Millcreek Rehabilitation And Nursing
Salt Lake City, Salt Lake County, Utah · CCN 465185 · Government (City/county) · part of Beaver Valley Hospital (5 facilities, chain average 2.2 stars)
CMS rates Millcreek Rehabilitation And Nursing 2 of 5 overall as of August 2026. 61 certified beds, 58 residents a day on average. 29 citations on record from the current inspection cycles, 2 at immediate jeopardy; 1 fine totalling $25,441.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / — of 5 |
Staffing
| Total nurse staffing | 2.24525 hours per resident per day |
|---|---|
| Registered nurses | 0.68916 hours per resident per day |
| Weekend total | 1.95126 hours per resident per day |
| Nursing staff turnover | 52.4% (registered nurses 30.8%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-07 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-08 |
| 2026-04-07 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance |
| 2025-03-31 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 | Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · tag F0775 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · tag F0924 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 complaint survey |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · tag F0770 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-11 |
| 2025-03-31 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-04 |
| 2023-06-15 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0636 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-12-10 |
| 2021-09-30 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · tag F0638 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Quality of Life and Care Deficiencies · tag F0676 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-11-19 |
| 2021-09-30 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-11-15 |
| 2021-09-30 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-11-18 |
| 2021-09-30 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-10 |
| 2021-09-30 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-10 |
| 2021-09-30 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-10 |
| 2021-09-30 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · tag F0825 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Administration Deficiencies · tag F0840 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-10 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-03-31 | Fine | $25,441 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Cottonwood Healthcare LLC Organization | adp of the snf | — | 2025-07-03 |
| Millcreek Rehabilitation And Nursing LLC Organization | adp of the snf | — | 2025-07-11 |
| Cottonwood Healthcare LLC Organization | operational/managerial control | — | 2016-02-10 |
| Millcreek Rehabilitation And Nursing LLC Organization | operational/managerial control | — | 2025-07-11 |
| Clark, Brendan Individual | adp of the snf | — | 2025-07-03 |
| Stubbs, Rachael Individual | adp of the snf | — | 2025-07-03 |
| Langford, Scott Individual | corporate officer | — | 2017-07-01 |
| Myers, Katie Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-07-11 |
| Swain, Holly Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-07-11 |
| Swain, Jared Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-07-11 |
| Clark, Brendan Individual | operational/managerial control | — | 2025-07-03 |
| Myers, Walter Individual | operational/managerial control | — | 2016-04-04 |
| Stubbs, Rachael Individual | operational/managerial control | — | 2025-07-03 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Millcreek Rehabilitation And Nursing.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Salt Lake County.