Millcreek Rehabilitation and Nursing
3520 South Highland Drive, Salt Lake City, UT 84106 · Salt Lake County · 61 certified beds · avg 58 residents/day · certified since Apr 4, 2016
Abuse citation flag (CMS)
Part of chain: BEAVER VALLEY HOSPITAL (5 facilities, chain avg rating 2.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 31, 2025 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 11, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Mar 31, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 11, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 31, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 11, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 7, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 7, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 31, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 31, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 31, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 31, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 31, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 31, 2025 | E · Potential for harm, repeated | The facility did not keep complete, dated laboratory records in residents' files. |
| Mar 31, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 31, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 31, 2025 | E · Potential for harm, repeated | The facility did not have firmly secured handrails on both sides of its hallways. |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 30, 2021 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Sep 30, 2021 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Sep 30, 2021 | E · Potential for harm, repeated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Sep 30, 2021 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Sep 30, 2021 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 30, 2021 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 30, 2021 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 30, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 30, 2021 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Sep 30, 2021 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Sep 30, 2021 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. |
| Sep 30, 2021 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 12 | 0 | E |
| 2023 | 2 | 0 | D |
| 2025 | 13 | 3 | J ▲ |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $25,441.
| Date | Type | Amount / length |
|---|---|---|
| Mar 31, 2025 | Fine | $25,441 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.27 | 3.87 | 3.95 | bottom 2% in Utah; bottom 2% in the U.S. |
| Registered Nurse hours | 0.70 | 1.17 | 0.69 | bottom 13% in Utah; top 37% in the U.S. |
| Weekend total nurse staffing | 1.97 | 3.39 | 3.50 | bottom 2% in Utah; bottom 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.49 | 0.88 | 0.48 | bottom 12% in Utah; top 34% in the U.S. |
| Total nursing staff turnover (%) | 52.4 | 50.7 | 45.8 | bottom 44% in Utah; bottom 31% in the U.S. |
| RN turnover (%) | 30.8 | 40.6 | 42.9 | top 37% in Utah; top 30% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.25, RN 0.69, weekend 1.95. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
Government - City/county
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Clark, Brendan | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/03/2025 |
| Clark, Brendan | Individual | ADP of the SNF | NOT APPLICABLE | 07/03/2025 |
| Cottonwood Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/10/2016 |
| Cottonwood Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/03/2025 |
| Langford, Scott | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2017 |
| Millcreek Rehabilitation and Nursing LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/11/2025 |
| Millcreek Rehabilitation and Nursing LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/11/2025 |
| Myers, Katie | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | 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 |
| Stubbs, Rachael | Individual | ADP of the SNF | NOT APPLICABLE | 07/03/2025 |
| 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 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How are lab results filed and reviewed, and how quickly does the doctor see abnormal results?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Mt. Olympus Rehabilitation Center | 1.3 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | |
| Meadow Brook Rehabilitation and Nursing | 1.6 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Monument Healthcare South Salt Lake | 1.6 mi | Salt Lake City, UT | ★☆☆☆☆ | 1/5 | SFF |
| Monument Healthcare Murray Creek | 1.9 mi | Millcreek, UT | ★★☆☆☆ | 1/5 | abuse |
| St Joseph Villa | 2.0 mi | Salt Lake City, UT | ★★★☆☆ | 3/5 | |
| Little Cottonwood Rehabilitation and Nursing | 2.1 mi | South Salt Lake, UT | ★★★★★ | 5/5 | |
| Monument Healthcare Canyon Rim | 2.2 mi | Millcreek, UT | ★★★☆☆ | 3/5 | |
| Highland Care Center | 2.3 mi | Holladay, UT | ★★★★★ | 4/5 | |
| Paramount Health and Rehabilitation | 2.4 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 | |
| Monument Healthcare Millcreek | 2.6 mi | Salt Lake City, UT | ★★★★☆ | 3/5 | |
| Spring Creek Healthcare Center | 3.0 mi | Salt Lake City, UT | ★★☆☆☆ | 2/5 | |
| Monument Healthcare Cottonwood Creek | 3.0 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 465185.