Monument Healthcare Millcreek
Open-data reference.
Monument Healthcare Millcreek is a for profit - limited liability company facility in Salt Lake City, UT with 120 certified beds and a 4-star overall CMS rating. The facility has 23 deficiency records on file.
1201 East 4500 South, Salt Lake City, UT 84117
Phone: 8012613664
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 465139
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 81
- In Hospital
- Yes
- County
- Salt Lake
- Last Inspection
- Nov 20, 2025
Staffing Data
- RN Hours
- 1.21 (nat'l avg: 0.68)
- LPN Hours
- 0.54
- CNA Hours
- 2.03
- Total Nursing Hours
- 3.79 (nat'l avg: 3.89)
- PT Hours
- 0.07
What the CMS Record Reveals About Monument Healthcare Millcreek
Monument Healthcare Millcreek operates 120 certified beds in Salt Lake City, UT with approximately 81 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 23 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.79 total nursing hours per resident day (national average 3.89), with RN coverage at 1.21 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider embedded within a hospital campus, Monument Healthcare Millcreek falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (23 most recent)
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Dec 26, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 26, 2025
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Category: Administration Deficiencies
Corrected: Dec 26, 2025
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category: Administration Deficiencies
Corrected: Dec 26, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Dec 26, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Dec 26, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Dec 26, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Dec 31, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Dec 31, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 31, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 31, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 31, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Dec 31, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 31, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 31, 2023
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category: Administration Deficiencies
Corrected: Dec 12, 2019
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 12, 2019
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.
Category: Pharmacy Service Deficiencies
Corrected: Dec 12, 2019
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Dec 12, 2019
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 12, 2019
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 12, 2019
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 12, 2019
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 22.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.0% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 5.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 99.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.3% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 31.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 19.5% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 97.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 95.5% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.2% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 32.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 3.3% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for Monument Healthcare Millcreek?
What are the staffing levels at Monument Healthcare Millcreek?
How many beds does Monument Healthcare Millcreek have?
Does Monument Healthcare Millcreek have any deficiencies on record?
Has Monument Healthcare Millcreek received any fines or penalties?
Who owns Monument Healthcare Millcreek?
When was Monument Healthcare Millcreek last inspected?
What quality measures are tracked for Monument Healthcare Millcreek?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.