Monument Healthcare Millcreek

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

67.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 183 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 127 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 84.1 residents a day — about 70% occupied, or roughly 36 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.05 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.28 hrs/resident/day on weekends vs 3.93 on weekdays — 17% thinner on weekends. RN hours go from 1.22 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.

• Potential for harm · D2026-01-21 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 2 was admitted to the facility on [DATE] with diagnoses which consisted of displaced bimalleolar fracture of right lower extremity, displaced avulsion fracture of right talus, chronic pulmonary edema, congestive heart failure, chronic kidney disease, kidney transplant status, unspecified protein-calorie malnutrition, fistula of the intestine, contusion of the abdominal wall, dyspnea, disorders of phosphorus metabolism, and hypokalemia. On 1/20/26 through 1/21/26 resident 2's medical records were reviewed. On 10/29/25, resident 2's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. On 10/24/25, resident 2's physician ordered TPN 1600 milliliter (ml) to run continuously in the evening per the pharmacy instructions. The pharmacy order summary documented the following for resident 2's TPN:Start Volume - 100 mlStart Rate - 62.5 ml/hour (hr.)Start Period - 1.6 hrs.Run Volume - 1600 mlRun Rate…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-21 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure that residents received the treatment and care in accordance with professional standards of practice, related to pain management. Specifically 1 of 4 residents sampled, was hospitalized due to opiate toxicity. Resident Identifier: 4 Findings Included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included sepsis, obstructive and reflux uropathy, and calculus of kidney. Review of resident 4's medical record was completed on 1/21/26. On 1/1/26 at 10:47 AM, a Physician's Progress Admit Note for resident 4 revealed that a medication reconciliation was done with the patient's family and his primary care physician's records. Morphine tablets (immediate release, 7.5 milligrams (mg) every 6 hours as needed), were ordered for resident 4's dorsalgia. On 1/2/26 at 1:49 PM, a Medical Doctor (MD) History and Physical Note for resident 4 stated, Patient with large kidney stones. Patient complains of ongoing pain…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-11-20 · tag F0757 — failed to avoid unnecessary drugs — pattern
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 3 out of 37 sampled residents, 2 of the residents' blood pressure medications were administered outside of the physician's ordered parameters and the third resident was not given an ordered medication as scheduled. Resident identifier: 26, 28, and 146.1. Resident 26 was admitted to the facility on [DATE] with diagnoses which included, hypertensive chronic kidney disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and atrial fibrillation. Resident 26's medical record was reviewed on 11/17/25 through 11/20/25. On 12/18/24, Metoprolol Tartrate oral tablet was ordered for hypertension, with the following…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-11-20 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff area for toilet facilities. Specifically, the facility had seven public bathrooms that were accessible by residents and were not equipped with a call light system. On 11/20/25, an observation was made of the public bathroom facilities. The 300 hallway bathroom near room [ROOM NUMBER] was observed and did not contain a call light inside. The 400 hallway bathroom near the nurse's station was observed and did not contain a call light inside. The bathroom next to the staff break room was observed and did not contain a call light inside. The bathroom next to the Human Resource office and front desk was observed and did not contain a call light inside. None of the public bathrooms were locked. On 11/20/25 at 2:36 PM, an interview was conducted with the Director of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 37 sampled residents, that the facility did not immediately inform or consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Specifically, the physician was not notified when a resident's Trulicity was held. Resident identifiers: 28.Findings included:1. Resident 28 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following amputation, Type 2 DM, and morbid obesity. On 11/18/25 9:37 AM, an interview was conducted with resident 28. Resident 28 stated that when she was first admitted she missed 3 weeks of injections of her Trulicity (Dulaglutide) medication. Resident 28 stated that the nurse had to re-order the medication and it delayed her injection. Resident 28's medical records were reviewed 11/17/25 through 11/20/25. On 9/3/25, resident 28's physician ordered Dulaglutide Subcutaneous Solution…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, a resident was admitted with wounds and dressings on their bilateral feet and did not have wound care orders initiated until 9 days after admission. Resident identifier: 117.Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 9:07 AM, an interview was conducted with resident 117. Resident 117 stated that he had both ankles surgically cleaned out and the left foot had MRSA. Resident 117 stated that he had 2 dressing changes completed since admission. Resident 117 stated that he was supposed to have dressing changes completed 3 times a week.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-20 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident was free from any significant medication errors. Specifically, multiple doses of Vancomycin were omitted from the residents scheduled medication administration. Resident identifier: 117. Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that he had 3 doses of Vancomycin that were missed by the facility. On 10/30/25, resident 117's physician ordered Vancomycin Hydrochloride (HCl) Solution Reconstituted, Use…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0773 — isolated
  Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 37 residents sampled, that the facility did not notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of the clinical reference ranges. Specifically, a resident's Vancomycin trough levels were high and the Medical Doctor (MD) was not notified of those high values. Resident identifier: 117.Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that he had 3 doses of Vancomycin that were missed by the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0779 — isolated
  Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological and other diagnostic services. Specifically, a resident 21's Kidney, Ureter, and Bladder (KUB) was not in the medical records. Resident identifier 21. Resident 21 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder.Review of resident 21's medical record was completed on 11/17/25 through 11/20/25.On 11/2/25, a physician's order documented an immediate (STAT) KUB radiograph (x-ray).On 11/2/25 at 12:48 pm, a nursing progress alert note stated the following: The patient decided to stay in bed all day today. The nurse noted that the patient's abdomen was blooded with a lot of gas and administered a gas pill. The patient stated that he had a watery bowel movement yesterday and last…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that for 1 of 37 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident was not placed on proper contact precautions. Resident Identifier: 117.Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that he had both ankles surgically cleaned out and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MONUMENT HEALTH GROUP — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 40 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in UT