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Nursing HomeMedicaid

City Creek Post Acute

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

165 South 1000 East, East Central · Salt Lake City, UT 84102108 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
3.8/5

based on 123 Google reviews

5
4
3
2
1
City Creek Post Acute Nursing Home in Salt Lake City, UT — Street View
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What this means for your family

While the facility has shown recent improvements in rehabilitation therapy and administrative oversight, the history of serious medication and safety errors is concerning. If you choose this facility, maintain daily contact with the nursing staff and personally verify that all medication protocols are being followed, as communication and oversight remain inconsistent.

Google Reviews

Google Reviews

123 reviews on Google
City Creek Post Acute presents a highly polarized experience for families, with recent reviews highlighting significant improvements under new management alongside persistent, severe reports of neglect. While many patients praise the rehabilitation therapy team and compassionate individual staff members, others report critical failures in medication management, hygiene, and basic patient safety. Families should be aware that experiences vary drastically, with some citing excellent care and others describing dangerous lapses in supervision and communication.

Quality Themes

Tap a score for details
Food4.0Staff5.0Clean3.0Activities6.0Meds2.0Memory2.0Comms3.0ValueN/A

Strengths

  • Effective physical and occupational therapy teams
  • Compassionate and attentive individual nursing staff
  • Recent improvements under new administrative leadership
  • Friendly and welcoming atmosphere reported by many

Concerns

  • Medication errors and mismanagement (mentioned by 6 reviewers)
  • Understaffing leading to neglect and slow response times (mentioned by 8 reviewers)
  • Poor facility hygiene and cleanliness (mentioned by 5 reviewers)
  • Poor communication with families and medical providers (mentioned by 5 reviewers)

Rating Trends

Tap a year to see what changed

234'16(1)'18(21)'20(24)'22(9)'24(23)'26(7)

Distribution · 125 analyzed

5
80
4
8
3
4
2
4
1
29
12 reviews posted between Oct 5, 2020Oct 9, 2020 · 12 were 5-star
12 reviews posted between Mar 2, 2018Mar 2, 2018 · 12 were 5-star
10 reviews posted between Apr 11, 2024Apr 11, 2024 · 10 were 5-star

How They Respond to Reviews

7%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1It's wonderful to see such positive feedback about your therapy teams; how do the physical and occupational therapists work with residents to help them regain independence?
  • 2We've heard great things about the new leadership here, so could you tell us about some of the recent improvements being made to the facility's daily operations?
  • 3What specific protocols do you have in place to ensure medication is administered accurately and on schedule for every resident?
  • 4How does the nursing staff manage communication with family members to ensure we are always kept up-to-date on our loved one's health and well-being?
  • 5Could you describe the daily activity schedule and how you ensure the dining experience is both nutritious and enjoyable for the residents?
  • 6What is the process for responding to medical emergencies or sudden changes in a resident's condition during the night shift?

Personalized based on this facility's data


Key Review Excerpts

The PT staff is amazing my daughter is finally able to walk bathroom with her walker plus go restroom by herself and getting little bit walking with her walker after 3 surgeries and over a year in facilties!!

Rehab patient's family · 2025★★★★★

Building is under new management both with Administration and Clinical leadership. The facility is agency free and recently had a great State Survey with only two deficiencies.

Facility leadership · 2024★★★★★

This place isn't set up for memory care/caring for those with dementia. They placed her on the second floor, which mainly seemed to be for those recovering from medical issues.

Memory care family member · 2024★★★☆☆
Source: 123 Google reviews

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

10

measures

Worse Than Avg

5

measures

Mixed Results

2

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility29.1%
Worse than Avg
Here
29.1%
US
12.1%
UT
16.5%
Salt lake
22.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility8.8%
Better than Avg
Here
8.8%
US
15.4%
UT
14.6%
Salt lake
14.0%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
UT
97.1%
Salt lake
97.9%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility25.3%
Worse than Avg
Here
25.3%
US
19.5%
UT
24.7%
Salt lake
21.9%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility8.7%
Better than Avg
Here
8.7%
US
14.4%
UT
12.1%
Salt lake
10.9%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
UT
98.0%
Salt lake
98.8%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility97.2%
Better than Avg
Here
97.2%
US
81.8%
UT
93.8%
Salt lake
94.3%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility91.0%
Mixed vs Avgs
Here
91.0%
US
79.7%
UT
91.0%
Salt lake
91.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
UT
0.8%
Salt lake
0.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

3deficiencies
Well below state avg (9.1)
3 complaint-triggered

City Creek Post Acute has notable concerns including families filing complaints about safety hazards and bladder care issues in 2024. The facility shows recurring problems across safety/accident prevention, infection control, medication management, and resident protection from abuse/neglect. While all deficiencies report corrections, the pattern of significant safety and care issues, combined with recent family complaints, warrants careful evaluation during visits.

Mar 30, 2026Complaint
1
0689Actual harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Jan 29, 2024Complaint
2
0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

May 4, 2022Routine
13
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0886Potential for harm · PatternCorrected

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

0888Potential for harm · PatternCorrected

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0770Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

0773Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Nov 7, 2019Routine
4
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0004Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Ownership & Operations

Who Operates This Facility

Owner / Operator

City Creek Post Acute

Organization Type

government

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

338 facilities nationwide

Chain avg rating: 3.2/5 · Rank 53 of 328 (Best)

Ownership & Management

Key personnel

Burnam, SoonOfficer / DirectorMoss, TylerOfficer / DirectorAvenues Healthcare, INC.ManagerBurnam, SoonManagerEllis, KcManager
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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