Millcreek, UT

Monument Healthcare Canyon Rim

4-star overall rating with 3-star inspections with $6,676 in total fines

2730 East 3300 South, Millcreek, UT

(801) 487-0897

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

90

Certified beds

Average residents

64

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Monument Health Group

Operator or chain grouping

Approved since

1984-08-03

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.08

Registered nurse staffing

LPN hours / resident day

0.30

Licensed practical nurse staffing

Aide hours / resident day

1.92

Nurse aide staffing

Weekend hours

2.63

Weekend nurse staffing

RN turnover

67%

Annual RN turnover

Total nurse turnover

66%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 96.8%
96.8%
About the same
93.4%
3.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97.3%
98.0%
0.7 pts worse
95.5%
1.8 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 3.2%
2.6%
0.6 pts worse
3.3%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 15.1%
16.1%
1 pts better
11.4%
3.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 1.3%
3.8%
2.5 pts better
5.4%
4.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 31.8%
24.1%
7.7 pts worse
19.6%
12.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 10.8%
15.4%
4.6 pts better
16.7%
5.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 13.6%
18.3%
4.7 pts better
16.3%
2.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 18.1%
13.6%
4.5 pts worse
14.9%
3.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.6%
0.9%
0.3 pts better
1.0%
0.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 0.6%
1.8%
1.2 pts better
1.7%
1.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 16.1%
22.4%
6.3 pts better
19.8%
3.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 2.9%
4.1%
1.2 pts better
5.1%
2.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 89.4%
93.3%
3.9 pts worse
81.7%
7.7 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who newly received an antipsychotic medication 0.6%
0.9%
0.3 pts better
1.6%
1 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 84.6%
91.0%
6.4 pts worse
79.7%
4.9 pts better
Short Stay · 2024Q3-2025Q2

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-06-27 · Fire 2024-06-27

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-08-17 · Fire 2022-08-17

12 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2020-02-25 · Fire 2020-02-25

13 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2020-02-25

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2020-04-01

Inspection history

Recent health citations

J · Immediate jeopardy 2024-12-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-12-16

J · Immediate jeopardy 2024-12-16

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-16

E · Potential for more than minimal harm 2022-08-17

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-09-09

E · Potential for more than minimal harm 2022-08-17

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F568 · Resident Rights Deficiencies

Health

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-09-09

D · Potential for more than minimal harm 2022-08-17

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-09-09

H · Actual harm 2020-02-25

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2020-07-25

G · Actual harm 2020-02-25

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2020-07-25

G · Actual harm 2020-02-25

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F841 · Nursing and Physician Services Deficiencies

Health

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Corrected 2020-07-25

E · Potential for more than minimal harm 2020-02-25

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2020-07-25

D · Potential for more than minimal harm 2020-02-25

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2020-07-25

Penalties and ownership

What sits behind the stars

$6,676 2024-12-16

Fine

Fine · fine $6,676

Fine

Ownership

Gunnison Valley Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 14 facilities 2020-07-01
Balser, Brandon

Operational/Managerial Control · Individual

0% 1 facilities 2025-02-07
Clawson, Travis

Operational/Managerial Control · Individual

0% 11 facilities 2025-02-07
Espinosa, Stephanie

Operational/Managerial Control · Individual

0% 31 facilities 2025-02-07
Fragoso, Lindsay

Operational/Managerial Control · Individual

0% 31 facilities 2025-02-07
Galindo, Michael

Operational/Managerial Control · Individual

0% 3 facilities 2025-02-07
Gunnison Valley Hospital

Operational/Managerial Control · Organization

0% 14 facilities 2025-02-07
Health Group Management LLC

Operational/Managerial Control · Organization

0% 31 facilities 2025-02-07
Marriott, Stephen

Operational/Managerial Control · Individual

0% 9 facilities 2025-02-07
Monument Health Group LLC

Operational/Managerial Control · Organization

0% 10 facilities 2025-02-07
Murray, Brian

Operational/Managerial Control · Individual

0% 15 facilities 2020-07-01
Murray, Brian

Corporate Officer · Individual

0% 15 facilities 2020-07-01
Robertson, Brett

Operational/Managerial Control · Individual

0% 31 facilities 2025-02-07
Samuelian, Spencer

Operational/Managerial Control · Individual

0% 31 facilities 2025-02-07
Seastrand, Jason

Operational/Managerial Control · Individual

0% 31 facilities 2025-02-07
Tonga, Elaine

Operational/Managerial Control · Individual

0% 1 facilities 2025-02-07
West, Christian

Operational/Managerial Control · Individual

0% 31 facilities 2025-02-07

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Millcreek Rehabilitation and Nursing LLC

Salt Lake City, UT

2-star overall rating with 1-star inspections with abuse icon flag with $25,441 in total fines with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

Overall
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Health
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Staffing
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Fines
$25,441

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