Federal inspection record · CMS data as of October 1, 2026
Millcreek Rehabilitation and Nursing
3520 South Highland Drive, Salt Lake City, UT · (801) 484-7638
- Cited for abuse (CMS abuse icon)
- Certified beds
- 61
- Residents per day
- 59
- Ownership
- Government
- Chain
- Beaver Valley Hospital
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 4, 2016
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Utah.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Utah homes
Millcreek Rehabilitation and Nursing carries 183.5 inspection points. That is fewer than 8% of Utah's 96 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Utah: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–15 pts
- 4★ 15–38 pts
- 3★ 38–66 pts
- 2★ 66–118.25 pts
- 1★ over 118.25 pts
Bars show every rated home in Utah by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
29 health citations on record since 2021. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (3)
-
J
Respond appropriately to all alleged violations.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Quality of Life and Care5E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide or get specialized rehabilitative services as required for a resident.
Resident Assessment and Care Planning4E
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Administration3E
- E
Keep complete, dated laboratory records in the resident's record.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Infection Control3E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Resident Rights3E
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
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.
- E
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.
Nutrition and Dietary3E
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Freedom from Abuse, Neglect, and Exploitation2E
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Pharmacy Service2E
- E
Ensure medication error rates are not 5 percent or greater.
- D
Ensure that residents are free from significant medication errors.
Environmental1E
- E
Put firmly secured handrails on each side of hallways.
Inspection history
2025-03-31
15 health deficiencies · 8 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2023-06-15
2 health deficiencies · 4 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2021-09-30
12 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 16 min of nursing staff time a day, 42 min of it from a registered nurse.
This home
2 h 16 min
Utah average
4 h 5 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 54% of nursing staff and 39% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$25,441 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-03-31 | Fine | $25,441 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.5 pts worse | 1.7 | 1.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.1 pts worse | 1.5 | 1.4 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.2 pts better | 100.0% | 97.8% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.1 pts better | 98.3% | 98.2% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.6 pts better | 0.9% | 2.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms9.5 pts better | 7.4% | 16.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.5 pts better | 1.8% | 3.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication13.5 pts better | 12.3% | 25.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.4 pts better | 8.4% | 13.8% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened6.2 pts better | 6.5% | 12.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased5.3 pts better | 5.4% | 10.7% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.6 pts better | 0.0% | 0.6% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.6 pts better | 1.3% | 1.9% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence6.2 pts better | 14.1% | 20.3% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.8 pts better | 1.0% | 3.8% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.5 pts better | 97.6% | 94.1% | 82.3% |
·
Who owns and runs it
13 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Clark, Brendan | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Clark, Brendan | Adp Of The SNF · Individual | 0% | 1 facilities |
| Cottonwood Healthcare LLC | Operational/Managerial Control · Organization | 0% | 26 facilities |
| Cottonwood Healthcare LLC | Adp Of The SNF · Organization | 0% | 26 facilities |
| Langford, Scott | Corporate Officer · Individual | 0% | 24 facilities |
| Millcreek Rehabilitation And Nursing LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Millcreek Rehabilitation And Nursing LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Myers, Katie | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 17 facilities |
| Myers, Walter | Operational/Managerial Control · Individual | 0% | 25 facilities |
| Stubbs, Rachael | Operational/Managerial Control · Individual | 0% | 5 facilities |
| Stubbs, Rachael | Adp Of The SNF · Individual | 0% | 5 facilities |
| Swain, Holly | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 16 facilities |
| Swain, Jared | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 20 facilities |
·
Fire safety
16 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems5F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D
Ensure gas cylinders are properly stored.
- D
Ensure proper usage of power strips and extension cords.
- D
Meet requirements for the use of electrical equipment.
Smoke4F
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Emergency Preparedness3F
- D
Conduct testing and exercise requirements.
- D
Develop and maintain an Emergency Preparedness Program (EP).
- F
Conduct testing and exercise requirements.
Egress2F
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Construction1D
- D
Use approved construction type or materials.
Miscellaneous1D
- D
Have simulated fire drills held at unexpected times.
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Other homes nearby
-
Mt. Olympus Rehabilitation Center
Salt Lake City, UT · Cascades Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 14 min
- Fines
- $144,459
-
Meadow Brook Rehabilitation and Nursing
Salt Lake City, UT · Cascades Healthcare · Abuse icon
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 9 min
- Fines
- $31,331
-
Monument Healthcare South Salt Lake
Salt Lake City, UT · Monument Health Group · Special Focus
★★★★★- Worst citation, 3 yrs
- L
- Nursing / resident / day
- 3 h 40 min
- Fines
- $36,546