Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Millcreek Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident reported to social services that another resident’s w/c had not been properly secured to the floor of a facility van during transport to an appointment, and this concern was documented and confirmed as a grievance. The ADM later explained that the facility used a group “trigger call” with corporate leadership and the DON to decide whether alleged abuse or neglect incidents should be reported, and they determined this event did not meet their criteria for neglect because no injury occurred. When provided the regulatory definition of neglect during interview, the ADM acknowledged the incident should have been reported, confirming the facility failed to immediately report an allegation of neglect to the State Survey Agency.
A deficiency occurred when a resident’s wheelchair was not secured during van transport between buildings on a medical campus. A resident reported, and video confirmed, that another resident’s wheelchair was not anchored to the van floor; instead, the driver was seen driving while holding the wheelchair base with one hand, and the resident was holding the back of the driver’s seat. The driver later admitted he did not apply the wheelchair straps because the distance was short and he was in a hurry, while the DON and ADM confirmed that the resident had not been properly secured despite usual practice of securing residents during transport.
A resident with multiple medical conditions fell backward in a wheelchair while being transported in a facility van, reportedly hitting his head and neck. The incident was not thoroughly investigated or reported to the State Survey Agency as required. Interviews revealed that staff did not follow proper procedures for incident assessment, documentation, or notification, and there was no evidence of an abuse investigation despite the resident's ongoing pain and concerns about the incident report's accuracy.
Two residents were not provided with adequate supervision or properly secured during transport, resulting in one resident falling backward in a facility van and sustaining a head and neck injury. Staff interviews revealed inconsistent and insufficient training on wheelchair securement and accident response, and the incident report did not accurately reflect the event. The deficiency was cited at the Immediate Jeopardy level due to the facility's failure to follow recommended safety practices.
A resident reported being sexually abused by another resident, with the facility failing to ensure separation or provide individualized interventions following the incident. Both residents had moderate cognitive impairment and psychiatric diagnoses. The capacity to consent to sexual activity was not assessed prior to the event, and care plan interventions addressing the altercation were delayed by several months. Staff interviews revealed a lack of timely communication and coordinated response to the abuse allegation.
Three residents with complex medical and psychosocial needs did not have comprehensive, individualized care plans addressing their specific conditions. One resident on dialysis lacked a care plan for fistula care and monitoring, another with repeated THC vape use had no substance use interventions in their care plan, and a third with frequent falls had care plan interventions that were not consistently implemented by staff, as observed and confirmed in interviews.
The facility did not consistently file laboratory reports in the clinical records for three residents, resulting in missing or misfiled lab results for routine and stat orders, including respiratory panels and metabolic panels. Staff interviews confirmed that some results were delayed, not uploaded, or placed in the wrong chart, leading to incomplete documentation.
Staff failed to maintain accurate and confidential medical records by documenting other residents' names in progress notes and misfiling discharge documentation, and did not ensure required physician rationale for ongoing PRN psychotropic medication was present in the chart. These actions resulted in incomplete, inaccurate, and insecure records for several residents with complex medical and psychiatric histories.
Staff failed to use proper infection control practices during snack distribution by handling food with bare hands, and did not implement Enhanced Barrier Precautions for two residents with indwelling medical devices or wounds. Staff interviews revealed a lack of awareness and adherence to required precautions, and there was no signage indicating EBP for affected residents.
Three handrails in resident corridors were found to be loose and not properly secured to the wall. The Maintenance and Housekeeping Supervisor reported that daily audits, including handrail inspections, were conducted but did not identify these deficiencies. The issue was confirmed during inspection with a State Surveyor.
The facility did not ensure timely reporting of alleged abuse, neglect, or injury to the administrator, SSA, APS, or law enforcement. In multiple cases, including incidents of sexual abuse and an injury during transportation, notifications to required authorities were delayed beyond the mandated 2-hour window. Staff and leadership interviews confirmed delays and uncertainty regarding reporting requirements.
A resident with multiple medical conditions reported fecal matter on the bathroom wall that remained unaddressed for an extended period, despite daily cleaning routines and available reporting mechanisms. Observations confirmed the substance persisted, indicating a failure to provide a safe, clean, and homelike environment.
A resident with complex medical needs did not have required routine laboratory tests, including CBC, CMP, and HbA1c, completed and documented as ordered by the facility physician. The DON reported that some labs were obtained from a dialysis center, but not all required tests were included, and results were not consistently documented in the resident's medical record.
A resident with no teeth and moderate cognitive impairment, who had reported difficulty chewing and swallowing, was served a minced and moist diet without physician approval after the Dietary Manager downgraded the diet based on the resident's complaints. Staff interviews revealed confusion about the resident's prescribed diet, and the Speech-Language Pathologist had not yet evaluated the resident. The facility failed to provide food in a form consistent with the physician's order.
A resident assessed as safe to smoke independently was restricted from accessing the secured outside smoking patio after 9:00 PM, except during set supervised times, due to facility policy and staffing limitations. The resident reported being unable to go outside at night as desired, and staff confirmed the door was locked and only opened at specific times, despite the resident's independent status.
Failure to Report Alleged Neglect Related to Unsafe Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of neglect to the State Survey Agency after a resident grievance identified a safety concern during transportation in a facility van. A grievance dated 3/26/26 documented that a resident reported to social services/resident advocate that, during transport to an appointment earlier that week, another resident in the van was not strapped in appropriately. Specifically, the reporting resident observed that the other resident’s wheelchair was not anchored to the van floor with straps. The grievance was reviewed and confirmed through the facility’s grievance process. During an interview on 4/7/26, the Administrator explained that when there was an abuse or neglect allegation, a “trigger call” was held with the company president, a corporate representative, and the DON to determine if the incident met the level of abuse to report. The Administrator stated that neglect was defined as residents not receiving goods and services and that this incident was not reported to the State Survey Agency because they felt it did not meet the criteria, noting that the resident was not injured. After being provided the regulatory definition of neglect during the interview, the Administrator acknowledged that, under that definition, the incident should have been reported, confirming that the allegation of neglect was not reported immediately as required.
Unsecured Wheelchair During Resident Transport in Facility Van
Penalty
Summary
A deficiency occurred when a resident’s wheelchair was not secured during transport in the facility van, resulting in an environment that was not free from accident hazards. A grievance documented that during a transportation event earlier in the week, one resident observed that another resident’s wheelchair was not anchored to the van floor with straps. The grievance was confirmed. In an interview, the driver involved stated that he transported the resident to an appointment, realized they were at the wrong location, and then drove across the parking lot to the correct destination without securing the resident’s wheelchair with straps. The driver also sent a text message to the Administrator acknowledging that during this short transfer he did not secure the wheelchair, recognized this was not the correct procedure, and accepted responsibility. In a video provided by the reporting resident, the transported resident was seen in the facility van in a wheelchair that was not secured, while the driver was operating the vehicle and holding the base of the wheelchair with one hand. The transported resident was observed holding onto the back of the driver’s seat. In interviews, the transported resident reported that staff usually secured her wheelchair and ensured she was buckled, and that she had never been injured or had an incident in the van. The DON and Administrator both confirmed that the driver did not secure the resident’s wheelchair because the destination was within the same parking lot and the driver was in a hurry, and acknowledged that the resident was not secured as required.
Failure to Investigate and Report Resident Fall During Transport
Penalty
Summary
The facility failed to thoroughly investigate and report an incident involving a resident who sustained a fall while being transported in a facility van. The incident occurred when the resident, who had a history of heart failure, type 2 diabetes, osteomyelitis, and diarrhea, was being taken to a cardiology appointment. During the transport, the resident fell backward in his wheelchair, reportedly hitting his head and neck. The resident stated that his wheelchair was strapped in, but he was unsure about the seatbelt placement. Upon returning to the facility, the resident reported the accident and was provided an x-ray the following day. The resident also expressed concerns about the accuracy of the incident report and the timeliness of his medical assessment and follow-up care. Interviews and record reviews revealed that the facility did not conduct a thorough investigation of the incident or report it to the State Survey Agency (SSA) within the required five working days. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that the incident was not investigated as potential abuse or neglect, and there was no documentation of an abuse investigation. The ADM admitted that the process for handling such incidents, including immediate notification and assessment, was not followed. The transportation driver reported the incident after returning to the facility, but the ADM did not document the event or initiate an investigation, relying instead on the driver's account that no injuries occurred and that the wheelchair was secured. Further interviews with another resident who witnessed the incident indicated that the wheelchair may not have been properly secured, as something in the front came undone, causing the wheelchair to fall backward rapidly. The witness could not confirm if the resident hit his head but noted that the resident complained of neck pain and requested an x-ray. The facility's lack of investigation, failure to assess the resident immediately upon return, and omission of timely reporting to the SSA constituted a deficiency at the Immediate Jeopardy level.
Failure to Ensure Safe Resident Transport and Adequate Supervision
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to ensure adequate supervision and the use of appropriate assistive devices to prevent accidents for two of 43 sampled residents. One resident, who had a history of heart failure, diabetes, bilateral below-knee amputations, and multiple wounds, fell backward while being transported in a facility van. The resident was not properly secured, resulting in a fall that caused injury to the head and neck. The incident was witnessed by another resident, and both the resident and the witness reported that the wheelchair tipped backward while the van was in motion. The transportation driver was unable to clearly recall or demonstrate the correct securement of the wheelchair and seatbelt, and there was inconsistency in staff training and understanding of proper transport procedures. The resident reported pain and symptoms consistent with a neck injury following the incident, including pain at the base of the skull and cracking sounds when turning the neck. Medical records confirmed that the resident received a cervical spine x-ray and was later referred for orthopedic evaluation, where a diagnosis of cervical spondylosis and whiplash injury was made. The resident and the witness both stated that the incident report provided by the facility was inaccurate, and the resident expressed dissatisfaction with the lack of immediate assessment upon return to the facility. The transportation driver and other staff interviews revealed gaps in training, inconsistent practices regarding the securement of wheelchairs and seatbelts, and a lack of clear protocols for responding to accidents during transport. Additionally, the facility failed to ensure that all staff involved in resident transport were adequately trained in safety procedures, including the proper securement of wheelchair-dependent residents and the appropriate response to accidents. Staff interviews indicated that training was often verbal, lacked documentation, and did not always include return demonstrations or specific guidance on accident protocols. The deficiency was determined to be at the Immediate Jeopardy level due to the facility's failure to implement CMS-recommended practices for hazard identification, risk evaluation, intervention implementation, and monitoring for effectiveness.
Failure to Protect Residents from Sexual Abuse and Inadequate Response to Allegation
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, specifically sexual abuse, as evidenced by an incident involving inappropriate sexual contact between two residents. One resident reported waking up to another resident touching his genitals and attempting to penetrate his anus without consent. The incident was reported to the Resident Advocate and the police were contacted, but the alleged perpetrator was not arrested. The victim expressed ongoing anger and anxiety related to the incident and reported that the facility did not take sufficient action to keep the residents separated following the event. Documentation shows that the alleged perpetrator remained in the facility for several months after the incident, and the victim felt unsupported by staff in the aftermath. Medical records and interviews revealed that both residents involved had moderate cognitive impairments and significant psychiatric histories, including schizoaffective disorder, PTSD, and histories of trauma. The victim's care plan included trauma-informed care, but did not identify interventions specific to the sexual abuse incident. Additionally, the assessment of the resident's capacity to consent to sexual activity was not completed prior to the incident, and the care plan interventions addressing the altercation were not initiated until four months after the event. The facility's investigation was ultimately deemed inconclusive, with no conclusive evidence to verify the allegation, and the only interventions documented were the relocation of the alleged perpetrator and general monitoring. Interviews with facility staff, including the Resident Advocate, social worker, and administrator, indicated a lack of timely and coordinated response to the incident. The social worker was not informed of the sexual abuse allegation and did not address it in therapy or care planning. The administrator and Resident Advocate both acknowledged the incident and the subsequent anger and anxiety experienced by the victim, but could not recall or document any new or specific interventions implemented to support the resident or prevent further contact. The facility's failure to promptly assess capacity for consent, implement individualized interventions, and ensure separation of the residents contributed to the deficiency.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with significant medical and psychosocial needs. One resident with end stage renal disease and an arteriovenous fistula for dialysis did not have a care plan addressing dialysis care, monitoring of the fistula, or interventions for potential complications. Despite regular assessments and communication with the dialysis center, there were no documented care plan focus areas or interventions specific to dialysis or fistula management in the resident's medical record. Another resident with a history of substance use, including repeated possession and use of THC vape devices, did not have a care plan addressing substance use or interventions to manage the associated risks. Multiple incidents were documented where the resident was found with THC vapes, and staff, including the DON and ADON, acknowledged awareness of the resident's substance use and the need for a care plan. However, no goals or interventions related to substance use were present in the care plan, despite ongoing issues and the potential impact on other residents. A third resident with a history of falls, cognitive impairment, and physical limitations had a care plan that included several interventions, such as the use of a Gerihip hip protector, pressure alarm mat, and education on using the call light. However, observations and staff interviews revealed that these interventions were not consistently implemented. The resident was repeatedly observed without the hip protector, and some staff were unaware of the intervention or its purpose. The pressure alarm mat was not always positioned correctly, and the resident was seen ambulating in socks, increasing fall risk. These lapses contributed to the facility's failure to ensure that care plan interventions were effectively carried out to meet the resident's needs.
Failure to Maintain Complete Laboratory Records in Resident Charts
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of three residents. For one resident with multiple chronic conditions, including diabetes, end stage renal disease, and hypertension, there was no documentation in the medical record for the results of a respiratory panel ordered due to influenza A exposure, nor for routine labs (CBC, CMP, HbA1c) ordered for a specific month. The Assistant Director of Nursing (ADON) indicated that the resident only allowed the dialysis center to obtain labs, and the results were not present in the facility's records until much later. The Director of Nursing (DON) confirmed that the laboratory results for the routine labs were only recently obtained from the dialysis center. Another resident with psychiatric and substance use diagnoses also had a respiratory panel ordered due to influenza A exposure, but the results were not found in the medical record. Staff interviews revealed that while lab results were typically faxed to the facility and uploaded into the medical record, the respiratory panel result remained in the fax queue and had not been uploaded. For a third resident with cardiac and renal diagnoses, a one-time basic metabolic panel was ordered, but the results were not present in the medical record; the DON later stated that the results had been uploaded to the wrong resident's chart. These findings demonstrate that laboratory reports were not consistently filed in the correct resident records as required.
Failure to Maintain Accurate and Confidential Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and secure medical records for multiple residents. In several instances, staff documented other residents' names within a resident's medical record, rather than using appropriate identifiers such as room numbers. For example, in the medical record of a resident with schizoaffective disorder, PTSD, and other psychiatric diagnoses, progress notes included the full names of other residents involved in an altercation, contrary to facility policy and accepted standards. Additionally, another resident's discharge documentation was found in the wrong resident's medical record, and similar issues were identified in the records of other residents, where names of unrelated residents appeared in progress and event notes. Furthermore, the facility did not ensure that required physician documentation was present in the medical record for the ongoing use of a PRN psychotropic medication. In one case, a resident with PTSD and schizoaffective disorder had a PRN order for clonazepam extended, but the physician's rationale for this extension was not found in the medical record as required. The DON later located the missing document outside of the resident's chart, indicating a lapse in maintaining complete and accessible records. These deficiencies were identified through record review, staff interviews, and observation.
Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) was observed distributing snacks to residents in the hallway using bare hands, without the use of tongs or hand hygiene between residents. The Director of Nursing (DON) confirmed that staff are expected to use tongs and perform hand hygiene between each resident when handling food. This failure to follow proper infection control practices resulted in direct hand-to-food contact during snack distribution. Additionally, two residents with indwelling medical devices or wounds did not have Enhanced Barrier Precautions (EBP) in place as required. One resident with a wound vac for a right elbow wound and another with a foley catheter were not on EBP, and there was no signage indicating such precautions outside their rooms. Interviews with staff revealed a lack of awareness and implementation of EBP for residents with invasive devices, despite physician orders and care plans indicating the presence of these devices and associated infection risks.
Loose Handrails in Resident Corridors
Penalty
Summary
The facility failed to ensure that all corridors were equipped with firmly secured handrails, as required. During observations on multiple occasions, three separate handrails in resident corridors were found to be loose and not properly secured to the wall. These deficiencies were identified outside and between various resident rooms. In an interview, the Maintenance and Housekeeping Supervisor (MHS) stated that daily audits were conducted, including inspection of handrails, but acknowledged that the loose handrails had not been noticed during these audits. The MHS further confirmed during inspection with the State Surveyor that the handrails were loose and needed tightening or possible replacement. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Timely Report Alleged Abuse, Neglect, or Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately, but not later than 2 hours after the allegation was made, to the administrator, State Survey Agency (SSA), Adult Protective Services (APS), and local law enforcement. In several instances, staff did not notify the administrator or external agencies within the required timeframe after becoming aware of incidents involving residents. For example, after a resident reported being touched inappropriately by another resident, staff became aware of the incident at 5:51 AM, but the administrator was not notified until over 3 hours later, and notifications to SSA, APS, and law enforcement were delayed by more than 4 to 5 hours. In another case, two residents were found engaging in a sexual act in a bathroom. While the SSA was notified within an hour, notifications to APS and law enforcement were not made until four days after the facility became aware of the incident. The documentation did not include the exact time of these notifications, further indicating a lack of timely reporting as required by regulations. Additionally, a resident sustained an injury after falling in a transportation van. The incident was not reported to the SSA until several days later, and other agencies were not notified at the time of the incident. Interviews with the Director of Nursing and the administrator revealed uncertainty about whether the incident constituted neglect and acknowledged that the incident should have been reported. These failures demonstrate that the facility did not consistently follow required protocols for timely reporting of alleged abuse, neglect, or theft.
Failure to Maintain Clean and Homelike Resident Bathroom Environment
Penalty
Summary
A resident with a history of heart failure, type 2 diabetes, osteomyelitis, and diarrhea reported the presence of fecal matter on the wall next to the toilet in their bathroom, which had been there since admission. Multiple observations by the State Surveyor confirmed the presence of a brown substance on the wall near the toilet paper dispenser over several days, indicating the issue persisted throughout the survey period. Housekeeping staff interviewed stated that they cleaned the bathrooms daily, including the walls if needed, but did not notice the substance until it was pointed out. The Maintenance and Housekeeping Supervisor reported monitoring staff and addressing complaints as they arose, but was unaware of this specific issue until shown. Despite daily cleaning routines and available reporting mechanisms, the brown substance remained on the wall for an extended period, demonstrating a failure to maintain a safe, clean, and homelike environment for the resident.
Failure to Obtain and Document Required Laboratory Tests
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including type II diabetes mellitus, end stage renal disease, and hypertension, did not have required laboratory tests completed as ordered. The resident had physician orders for routine laboratory tests, specifically a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and hemoglobin A1c (HbA1c) to be performed every six months in February and August. Upon review of the resident's medical records, there was no documentation of the CBC, CMP, or HbA1c results for the required periods. Interviews with the Director of Nursing (DON) revealed that while some laboratory results for CBC and CMP were eventually obtained from the dialysis center, the HbA1c was not included. The DON further explained that the dialysis center was conducting its own lab tests based on orders from their Nurse Practitioner, not the facility's physician orders, and that these results were not consistently communicated to or documented in the facility's medical records. Additionally, it was unclear if the facility's physician had access to the dialysis center's lab results, and the required lab results were not present in the resident's records.
Failure to Provide Physician-Ordered Diet Texture for Resident with Chewing and Swallowing Difficulties
Penalty
Summary
A deficiency occurred when a resident with no teeth, moderate cognitive impairment, and documented swallowing difficulties was served a modified diet that was not approved by the physician. The resident was observed eating chopped Lo Mein, chicken, vegetables, and whole French fries, despite a physician's order for a soft and bite-sized diet. The resident had previously reported difficulty chewing large chunks of food, prompting the Dietary Manager (DM) to downgrade the diet to minced and moist and notify the Speech-Language Pathologist (SLP) and the clinical team. However, this change was not approved by the physician, and the SLP had not yet evaluated the resident. Staff interviews revealed confusion regarding the resident's prescribed diet, with CNAs unsure of the current order and the DM stating that the meal card had been updated to minced and moist without physician approval. The Director of Nursing (DON) acknowledged being notified of the resident's difficulties and the dietary change but confirmed that any diet downgrade required provider approval and SLP evaluation, which had not occurred at the time of the survey. As a result, the facility failed to ensure that food was prepared and provided in a form designed to meet the resident's individual needs as ordered by the physician.
Failure to Support Resident Choice for Independent Smoking Access After Hours
Penalty
Summary
A deficiency was identified when a resident, who had been assessed as safe to smoke without supervision, was not allowed access to the secured outside smoking patio after 9:00 PM except during designated supervised smoking times at 11:00 PM and 3:00 AM. The resident expressed a desire to sit outside on the patio at night but was informed by staff that he had to be inside by 9:00 PM. The resident reported feeling treated like a child and unable to leave when he wanted. Review of the resident's smoking evaluations confirmed that he was considered safe to smoke independently. Facility staff, including the ADON, stated that the back interior door to the patio locked automatically at 9:00 PM and reopened at 6:00 AM, and that the policy required residents to wait for supervised smoking times at night, even if they were independent smokers. The ADON cited staffing limitations as the reason for this policy, noting that staff could not accommodate letting residents in and out at will during the night. The Administrator indicated that independent smokers should be allowed access as they pleased, but acknowledged there was no way for residents to alert staff to be let back in except by knocking, as the patio door lacked a doorbell.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 148 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt. Olympus Rehabilitation Center | 1.3 mi | ★★★★★ | 2 | 2 |
| Meadow Brook Rehabilitation And Nursing | 1.6 mi | ★★★★★ | 14 | 0 |
| Monument Healthcare South Salt Lake | 1.6 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Murray Creek | 1.9 mi | ★★★★★ | 2 | 0 |
| St Joseph Villa | 2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.