Millcreek Rehabilitation and Nursing

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

61 certified beds Government - City/county Chain: Beaver Valley Hospital

Why this verdict

  • Carries CMS’s abuse warning icon.
  • Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
  • Inspection record is far worse than the national median (deficiency count and severity).
  • Inspection results are getting worse cycle over cycle, not better.

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Red flags

CMS abuse warning

CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.

2 immediate-jeopardy citations in the most recent inspection cycle

Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.

2 abuse-related citations at the actual-harm level

Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.

Total nurse staffing below 3.0 hours per resident-day

2.12 reported hours vs the 3.48 minimum CMS's own staffing study recommends.

Score breakdown

Inspection record 30% of score 28
Serious harm & abuse 20% 0
Staffing 20% 48
Federal penalties 15% 70
Trend 10% 18
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 5 of 5

Total nurse hours / resident-day2.123.48 min · 4.1 strong
RN hours / resident-day0.650.55–0.75
Weekend hours / resident-day1.88≈ weekday level
Nursing turnover / year47%median 45%
Fines (3-yr window)1 · $25,441

Inspection citations (29 in the current record)

  • Potential for harm · D April 7, 2026 · found via complaint

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

    Corrected April 8, 2026 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D April 7, 2026 · found via complaint

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

    Past Non-Compliance · Quality of Life and Care

  • Immediate jeopardy · J March 31, 2025 · found via complaint

    Respond appropriately to all alleged violations.

    Corrected April 11, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Immediate jeopardy · J March 31, 2025 · found via complaint

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

    Corrected April 11, 2025 · Quality of Life and Care

  • Actual harm · G March 31, 2025 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected April 11, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D March 31, 2025

    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.

    Corrected April 11, 2025 · Resident Rights

  • Potential for harm · E March 31, 2025

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected April 11, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D March 31, 2025

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

    Corrected April 11, 2025 · Administration

  • Potential for harm · E March 31, 2025

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

    Corrected April 11, 2025 · Administration

  • Potential for harm · D March 31, 2025

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

    Corrected April 11, 2025 · Nutrition and Dietary

  • Potential for harm · E March 31, 2025

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected April 11, 2025 · Resident Assessment and Care Planning

  • Potential for harm · E March 31, 2025

    Provide and implement an infection prevention and control program.

    Corrected April 11, 2025 · Infection Control

  • Potential for harm · E March 31, 2025

    Put firmly secured handrails on each side of hallways.

    Corrected April 11, 2025 · Environmental

  • Potential for harm · D March 31, 2025 · found via complaint

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

    Corrected April 11, 2025 · Resident Rights

  • Potential for harm · E March 31, 2025 · found via complaint

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

    Corrected April 11, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D June 15, 2023

    Provide and implement an infection prevention and control program.

    Corrected August 4, 2023 · Infection Control

  • Potential for harm · D June 15, 2023 · found via complaint

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

    Corrected August 4, 2023 · Quality of Life and Care

  • Potential for harm · E September 30, 2021

    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.

    Corrected November 19, 2021 · Resident Rights

  • Potential for harm · E September 30, 2021

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    Corrected December 10, 2021 · Resident Assessment and Care Planning

  • Potential for harm · E September 30, 2021

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

    Corrected December 10, 2021 · Resident Assessment and Care Planning

  • Potential for harm · E September 30, 2021

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

    Corrected November 19, 2021 · Quality of Life and Care

  • Potential for harm · D September 30, 2021

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

    Corrected December 10, 2021 · Quality of Life and Care

  • Potential for harm · E September 30, 2021

    Ensure medication error rates are not 5 percent or greater.

    Corrected December 10, 2021 · Pharmacy Service

  • Potential for harm · D September 30, 2021

    Ensure that residents are free from significant medication errors.

    Corrected December 10, 2021 · Pharmacy Service

  • Potential for harm · D September 30, 2021

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

    Corrected December 10, 2021 · Nutrition and Dietary

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
March 31, 2025Fine$25,441

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 465185 · certified since April 4, 2016. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.