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.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
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-day | 2.12 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.65 | 0.55–0.75 |
| Weekend hours / resident-day | 1.88 | ≈ weekday level |
| Nursing turnover / year | 47% | median 45% |
| Fines (3-yr window) | 1 · $25,441 |
Inspection citations (29 in the current record)
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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
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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
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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
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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
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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
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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
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Potential for harm · D March 31, 2025
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected April 11, 2025 · Administration
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Potential for harm · E March 31, 2025
Keep complete, dated laboratory records in the resident's record.
Corrected April 11, 2025 · Administration
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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
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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
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Potential for harm · E March 31, 2025
Provide and implement an infection prevention and control program.
Corrected April 11, 2025 · Infection Control
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Potential for harm · E March 31, 2025
Put firmly secured handrails on each side of hallways.
Corrected April 11, 2025 · Environmental
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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
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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
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Potential for harm · D June 15, 2023
Provide and implement an infection prevention and control program.
Corrected August 4, 2023 · Infection Control
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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
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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
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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
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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
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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
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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
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Potential for harm · E September 30, 2021
Ensure medication error rates are not 5 percent or greater.
Corrected December 10, 2021 · Pharmacy Service
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Potential for harm · D September 30, 2021
Ensure that residents are free from significant medication errors.
Corrected December 10, 2021 · Pharmacy Service
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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
| Date | Type | Amount / length |
|---|---|---|
| March 31, 2025 | Fine | $25,441 |
Family & resident reviews — a separate signal, never mixed into the score
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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.