0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Millcreek, UT
4-star overall rating with 3-star inspections with $6,676 in total fines
2730 East 3300 South, Millcreek, UT
(801) 487-0897
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
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
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
| 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
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
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
Establish an Emergency Preparedness Program (EP).
Corrected 2020-04-01
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-16
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-09-09
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-09-09
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-09-09
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-09-09
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-09
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
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-09
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
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-09
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
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-07-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-07-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-07-25
Health
Respond appropriately to all alleged violations.
Corrected 2020-07-25
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
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
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2020-07-25
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
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
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
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-07-25
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
Fine · fine $6,676
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
Salt Lake City, UT
2-star overall rating with 1-star inspections with $149,703 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Holladay, UT
5-star overall rating with 4-star inspections with 5 recent health deficiencies
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
Jump out