.0 | 40.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 0.00, RN 0.00, weekend 0.00. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Partnership
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avenues Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2016 |
| Avenues Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 09/15/2025 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2016 |
| Caretrust GP LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2006 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2006 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 08/28/2014 |
| Ellis, KC | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2016 |
| Ellis, KC | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2016 |
| Ellis, KC | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2016 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2006 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Moss, Tyler | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2016 |
| Tenth East Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/28/2014 |
| Workman, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/20/2024 |
| Workman, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/20/2024 |
| Workman, David | Individual | ADP of the SNF | NOT APPLICABLE | 09/20/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "How do you track each resident's food allergies and preferences, and what happens if they don't like what's served?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Maple Ridge Rehabilitation and Nursing | 0.5 mi | Salt Lake City, UT | ★☆☆☆☆ | 2/5 | abuse |
| William E Christofferson Salt Lake Veterans Home | 1.6 mi | Salt Lake City, UT | ★★★★★ | 4/5 | |
| St Joseph Villa | 2.5 mi | Salt Lake City, UT | ★★★☆☆ | 3/5 | |
| Pine Creek Rehabilitation and Nursing | 2.7 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 | abuse |
| Midtown Manor | 3.2 mi | Salt Lake City, UT | ★☆☆☆☆ | 2/5 | |
| Monument Healthcare South Salt Lake | 3.2 mi | Salt Lake City, UT | ★☆☆☆☆ | 1/5 | SFF |
| Meadow Brook Rehabilitation and Nursing | 3.5 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Millcreek Rehabilitation and Nursing | 3.5 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Little Cottonwood Rehabilitation and Nursing | 4.2 mi | South Salt Lake, UT | ★★★★★ | 5/5 | |
| Mt. Olympus Rehabilitation Center | 4.5 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | |
| Monument Healthcare Canyon Rim | 4.9 mi | Millcreek, UT | ★★★☆☆ | 3/5 | |
| Monument Healthcare Murray Creek | 5.0 mi | Millcreek, UT | ★★☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 465072.