nursing home in Salt Lake City, UT
Millcreek Rehabilitation and Nursing
3520 South Highland Drive, Salt Lake City, UT 84106 · (801) 484-7638
★★★★★2
Below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★1
- Staffing★★★★★2
- Quality measures★★★★★5
- Abuse citation
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Millcreek Rehabilitation and Nursing at a glance
Millcreek Rehabilitation and Nursing is a 61-bed government nursing home in Salt Lake City, Utah (Salt Lake County).
CMS gives it 2 out of 5 stars on its overall star rating, worse than the Utah average of 3.3.
Residents receive about 2.2 hours of nursing care per day (0.7 of them from registered nurses), worse than the state average of 4.1 hours.
Its most recent standard health inspection (March 31, 2025) found 15 health citations. The Utah average is 8.8.
Federal regulators fined it 1 time in the past three years, totaling $25,441.
Nursing staff turnover is 52.4% per year (state average 50.7%).
Facility details
- Type
- Nursing home
- Ownership
- Government - City/County
- Beds
- 61
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Beaver Valley Hospital
- Medicare-certified since
- April 4, 2016
- Resident/family council
- Resident
- County
- Salt Lake County
- CMS Certification Number
- 465185
Ratings
| Measure | This facility | Utah avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 2 / 5 | 3.3 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 1 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 2 / 5 | 3.2 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 5 / 5 | 4.6 / 5 | 3.6 / 5 | Better |
| Long-stay quality rating (higher is better) | 5 / 5 | 4.4 / 5 | 3.8 / 5 | Better |
Staffing
| Measure | This facility | Utah avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 2.25 hrs | 4.09 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.69 hrs | 1.25 hrs | 0.69 hrs | Average |
| Nurse aide hours per resident per day (higher is better) | 1.39 hrs | 2.36 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 1.95 hrs | 3.58 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 52.4% | 50.7% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 30.8% | 40.6% | 42.9% | Better |
| Administrators who left in the past year (lower is better) | 0 | 1 | 1 | Better |
Inspections
| Measure | This facility | Utah avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 15 | 9 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 7 | 3 | 3 | Worse |
| Weighted health inspection score ⓘ (lower is better) | 183.5 | 83.8 | 80.6 | Worse |
Penalties
| Measure | This facility | Utah avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 1 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $25,441 | $23,954 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 1 | 1 | 1 | Average |
Size
| Measure | This facility | Utah avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 61 | 86 | 107 | |
| Average residents per day | 58 | 61 | 86 | |
| Occupancy | 94.4% | 74.7% | 80.9% |
Long-stay residents
| Measure | This facility | Utah avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 0.9% | 2.5% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 1.6% | 3.9% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 9.9% | 14.2% | 15.4% | Better |
| Long-stay residents with a urinary tract infection (lower is better) | 1.4% | 1.8% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.7% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 5.9% | 11.3% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 8.7% | 15.1% | 14.1% | Better |
| Long-stay residents who lose too much weight (lower is better) | 0.9% | 3.4% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 4.7% | 16.5% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 12.9% | 25.3% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 15.2% | 21.5% | 19% | Better |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 98% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 100% | 97.4% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Utah avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents given a pneumonia vaccine (higher is better) | 96.3% | 93.8% | 82% | Better |
Inspection citations
State inspectors cited this home for 29 health deficiencies and 16 fire safety deficiencies in the inspection records CMS currently publishes. 3 citations involved actual harm, including 2 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| April 7, 2026 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected April 8, 2026 |
| April 7, 2026 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Past Non-Compliance |
| January 21, 2026 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | F Potential harm, widespread | Corrected January 22, 2026 |
| March 31, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected April 11, 2025 |
| March 31, 2025 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | F Potential harm, widespread | Corrected April 11, 2025 |
| March 31, 2025 Fire safety | Have stairways and smokeproof enclosures used as exits that meet safety requirements. Egress Deficiencies · Tag K0225 | E Potential harm, pattern | Corrected April 11, 2025 |
| March 31, 2025 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | D Potential harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Fire safety | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Tag E0004 | D Potential harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | D Potential harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Fire safety | Use approved construction type or materials. Construction Deficiencies · Tag K0161 | D Potential harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | J Immediate jeopardy, isolated | Corrected April 11, 2025 |
| March 31, 2025 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | J Immediate jeopardy, isolated | Corrected April 11, 2025 |
| March 31, 2025 Complaint | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | G Actual harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | E Potential harm, pattern | Corrected April 11, 2025 |
| March 31, 2025 Standard | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · Tag F0924 | E Potential harm, pattern | Corrected April 11, 2025 |
| March 31, 2025 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | E Potential harm, pattern | Corrected April 11, 2025 |
| March 31, 2025 Standard | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | E Potential harm, pattern | Corrected April 11, 2025 |
| March 31, 2025 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected April 11, 2025 |
| March 31, 2025 Standard | Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · Tag F0775 | E Potential harm, pattern | Corrected April 11, 2025 |
| March 31, 2025 Standard | 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. Resident Rights Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Standard | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Tag F0805 | D Potential harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Standard | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Tag F0770 | D Potential harm, isolated | Corrected April 11, 2025 |
| March 31, 2025 Complaint | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Tag F0561 | D Potential harm, isolated | Corrected April 11, 2025 |
| June 15, 2023 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | F Potential harm, widespread | Corrected July 13, 2023 |
| June 15, 2023 Fire safety | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0914 | F Potential harm, widespread | Corrected July 3, 2023 |
| June 15, 2023 Fire safety | Ensure gas cylinders are properly stored. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0906 | D Potential harm, isolated | Corrected July 13, 2023 |
| June 15, 2023 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | D Potential harm, isolated | Corrected July 13, 2023 |
| June 15, 2023 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected August 4, 2023 |
| June 15, 2023 Standard | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | D Potential harm, isolated | Corrected August 4, 2023 |
| September 30, 2021 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | E Potential harm, pattern | Corrected September 29, 2021 |
| September 30, 2021 Fire safety | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0919 | D Potential harm, isolated | Corrected September 29, 2021 |
| September 30, 2021 Fire safety | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Tag K0372 | D Potential harm, isolated | Corrected September 29, 2021 |
| September 30, 2021 Fire safety | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Tag K0374 | D Potential harm, isolated | Corrected September 29, 2021 |
| September 30, 2021 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected November 18, 2021 |
| September 30, 2021 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected November 15, 2021 |
| September 30, 2021 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | E Potential harm, pattern | Corrected December 10, 2021 |
| September 30, 2021 Standard | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | E Potential harm, pattern | Corrected November 19, 2021 |
| September 30, 2021 Standard | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Tag F0638 | E Potential harm, pattern | Corrected December 10, 2021 |
| September 30, 2021 Standard | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Tag F0636 | E Potential harm, pattern | Corrected December 10, 2021 |
| September 30, 2021 Standard | 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. Resident Rights Deficiencies · Tag F0584 | E Potential harm, pattern | Corrected November 19, 2021 |
| September 30, 2021 Standard | 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. Administration Deficiencies · Tag F0840 | D Potential harm, isolated | Corrected December 10, 2021 |
| September 30, 2021 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected December 10, 2021 |
| September 30, 2021 Standard | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected December 10, 2021 |
| September 30, 2021 Standard | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Tag F0805 | D Potential harm, isolated | Corrected December 10, 2021 |
| September 30, 2021 Standard | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Tag F0825 | D Potential harm, isolated | Corrected December 10, 2021 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 1 federal penalty in the past three years, including $25,441 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| March 31, 2025 | Fine | $25,441 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| CLARK, BRENDAN Individual | adp of the snf | NOT APPLICABLE | 07/03/2025 |
| COTTONWOOD HEALTHCARE LLC Organization | adp of the snf | NOT APPLICABLE | 07/03/2025 |
| MILLCREEK REHABILITATION AND NURSING LLC Organization | adp of the snf | NOT APPLICABLE | 07/11/2025 |
| STUBBS, RACHAEL Individual | adp of the snf | NOT APPLICABLE | 07/03/2025 |
| LANGFORD, SCOTT Individual | corporate officer | NOT APPLICABLE | 07/01/2017 |
| MYERS, KATIE Individual | individual is an owner, partner or trustee of any adp of the snf | NOT APPLICABLE | 07/11/2025 |
| SWAIN, HOLLY Individual | individual is an owner, partner or trustee of any adp of the snf | NOT APPLICABLE | 07/11/2025 |
| SWAIN, JARED Individual | individual is an owner, partner or trustee of any adp of the snf | NOT APPLICABLE | 07/11/2025 |
| CLARK, BRENDAN Individual | operational/managerial control | NOT APPLICABLE | 07/03/2025 |
| COTTONWOOD HEALTHCARE LLC Organization | operational/managerial control | NOT APPLICABLE | 02/10/2016 |
| MILLCREEK REHABILITATION AND NURSING LLC Organization | operational/managerial control | NOT APPLICABLE | 07/11/2025 |
| MYERS, WALTER Individual | operational/managerial control | NOT APPLICABLE | 04/04/2016 |
| STUBBS, RACHAEL Individual | operational/managerial control | NOT APPLICABLE | 07/03/2025 |
Other nursing homes near Millcreek Rehabilitation and Nursing
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★★★★★1Much below averageMonument Healthcare Murray Creek
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★★★★★2Below averageSt Joseph Villa
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Frequently asked questions
What is Millcreek Rehabilitation and Nursing's rating?
Millcreek Rehabilitation and Nursing has 2 out of 5 stars on the CMS overall star rating. The average for Utah nursing homes is 3.3 stars.
How many inspection citations did Millcreek Rehabilitation and Nursing receive?
Its most recent standard health inspection found 15 citations, compared with a Utah average of 8.8. Every citation is listed on this page with its severity.
Does Millcreek Rehabilitation and Nursing accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Millcreek Rehabilitation and Nursing?
It is government - city/county and part of Beaver Valley Hospital. The ownership section on this page lists the owners and managers reported to CMS.
Where is Millcreek Rehabilitation and Nursing and how do I contact it?
Millcreek Rehabilitation and Nursing is at 3520 South Highland Drive, Salt Lake City, UT 84106. Phone: (801) 484-7638.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.