D62

Millcreek Rehabilitation and Nursing LLC

Grade D 62/100 composite score

Government - City/countyAbuse Citation

CMS Star Ratings

Overall
2/5
Health Insp.
1/5
Quality
5/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

61

Ownership

Government - City/county

Total Fines

$25,441

Last Survey

N/A

3520 South Highland Drive, Salt Lake City, UT 84106
8014847638

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.76h
LPN
0.07h
CNA
1.34h
Total
2.17h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

BEAVER VALLEY HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Nov 2015

100%

COTTONWOOD HEALTHCARE LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Feb 2016

MILLCREEK REHABILITATION AND NURSING LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jul 2025

CLARK, BRENDAN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2025

MYERS, WALTER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2016

STUBBS, RACHAEL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2025

LANGFORD, SCOTT

IndividualCORPORATE OFFICERSince Jul 2017

Penalties & Fines (1)

$25,441total fines
DateTypeDescriptionAmount
Mar 31, 2025Fine$25,441

Health Inspection Deficiencies (27)

March 31, 2025Health13 deficiencies3 severe
0584DMinimal harm, Isolated

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

Corrected Apr 11, 2025
0656EMinimal harm, Pattern

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

Corrected Apr 11, 2025
0770DMinimal harm, Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Corrected Apr 11, 2025
0775EMinimal harm, Pattern

Keep complete, dated laboratory records in the resident's record.

Administration Deficiencies

Corrected Apr 11, 2025
0805DMinimal harm, Isolated

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Corrected Apr 11, 2025
0842EMinimal harm, Pattern

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

Corrected Apr 11, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 11, 2025
0924EMinimal harm, Pattern

Put firmly secured handrails on each side of hallways.

Environmental Deficiencies

Corrected Apr 11, 2025
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Apr 11, 2025
0600GActual harm, Isolated

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

Corrected Apr 11, 2025
0609EMinimal harm, Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 11, 2025
0610JImmediate jeopardy, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 11, 2025
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 11, 2025
June 15, 2023Health2 deficiencies
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 4, 2023
0676DMinimal harm, Isolated

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

Corrected Aug 4, 2023
September 30, 2021Health12 deficiencies
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 18, 2021
0584EMinimal harm, Pattern

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

Corrected Nov 19, 2021
0636EMinimal harm, Pattern

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

Corrected Dec 10, 2021
0638EMinimal harm, Pattern

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 10, 2021
0676EMinimal harm, Pattern

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

Corrected Nov 19, 2021
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 10, 2021
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Dec 10, 2021
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Dec 10, 2021
0805DMinimal harm, Isolated

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Corrected Dec 10, 2021
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Nov 15, 2021
0825DMinimal harm, Isolated

Provide or get specialized rehabilitative services as required for a resident.

Quality of Life and Care Deficiencies

Corrected Dec 10, 2021
0840DMinimal harm, Isolated

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

Corrected Dec 10, 2021

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Frequently Asked Questions

What is the CareGrader rating for Millcreek Rehabilitation and Nursing LLC?

Millcreek Rehabilitation and Nursing LLC in Salt Lake City, Utah has a CareGrader grade of D (Below Average), with a composite score of 61.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Millcreek Rehabilitation and Nursing LLC?

Millcreek Rehabilitation and Nursing LLC has an overall CMS star rating of 2 out of 5, a health inspection rating of 1/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Millcreek Rehabilitation and Nursing LLC have?

Millcreek Rehabilitation and Nursing LLC has 27 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has Millcreek Rehabilitation and Nursing LLC been fined?

Yes. Millcreek Rehabilitation and Nursing LLC has $25,441 in total fines from CMS enforcement actions across 1 penalty.

How many beds does Millcreek Rehabilitation and Nursing LLC have?

Millcreek Rehabilitation and Nursing LLC has 61 certified beds with approximately 59 current residents (97% occupancy). The facility is located at 3520 South Highland Drive, Salt Lake City, Utah 84106. It is a government - city/county facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.