Millcreek Rehabilitation and Nursing LLC
3520 South Highland Drive, Salt Lake City, UT 84106 · CCN 465185
Abuse icon
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★★★★ 5
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- Government - City/county
- Certified beds
- 61
- Avg residents/day
- 59.6
- Phone
- 8014847638
Inspection history vs Utah & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Utah avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-03-31 | 13 | 9.1 | 9.5 | +3.9 worse |
| 2 | 2023-06-15 | 2 | 8.4 | 9.8 | -6.4 better |
| 3 | 2021-09-30 | 12 | 10.3 | 9.3 | +1.7 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 3 |
| Quality of life and care | 1 |
| Resident assessment and care planning | 2 |
| Resident rights | 2 |
| Nutrition and dietary | 1 |
| Environmental | 1 |
| Administration | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.21 | 51.2% |
| RN staffing (reported) | 0.78 | 46.2% |
| Total nurse staffing (adjusted) | 2.17 | — |
Fines & penalties
- Total fines
- $25,441
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- BEAVER VALLEY HOSPITAL
- Facilities in chain
- 5
- Chain avg overall
- 2.00 / 5
Inspection citations (27)2 immediate jeopardy1 actual harm
- DF0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0584Honor 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.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- GF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-03-31 · Health · corrected 2025-04-11
Actual harm
- EF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- JF0610Respond appropriately to all alleged violations.2025-03-31 · Health · corrected 2025-04-11
Immediate jeopardy
- EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-03-31 · Health · corrected 2025-04-11
Immediate jeopardy
- DF0770Provide timely, quality laboratory services/tests to meet the needs of residents.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0775Keep complete, dated laboratory records in the resident's record.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0924Put firmly secured handrails on each side of hallways.2025-03-31 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.2023-06-15 · Health · corrected 2023-08-04
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-06-15 · Health · corrected 2023-08-04
Potential for more than minimal harm
- EF0584Honor 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.2021-09-30 · Health · corrected 2021-11-19
Potential for more than minimal harm
- EF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- EF0638Assure that each resident’s assessment is updated at least once every 3 months.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- EF0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.2021-09-30 · Health · corrected 2021-11-19
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- EF0759Ensure medication error rates are not 5 percent or greater.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- DF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2021-09-30 · Health · corrected 2021-11-15
Potential for more than minimal harm
- DF0825Provide or get specialized rehabilitative services as required for a resident.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- DF0840Employ 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.2021-09-30 · Health · corrected 2021-12-10
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2021-09-30 · Health · corrected 2021-11-18
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| BEAVER VALLEY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2015-11-01 |
| COTTONWOOD HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2016-02-10 |
| MILLCREEK REHABILITATION AND NURSING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-07-11 |
| CLARK, BRENDAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-07-03 |
| MYERS, WALTER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2016-04-04 |
| STUBBS, RACHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-07-03 |
| LANGFORD, SCOTT | Individual | CORPORATE OFFICER | — | 2017-07-01 |
Other facilities in Salt Lake City
| Name | Overall | Beds |
|---|---|---|
| William E Christofferson Salt Lake Veterans Home | ★★★★★ | 81 |
| City Creek Post Acute | ★★★★★ | 108 |
| Monument Healthcare Taylorsville | ★★★★☆ | 120 |
| Monument Healthcare Millcreek | ★★★★☆ | 120 |
| St Joseph Villa | ★★★☆☆ | 221 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.