Hearth Record

Millcreek Rehabilitation and Nursing

A nursing home in Salt Lake City, Utah 84106

3520 South Highland Drive, Salt Lake City, Utah 84106. (801) 484-7638.

  • Cited for abuse (CMS flag)
CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 28, 2026.

The last 24 months 15 citations in 2 months of the last 36. Last cited Apr 2026. Most serious: immediate jeopardy to health or safety (J). Every month

Each figure’s source sits beside it, in its section below.

What these words mean8
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
Scope and severity (A to L)
CMS grades each nursing home deficiency with a letter. A to C: no actual harm, with potential for minimal harm. D to F: no actual harm, but potential for more. G to I: actual harm. J to L: immediate jeopardy. Within each band, the letter rises as more residents were affected or could be: one or a few, a pattern, or widespread. Source: CMS, nursing home scope and severity grid (State Operations Manual, chapter 7).
Nurse staffing hours
The hours registered nurses, licensed practical nurses and nurse aides worked, per resident per day, from the payroll records each home sends CMS. Source: CMS, Payroll-Based Journal.
Fines and payment denials
A fine (civil money penalty) is money CMS makes a nursing home pay when it falls short of federal rules. A payment denial means Medicare and Medicaid stop paying for new admissions until the home meets the rules again. Source: CMS; 42 CFR 488.430 and 488.417.
Immediate jeopardy
CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3.
Capacity
The most people the licence or certification lets the place care for at once: residents, children, beds or apartments, as the state counts them. It isn’t how many are there now. Source: Each state’s licensing agency.

What did inspectors find?

15 health citations at the latest inspection cycle

The Utah average is 8.8.

Last standard inspection Mar 31, 2025.

Most serious in three years: immediate jeopardy to health or safety (J), at a standard and complaint inspection on Mar 31, 2025

Source:

CMS, Provider Information, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

When those citations happened

15 citations in 2 months of the last 36. Last cited Apr 2026. Most serious: immediate jeopardy to health or safety (J). The last 3 years, to Nov 5, 2026.

15 citations by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

All 15 citations in the last three years

Grouped by inspection, newest first. Each carries , from A, the least serious, to L, the most. 7 came from complaint inspections.

Source:

CMS, Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Apr 7, 2026: complaint inspection2 citations

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

    Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 8, 2026.

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

    Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint.

Mar 31, 2025: standard inspection8 citations

  • 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.

    Rule F0584. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0656. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0770. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0775. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0805. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0842. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

  • Provide and implement an infection prevention and control program.

    Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

  • Put firmly secured handrails on each side of hallways.

    Rule F0924. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 11, 2025.

Mar 31, 2025: standard and complaint inspection5 citations

  • Respond appropriately to all alleged violations.

    Rule F0610. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0600. G: actual harm. From a complaint. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0561. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 11, 2025.

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

    Rule F0609. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 11, 2025.

Is it certified, and in good standing?

  • Certified for Medicare and Medicaid since Apr 4, 2016.
  • Not on CMS’s special focus list.
  • CMS marks it with its abuse icon: cited for abuse or neglect that harmed a resident.
  • No change of ownership in the last 12 months.
  • CMS lists its ownership as government, city/county.
  • 61 certified beds.
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Has it been fined or penalized?

  • 1 fine in the last three years, $25,441 in all.
  • No Medicare payment denials in the last three years.
  • 7 citations in the last three years came from complaint inspections.
Source:

CMS, Penalties and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Fines and payment denials, newest first
DateKindAmount
Mar 31, 2025Fine$25,441

Who does the caring?

2.26 nurse hours per resident per day

The Utah average is 4.08.

CMS publishes staffing about four months after the fact.

Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

Staffing measures
MeasureThis homeUtah average
Nurse hours per resident per day2.264.08
Of which registered nurses0.701.24
At weekends2.023.54
Nursing staff turnover53.5%50%
Registered nurse turnover38.5%40.1%
Administrators who left0Not given

Who owns it?

  • Beaver Valley Hospital owns 100% directly since Nov 1, 2015.
  • Millcreek Rehabilitation and Nursing LLC and Cottonwood Healthcare LLC run it.
  • 6 owners or officers are people: Walter E Myers (runs it (operational or managerial control), 100%); Scott A Langford (corporate officer, 0%); Brendan Clark (runs it (operational or managerial control)); Brendan Clark (additional disclosable party (controls, leases property to, or provides services to the home)); Rachael Stubbs (runs it (operational or managerial control)); Rachael Stubbs (additional disclosable party (controls, leases property to, or provides services to the home)).
  • Part of Beaver Valley Hospital (5 homes in CMS’s data).
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, All Owners. Checked Nov 5, 2026. Updated monthly.

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Organisations CMS lists
OrganisationRoleShareSince
Beaver Valley HospitalOwns 5% or more directly100%Nov 1, 2015
Millcreek Rehabilitation and Nursing LLCRuns it (operational or managerial control)Jul 11, 2025
Millcreek Rehabilitation and Nursing LLCAdditional disclosable party (controls, leases property to, or provides services to the home)Jul 11, 2025
Cottonwood Healthcare LLCRuns it (operational or managerial control)Feb 10, 2016
Cottonwood Healthcare LLCAdditional disclosable party (controls, leases property to, or provides services to the home)Jul 3, 2025

How do residents fare?

  • CMS rates its quality measures 5 of 5 (Utah average 4.7).
Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

CMS’s star ratings, from 1 to 5
MeasureRating
Overall rating2 of 5
Health inspections1 of 5
Staffing2 of 5
Quality measures5 of 5

How does it compare nearby?

  • Among the 12 nearest homes, within 2.9 miles, this one had the 4th most health citations at the latest inspection cycle (15; the middle value was 10).
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

The 12 nearest, by straight-line distance
PlaceMiles awayCitations, latest cycle
Millcreek Rehabilitation and Nursing This nursing home15
Mt. Olympus Rehabilitation Center1.310
Meadow Brook Rehabilitation and Nursing1.612
Monument Healthcare South Salt Lake1.621
Monument Healthcare Murray Creek1.916
St Joseph Villa2.05
Little Cottonwood Rehabilitation and Nursing2.25
Monument Healthcare Canyon Rim2.22
Highland Care Center2.37
Paramount Health and Rehabilitation2.44
Monument Healthcare Millcreek2.610
Spring Creek Healthcare Center2.918

What the record doesn’t say

  • Complaints that didn’t lead to a citation aren’t published.
  • Inspections reach CMS’s data about six weeks after they happen, and staffing about four months after.
  • CMS publishes the inspectors’ full written findings in a separate monthly file, which isn’t loaded yet.
  • Fines and Medicare payment denials are the only enforcement CMS publishes; state licence actions aren’t included.

Sources

  • Centers for Medicare & Medicaid Services, Provider Information (4pq5-n9py).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Health Deficiencies (r5ix-sfxw).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Penalties (g6vv-u9sr).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, All Owners (afe44b85-cc6d-40d7-b5df-00ae8910d1d2).

    Checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, State and US Averages (xcdc-v8bm).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the home

The public record above comes first. Anything the home adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the home will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the home”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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Who published it, when, and how often it changes sit beside each fact, with a link to the agency’s own file.

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