Monument Healthcare Murray Creek
3855 South 700 East, Millcreek, UT 84106 · Salt Lake County · 184 certified beds · avg 113 residents/day · certified since Jul 16, 1984
Abuse citation flag (CMS)
Part of chain: MONUMENT HEALTH GROUP (11 facilities, chain avg rating 2.8★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 31, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 26, 2025 (Past Non-Compliance)
▲ Actual harm, repeated · Jun 28, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Jul 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 31, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 11, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (50)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 31, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 31, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 28, 2025 | ▲ H · Actual harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 28, 2025 | F · Potential for harm, facility-wide | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Jun 28, 2025 | F · Potential for harm, facility-wide | The facility did not provide a neutral and fair arbitration process. Arbitration is a way of settling disputes outside of court, and if it's used, the facility must agree with the resident on a neutral arbitrator and a convenient location. |
| Jun 28, 2025 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Jun 28, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 28, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 28, 2025 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Jun 28, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jun 28, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 28, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 28, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jun 28, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jun 28, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 28, 2025 | D · Potential for harm, one-off | The facility did not make sure resident rooms met each resident's needs. |
| Jan 31, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 31, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 6, 2021 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 6, 2021 | E · Potential for harm, repeated | The facility did not perform required COVID-19 testing on residents and staff. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. |
| Dec 6, 2021 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (11 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 21 | 0 | F |
| 2023 | 12 | 0 | F |
| 2024 | 1 | 1 | G ▲ |
| 2025 | 14 | 1 | H ▲ |
| 2026 | 2 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $81,468.
| Date | Type | Amount / length |
|---|---|---|
| Jun 28, 2025 | Fine | $73,320 |
| Jan 31, 2024 | Fine | $8,148 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.33 | 3.87 | 3.95 | bottom 31% in Utah; bottom 28% in the U.S. |
| Registered Nurse hours | 0.89 | 1.17 | 0.69 | bottom 34% in Utah; top 22% in the U.S. |
| Weekend total nurse staffing | 2.93 | 3.39 | 3.50 | bottom 34% in Utah; bottom 27% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.74 | 0.88 | 0.48 | bottom 48% in Utah; top 14% in the U.S. |
| Total nursing staff turnover (%) | 42.2 | 50.7 | 45.8 | top 28% in Utah; top 42% in the U.S. |
| RN turnover (%) | 53.8 | 40.6 | 42.9 | bottom 31% in Utah; bottom 30% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.82, RN 1.02, weekend 3.37. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Clawson, Travis | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Clawson, Travis | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Espinosa, Stephanie | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Espinosa, Stephanie | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Fragoso, Lindsay | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Fragoso, Lindsay | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Gangotena-Bernard, Fatima | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Gangotena-Bernard, Fatima | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Health Group Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Health Group Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/28/2025 |
| Marriott, Stephen | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Marriott, Stephen | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Monument Health Group LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Monument Health Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/26/2025 |
| Monument Health Properties LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Monument Real Estate Murray Creek LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Murray, Brian | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2018 |
| Robertson, Brett | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Robertson, Brett | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Samuelian, Spencer | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Is signing an arbitration agreement required for admission, and can we refuse it without affecting my family member's care?"
- "Does your admission agreement include an arbitration clause, and is signing it optional?"
- "How does your quality committee work, and can you share an example of a problem it identified and fixed?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Paramount Health and Rehabilitation | 0.6 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 | |
| Monument Healthcare Millcreek | 1.1 mi | Salt Lake City, UT | ★★★★☆ | 3/5 | |
| Little Cottonwood Rehabilitation and Nursing | 1.5 mi | South Salt Lake, UT | ★★★★★ | 5/5 | |
| Monument Healthcare Cottonwood Creek | 1.5 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 | |
| Highland Care Center | 1.7 mi | Holladay, UT | ★★★★★ | 4/5 | |
| Meadow Brook Rehabilitation and Nursing | 1.8 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Millcreek Rehabilitation and Nursing | 1.9 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Monument Healthcare South Salt Lake | 2.1 mi | Salt Lake City, UT | ★☆☆☆☆ | 1/5 | SFF |
| Spring Creek Healthcare Center | 2.1 mi | Salt Lake City, UT | ★★☆☆☆ | 2/5 | |
| Mt. Olympus Rehabilitation Center | 2.2 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 465094.