Millcreek Rehabilitation and Nursing

Nursing Home · Salt Lake City, UT

CMS overall rating 2/5 Abuse citation Government - City/county

CMS certification number465185
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).

Contact & location

3520 South Highland Drive
Salt Lake City, UT 84106
Salt Lake County
Phone
(801) 484-7638
ZIP code
84106 – all care providers

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Facility details

Certified beds
61
Residents per day
57.6 (94% occupied)
Ownership
Government - City/county
Legal name
Beaver Valley Hospital
Chain
Beaver Valley Hospital (5 facilities, avg 2.2★)
Medicare certified since
April 4, 2016
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 2/5
State avg 3.3
Health inspections★★★★★ 1/5
State avg 2.8
Staffing★★★★★ 2/5
State avg 3.0
Quality measures★★★★★ 5/5
State avg 4.6
Long-stay quality★★★★★ 5/5
Short-stay qualityNot rated

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
2.25 (state 4.07 · U.S. 3.86)
Registered nurses (RN)
0.69 (state 1.25 · U.S. 0.69)
Licensed practical nurses
0.16 (state 0.48 · U.S. 0.86)
Nurse aides
1.39 (state 2.35 · U.S. 2.32)
Weekend total
1.95 (state 3.56 · U.S. 3.42)
Nursing staff turnover
52.4 (state 50.7 · U.S. 45.8)%
RN turnover
30.8 (state 40.6 · U.S. 42.9)%
Administrators who left
0 in the last year

Inspections

Last standard inspection
March 31, 2025
Health deficiencies (last cycle)
15.0 (state 8.6 · U.S. 9.3)
From complaints
7
Citations on record (3 years)
29 health · 16 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-04-07 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-08
2026-04-07 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Past Non-Compliance
2025-03-31 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2025-04-11
2025-03-31 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2025-04-11
2025-03-31 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2025-04-11
2025-03-31 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Keep complete, dated laboratory records in the resident's record.
F0775 · Administration Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Put firmly secured handrails on each side of hallways.
F0924 · Environmental Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F0561 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 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.
F0584 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Provide timely, quality laboratory services/tests to meet the needs of residents.
F0770 · Administration Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2025-03-31 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-11
2023-06-15 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F0676 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-04
2023-06-15 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-04
2021-09-30 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.
F0584 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2021-11-19
2021-09-30 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F0636 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10
2021-09-30 Assure that each resident’s assessment is updated at least once every 3 months.
F0638 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10
2021-09-30 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F0676 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2021-11-19
2021-09-30 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10
2021-09-30 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2021-11-15
2021-09-30 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2021-11-18
2021-09-30 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10
2021-09-30 Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10
2021-09-30 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10
2021-09-30 Provide or get specialized rehabilitative services as required for a resident.
F0825 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10
2021-09-30 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.
F0840 · Administration Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2021-12-10

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

1 penalty in the last three years, including $25,441 in fines.

DateTypeAmount
2025-03-31Fine$25,441

Ownership & management

NameRoleSince
Clark, Brendan (individual)Administrator · NOT APPLICABLE
Cottonwood Healthcare LLC (organization)Administrator · NOT APPLICABLE
Millcreek Rehabilitation and Nursing LLC (organization)Administrator · NOT APPLICABLE
Stubbs, Rachael (individual)Administrator · NOT APPLICABLE
Langford, Scott (individual)Corporate Officer · NOT APPLICABLE
Myers, Katie (individual)Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE
Swain, Holly (individual)Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE
Swain, Jared (individual)Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE
Clark, Brendan (individual)Operational/managerial Control · NOT APPLICABLE
Cottonwood Healthcare LLC (organization)Operational/managerial Control · NOT APPLICABLE
Millcreek Rehabilitation and Nursing LLC (organization)Operational/managerial Control · NOT APPLICABLE
Myers, Walter (individual)Operational/managerial Control · NOT APPLICABLE
Stubbs, Rachael (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Millcreek Rehabilitation and Nursing?

Millcreek Rehabilitation and Nursing has a 2-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.3-star average in Utah.

How many beds does Millcreek Rehabilitation and Nursing have?

It has 61 certified beds and cares for about 58 residents per day.

Has Millcreek Rehabilitation and Nursing been fined?

Yes. CMS lists 1 penalty totaling $25,441 in the last three years.

Who owns Millcreek Rehabilitation and Nursing?

It is part of Beaver Valley Hospital and is classified as government - city/county. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Millcreek Rehabilitation and Nursing?

(801) 484-7638. The facility is located at 3520 South Highland Drive, Salt Lake City, UT 84106.

Other nursing homes in Salt Lake City

Compare all nursing homes in Salt Lake City, UT →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.