SNF
City Creek Post Acute
CCN: 465072 · Salt Lake City, UT 84102 · Salt Lake County
Inspection > 2 years ago
Overview
- Address
- 165 South 1000 East, Salt Lake City, UT 84102
- Phone
- 8013225521
- Certified beds
- 108
- Avg daily residents
- 69 (64% of beds filled)
- Ownership
- Government (hospital district)
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1979-12-15
- Setting
- Urban
5 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.58 | 3.56 | 3.88 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.67 | 0.62 | 0.73 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.75 | 0.79 | 0.81 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.15 | 2.15 | 2.34 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.42 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.16 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.13
hrs / resident / day
RN (weekend)
0.42
hrs / resident / day
Total nurse (adjusted, weekend)
3.40
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
50.0%
annual
RN turnover
36.4%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.26
higher acuity than avg
Case-Mix Index Ratio
0.91
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2024-01-29 | 2 | 2 | 2 | 12 | 1 | 12 |
| Cycle 2/3 (prior) | 2022-05-04 | 13 | 13 | 0 | 96 | 1 | 96 |
Total weighted health score
33.0
lower is better
Deficiencies (18)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
16 D/E/F Actual harm — potential for minor
2 G/H/I Actual harm
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | 2024-01-29 | 2024-02-16 |
| 0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | 2024-01-29 | 2024-02-16 |
| 0578 | 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. | D | 2022-05-04 | 2022-07-03 |
| 0584 | 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. | D | 2022-05-04 | 2022-07-03 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | 2022-05-04 | 2022-07-03 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2022-05-04 | 2022-07-03 |
| 0610 | Respond appropriately to all alleged violations. | D | 2022-05-04 | 2022-07-03 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | 2022-05-04 | 2022-07-03 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2022-05-04 | 2022-07-03 |
| 0761 | 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. | D | 2022-05-04 | 2022-07-03 |
| 0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. | D | 2022-05-04 | 2022-07-03 |
| 0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | D | 2022-05-04 | 2022-07-03 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2022-05-04 | 2022-07-03 |
| 0886 | Perform COVID19 testing on residents and staff. | E | 2022-05-04 | 2022-07-03 |
| 0888 | Ensure staff are vaccinated for COVID-19 | E | 2022-05-04 | 2022-07-03 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2019-11-07 | 2019-12-18 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2019-11-07 | 2019-12-18 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2019-11-07 | 2019-12-18 |
Financial Health (FY 2024)
Payer mix (share of resident days)
Medicare 3.3% Medicaid 76.1% Other 20.6%
Operating performance
Operating Margin
-1.7%
Total Margin
-1.7%
Occupancy Rate
70.8%
Cost per Resident Day
$52
Revenue & costs
Net Patient Revenue
$7.9M
Total Costs
$1.1M
Net Income
-$133K
Balance sheet
Total Assets
$6.2M
Total Liabilities
$3.5M
Fund Balance
$2.7M
Current Ratio
4.04
Source: CMS SNF Cost Report (FY 2024). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: THE ENSIGN GROUP
- Chain ID
507- Facilities in chain
- 329
- Legal business name
- BEAVER VALLEY HOSPITAL
Chain-average star ratings (for peer context)
Overall
3.2
Health
2.9
Staffing
2.7
QM
4.3
Owner / manager organizations (2)
| Organization | Role | Association |
|---|---|---|
| BEAVER VALLEY HOSPITAL | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 05/01/2016 |
| AVENUES HEALTHCARE, INC. | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2016 |
Owner / manager individuals (4)
| Name | Role | Association |
|---|---|---|
| BURNAM, SOON | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2016 |
| ELLIS, KC | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2016 |
| BURNAM, SOON | CORPORATE OFFICER | since 05/01/2016 |
| MOSS, TYLER | CORPORATE OFFICER | since 01/01/2021 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2024, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $52 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 4.04 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,024 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 76.1% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 3.3% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-133,125 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $7,880,773 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 70.8% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -1.7% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $6,199,219 | metrics.total_assets |
| Cost Report | Total Costs ($) | $1,075,629 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $2,701,989 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $3,497,230 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -1.7% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.81178 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.33752 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.73182 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.88112 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 3.39919 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 68.6 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.78941 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.14543 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.62223 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.55707 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.13518 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 2.9 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 3.2 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 4.3 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 2.7 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 507 | Chain ID |
| Provider Information | Chain Name | THE ENSIGN GROUP | Chain Name |
| Provider Information | City/Town | Salt Lake City | City/Town |
| Provider Information | CMS Certification Number (CCN) | 465072 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Salt Lake | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1979-12-15 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 4 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 40.7606 | Latitude |
| Provider Information | Legal Business Name | BEAVER VALLEY HOSPITAL | Legal Business Name |
| Provider Information | Location | 165 South 1000 East,Salt Lake City,UT,84102 | Location |
| Provider Information | Long-Stay QM Rating | 5 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -111.86 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | Y | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 108 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 329 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.26011 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.91468 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 5 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Government - Hospital district | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 165 South 1000 East | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | City Creek Post Acute | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 170 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 12 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 2 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 2 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2024-01-29 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 12 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 2 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 13 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2022-05-04 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 96 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 0 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 96 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 13 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.42180 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 36.4 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.42211 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.74789 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.15355 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.15852 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.67423 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.57567 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 4 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 3 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | UT | State |
| Provider Information | Telephone Number | 8013225521 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.13167 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 50.0 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 33.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 84102 | ZIP Code |