Cycle 1
Health 2025-11-20 · Fire 2025-11-20
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Salt Lake City, UT
Monument Healthcare Millcreek
4-star overall rating with 3-star inspections with 10 recent health deficiencies
1201 East 4500 South, Salt Lake City, UT
(801) 261-3664
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
120
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monument Health Group
Operator or chain grouping
Approved since
1994-06-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.21
Registered nurse staffing
LPN hours / resident day
0.54
Licensed practical nurse staffing
Aide hours / resident day
2.03
Nurse aide staffing
Weekend hours
3.29
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.5
1.5 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
98.0%
0.8 pts worse
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
2.6%
1.8 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
16.1%
10.3 pts better
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.8%
3.8 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
24.1%
4.6 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.3% |
15.4%
12.1 pts better
|
16.7%
13.4 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 | 31.3% |
18.3%
13 pts worse
|
16.3%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
13.6%
8.9 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.8%
1.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.0% |
22.4%
9.6 pts worse
|
19.8%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.1%
2.9 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
93.3%
5.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
11.8%
1.3 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
0.9%
0.6 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
91.0%
4.5 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
17.4%
4.9 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-28 · Fire 2021-12-28
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-12-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-01-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-02-16
E · Potential for more than minimal harm
2025-11-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-11-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-20
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-20
F779 · Administration Deficiencies
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
E · Potential for more than minimal harm
2023-11-02
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 2023-12-31
D · Potential for more than minimal harm
2023-11-02
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-02
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 2023-12-31
D · Potential for more than minimal harm
2023-11-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-07-20
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 2023-08-31
D · Potential for more than minimal harm
2023-07-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-31
Penalties and ownership
What sits behind the stars
Ownership
Milford Area Health Care Service District #3
5% Or Greater Direct Ownership Interest · Organization
Allen, Richard
Operational/Managerial Control · Individual
Beaver Valley Hospital
Operational/Managerial Control · Organization
Carter, Laurel
Operational/Managerial Control · Individual
Clawson, Travis
Operational/Managerial Control · Individual
Dansie, Guy
Corporate Officer · Individual
Devashrayee, Travis
Operational/Managerial Control · Individual
Dotson, Ward
Operational/Managerial Control · Individual
Espinosa, Stephanie
Operational/Managerial Control · Individual
Fragoso, Lindsay
Operational/Managerial Control · Individual
Health Group Management LLC
Operational/Managerial Control · Organization
Izatt, Brenda
Operational/Managerial Control · Individual
Langford, Scott
Corporate Officer · Individual
Mayer, Shauna
Operational/Managerial Control · Individual
Monument Health Properties LLC
5% Or Greater Mortgage Interest · Organization
Monument Real Estate Millcreek LLC
5% Or Greater Mortgage Interest · Organization
Moss, Tyler
Operational/Managerial Control · Individual
Moss, Tyler
Corporate Officer · Individual
Robertson, Brett
Operational/Managerial Control · Individual
Samuelian, Spencer
Operational/Managerial Control · Individual
Seastrand, Jason
Operational/Managerial Control · Individual
Symond, Scott
Operational/Managerial Control · Individual
West, Christian
Operational/Managerial Control · Individual
Wiseman, Brandon
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Highland Care Center
Holladay, UT
5-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Monument Healthcare Murray Creek
Millcreek, UT
2-star overall rating with 1-star inspections with abuse icon flag with $8,148 in total fines with 14 recent health deficiencies
#3
Spring Creek Healthcare Center
Salt Lake City, UT
2-star overall rating with 2-star inspections with $53,472 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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