Millcreek Rehabilitation and NursingCMS ratings, inspections and fines
- Address
- 3520 South Highland Drive, Salt Lake City, UT 84106
- CCN
- 465185
- Ownership type
- Government, city/county
- Certified beds
- 61
- Residents per day
- 58
- CMS flags
- CMS abuse icon
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Millcreek Rehabilitation and Nursing an overall rating of 2 of 5 stars. The last standard survey was on 31 Mar 2025. The latest survey cycle has 15 health citations. The median for nursing homes in Utah is 7. CMS lists 1 fine of $25,441 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Salt Lake County median | Utah median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 2 | 3.0 | 3.0 | 3.0 |
| Health inspection rating | 1 | 2.0 | 3.0 | 2.8 |
| Staffing rating | 2 | 3.0 | 3.0 | 2.9 |
| Quality measure rating | 5 | 5.0 | 5.0 | 3.6 |
A median is the middle value of the homes in the group: 35 homes in the county, 97 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Utah median |
|---|---|---|---|
| Cycle 1 (latest) | 31 Mar 2025 | 15 | 7 |
| Cycle 2 | 15 Jun 2023 | 2 | 6 |
| Cycle 3 | No date | 12 | 7 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | K0 | L0 | |
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | F0 | ||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 15 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 7 Apr 2026 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 8 Apr 2026 |
| 7 Apr 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | Past Non-Compliance |
| 31 Mar 2025 | F0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Complaint investigation | 11 Apr 2025 |
| 31 Mar 2025 | F0584 | 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. | D | Standard survey | 11 Apr 2025 |
| 31 Mar 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint investigation | 11 Apr 2025 |
| 31 Mar 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E | Complaint investigation | 11 Apr 2025 |
| 31 Mar 2025 | F0610 | Respond appropriately to all alleged violations. | J | Complaint investigation | 11 Apr 2025 |
| 31 Mar 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard survey | 11 Apr 2025 |
| 31 Mar 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 11 Apr 2025 |
| 31 Mar 2025 | F0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. | D | Standard survey | 11 Apr 2025 |
| 31 Mar 2025 | F0775 | Keep complete, dated laboratory records in the resident's record. | E | Standard survey | 11 Apr 2025 |
| 31 Mar 2025 | F0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D | Standard survey | 11 Apr 2025 |
| 31 Mar 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Standard survey | 11 Apr 2025 |
| 31 Mar 2025 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 11 Apr 2025 |
| 31 Mar 2025 | F0924 | Put firmly secured handrails on each side of hallways. | E | Standard survey | 11 Apr 2025 |
Survey cycle 2: 2 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 15 Jun 2023 | F0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Standard survey | 4 Aug 2023 |
| 15 Jun 2023 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 4 Aug 2023 |
Survey cycle 3: 12 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 30 Sep 2021 | F0584 | 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. | E | Standard survey | 19 Nov 2021 |
| 30 Sep 2021 | F0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | E | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0638 | Assure that each resident’s assessment is updated at least once every 3 months. | E | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | E | Standard survey | 19 Nov 2021 |
| 30 Sep 2021 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0759 | Ensure medication error rates are not 5 percent or greater. | E | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0760 | Ensure that residents are free from significant medication errors. | D | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 15 Nov 2021 |
| 30 Sep 2021 | F0825 | Provide or get specialized rehabilitative services as required for a resident. | D | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0840 | 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. | D | Standard survey | 10 Dec 2021 |
| 30 Sep 2021 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 18 Nov 2021 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 31 Mar 2025 | Fine | $25,441 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Utah median | Utah average (CMS) |
|---|---|---|---|
| All nurse staff | 2.25 | 3.70 | 4.07 |
| Registered nurses (RN) | 0.69 | 1.00 | 1.25 |
| Licensed practical nurses (LPN) | 0.16 | 0.48 | |
| Nurse aides | 1.39 | 2.35 | |
| All nurse staff, weekends | 1.95 | 3.20 | 3.56 |
- Nurse staff turnover in a year
- 52.4%
- Nurse staff turnover, Utah median
- 50.9%
- RN turnover in a year
- 30.8%
- Administrators who left in a year
- 0
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Utah median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 5.9% | 10.6% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.2% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.4% | 1.6% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.9% | 2.1% | 2.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.7% | 13.0% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.6% | 3.2% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 9.9% | 10.3% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- Government, city/county
- Legal business name
- Beaver Valley Hospital
- Chain
- Beaver Valley Hospital (5 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Cottonwood Healthcare LLC | Operational/managerial control | 10 Feb 2016 | |
| Millcreek Rehabilitation and Nursing LLC | Operational/managerial control | 11 Jul 2025 | |
| Cottonwood Healthcare LLC | Adp of the snf | 3 Jul 2025 | |
| Millcreek Rehabilitation and Nursing LLC | Adp of the snf | 11 Jul 2025 |
The site shows organisations only. It does not show the names of persons.
Other homes in Salt Lake County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Mt. Olympus Rehabilitation Center | Salt Lake City | 2 of 5 | 17 | $149,703 | 9 May 2024 | |
| Meadow Brook Rehabilitation and Nursing | Salt Lake City | 2 of 5 | 12 | $31,331 | 20 Nov 2025 | |
| Monument Healthcare South Salt LakeSpecial Focus candidate | Salt Lake City | 1 of 5 | 20 | $36,546 | 19 Jun 2025 | |
| Monument Healthcare Murray Creek | Millcreek | 2 of 5 | 16 | $81,468 | 28 Jun 2025 | |
| St Joseph Villa | Salt Lake City | 3 of 5 | 5 | $0 | 16 Jul 2024 | |
| Little Cottonwood Rehabilitation and Nursing | South Salt Lake | 5 of 5 | 5 | $0 | 9 Oct 2025 | |
| Monument Healthcare Canyon Rim | Millcreek | 3 of 5 | 0 | $6,676 | 27 Jun 2024 | |
| Highland Care Center | Holladay | 5 of 5 | 5 | $0 | 11 Jun 2024 | |
| Paramount Health and Rehabilitation | Salt Lake City | 3 of 5 | 4 | $106,480 | 21 May 2026 | |
| Monument Healthcare Millcreek | Salt Lake City | 4 of 5 | 10 | $0 | 20 Nov 2025 | |
| Spring Creek Healthcare Center | Salt Lake City | 2 of 5 | 12 | $53,472 | 3 Feb 2025 | |
| Monument Healthcare Cottonwood Creek | Salt Lake City | 3 of 5 | 6 | $17,940 | 4 Apr 2024 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Millcreek Rehabilitation and Nursing (CCN 465185). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/millcreek-rehabilitation-and-nursing-salt-lake-city-ut-465185/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Millcreek Rehabilitation and Nursing last inspected?
- The latest inspection with a citation in the CMS record was on 7 Apr 2026. It was a complaint investigation. It gave 2 citations. The standard survey before the last one was on 15 Jun 2023.
- Who operates Millcreek Rehabilitation and Nursing?
- The CMS record gives the ownership type as government, city/county. CMS lists the home in the chain Beaver Valley Hospital. The CMS ownership file names Cottonwood Healthcare LLC and Millcreek Rehabilitation and Nursing LLC for operational or managerial control. This site does not show the names of persons.
- Is Millcreek Rehabilitation and Nursing a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 1 home in Utah as a Special Focus Facility and 5 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.