Millcreek Rehabilitation and Nursing
3520 South Highland Drive, Salt Lake City, UT 84106
Millcreek Rehabilitation and Nursing is a nursing home in Salt Lake City, Utah. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionMarch 31, 2025 (1 year ago)
- Health citations since September 30, 202129 (Utah average 26)
- Fines in the past three years1, $25,441 in total
- CMS flagsCMS abuse icon
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CMS flags
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of June 24, 2026
Name
CMS lists a new name for this home. It was Millcreek Rehabilitation and Nursing LLC.
Health inspection on April 7, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 8, 2026.
CMS has cited this home for F0609 2 times since 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS has cited this home for F0689 3 times since 2021.
Fire safety inspection on January 21, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on January 22, 2026.
CMS update of January 14, 2026
Fine
CMS changed the fine from March 31, 2025 from $24,840 to $25,441.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
Ownership
CMS lists this home under a new chain.
Health inspection on March 31, 2025
13 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
8 of 97 Utah homes (8%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $25,441 on March 31, 2025.
Show the 13 citations
Citation F0610. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 11, 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 11, 2025.
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 11, 2025.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 11, 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 11, 2025.
Citation F0775. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep complete, dated laboratory records in the resident's record.
CMS lists it as corrected on April 11, 2025.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 11, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for F0880 3 times since 2021.
Citation F0924. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Put firmly secured handrails on each side of hallways.
CMS lists it as corrected on April 11, 2025.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on April 11, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for F0584 2 times since 2021.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on April 11, 2025.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for F0805 2 times since 2021.
Fire safety inspection on March 31, 2025
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for K0321 2 times since 2021.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 11, 2025.
Citation K0225. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on April 11, 2025.
Citation E0004. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on April 11, 2025.
Citation E0039. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for E0039 2 times since 2023.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on April 11, 2025.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 11, 2025.
Health inspection on June 15, 2023
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on August 4, 2023.
CMS has cited this home for F0676 2 times since 2021.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 4, 2023.
Fire safety inspection on June 15, 2023
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on July 13, 2023.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on July 3, 2023.
Citation K0906. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure gas cylinders are properly stored.
CMS lists it as corrected on July 13, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on July 13, 2023.
Health inspection on September 30, 2021
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 19, 2021.
Citation F0636. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on December 10, 2021.
Citation F0638. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Assure that each resident’s assessment is updated at least once every 3 months.
CMS lists it as corrected on December 10, 2021.
Citation F0676. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on November 19, 2021.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on December 10, 2021.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 15, 2021.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 18, 2021.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 10, 2021.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on December 10, 2021.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on December 10, 2021.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on December 10, 2021.
Citation F0840. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 10, 2021.
Fire safety inspection on September 30, 2021
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on September 29, 2021.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on September 29, 2021.
Citation K0374. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on September 29, 2021.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on September 29, 2021.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (801) 484-7638
- Last standard health inspection
- March 31, 2025 (1 year ago)
- Certified beds
- 61
- Residents per day, on average
- 58.9
- Ownership type
- Government - City/county
- Legal business name
- Beaver Valley Hospital
- Chain
- Beaver Valley Hospital
- Takes part in
- Medicare and Medicaid
More health citations than the Utah average (29 vs 26).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- COTTONWOOD HEALTHCARE LLCOperational/managerial control · not applicable · since 02/10/2016
- MILLCREEK REHABILITATION AND NURSING LLCOperational/managerial control · not applicable · since 07/11/2025
- CLARK, BRENDANOperational/managerial control · not applicable · since 07/03/2025
- MYERS, WALTEROperational/managerial control · not applicable · since 04/04/2016
- STUBBS, RACHAELOperational/managerial control · not applicable · since 07/03/2025
Questions
When was Millcreek Rehabilitation and Nursing last inspected?
CMS lists March 31, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Millcreek Rehabilitation and Nursing have?
CMS lists 29 health citations since September 30, 2021. CMS also calls these deficiencies.
Has Millcreek Rehabilitation and Nursing been fined?
CMS lists 1 fine in the past three years, $25,441 in total.
What is the CMS star rating of Millcreek Rehabilitation and Nursing?
Its CMS overall star rating is 2 of 5.
Is Millcreek Rehabilitation and Nursing a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
Other nursing homes in Salt Lake City
- City Creek Post Acute
- Holladay Healthcare Center
- Maple Ridge Rehabilitation and Nursing
- Meadow Brook Rehabilitation and Nursing
- Midtown Manor
- Monument Healthcare Cottonwood Creek
- Monument Healthcare Millcreek
- Monument Healthcare South Salt Lake
- Monument Healthcare Taylorsville
- Mt. Olympus Rehabilitation Center