City Creek Post Acute: Resident Burned by Hot Food - UT
That was how the facility operated until the burn happened. Nobody had measured a temperature.
The resident, identified in inspection records only as Resident 3, used a motorized wheelchair and was, by every account from staff, fiercely independent. He did not want people doing things for him. He did not want to be treated like a child. When staff reheated his food, he insisted on carrying it back to his room himself rather than letting them bring it.
A Licensed Practical Nurse told inspectors that before the burn, the process for reheating food was to microwave it in 30-second increments until it seemed warm enough, then touch the container. If the outside felt acceptable, the food went back to the resident. There was no thermometer involved. There was no temperature reading. There was a hand on a bowl.
A nursing assistant told inspectors that staff would not heat Resident 3's food at all if he refused to let them carry it safely, because they considered it dangerous for him to transport it himself. But the inspection record makes clear the burn still happened. At some point, food that was too hot reached him.
After the burn, the facility's own staff confirmed what had been missing. The nursing assistant said thermometers were not something they had searched for before the incident, because the search never happened. The LPN confirmed thermometers were not available before the burn. The Director of Nursing told inspectors that staff had been determining whether food was safe to return to residents based entirely on touch.
The Director of Nursing described what followed once the facility learned of the burn. All microwaves were pulled from the nutrition stations. Coffee pots were removed as well. Resident 3 was given wound care. A four-step action plan was started. Staff were trained on proper reheating and on how to use thermometers, which had not previously been part of the process. The microwaves were not returned until March 10, 2026, after the Director of Nursing said all staff had completed that training. When the microwaves came back, thermometers came with them, along with coffee thermoses fitted with pump dispensers to replace the brewers.
The standard the facility landed on after the burn was a maximum temperature of 140 degrees Fahrenheit before food could be returned to a resident. That number did not exist as a practice before Resident 3's injury established the need for one.
Federal inspectors, conducting a complaint inspection on March 26, 2026, cited the facility for causing actual harm to a resident, one of the more serious harm classifications in the inspection system, affecting a small number of residents.
What the record shows is a gap that was entirely visible in advance and filled only after someone got hurt. The facility had microwaves. It had residents who needed food reheated. It had a resident who was known to be independent, known to carry items himself, and known to be at risk if something went wrong in transit. The one tool that would have told staff whether what they were sending with him was safe to carry and safe to eat was not there.
Resident 3 insisted on his independence until the end. Staff knew that about him. They described it to inspectors in detail, the motorized wheelchair, the refusal to be helped, the insistence on carrying his own food. What they did not describe, because it did not exist, was any system for making sure what he was carrying would not hurt him.
He carried it. It did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for City Creek Post Acute from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
City Creek Post Acute in Salt Lake City, UT was cited for violations during a health inspection on March 30, 2026.
That was how the facility operated until the burn happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at City Creek Post Acute?
- That was how the facility operated until the burn happened.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Salt Lake City, UT, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from City Creek Post Acute or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 465072.
- Has this facility had violations before?
- To check City Creek Post Acute's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.