NursingHomeGrade

Millcreek Rehabilitation and Nursing

3520 South Highland Drive, Salt Lake City, UT 84106

Operator

COTTONWOOD HEALTHCARE · 22 facilities

Provider number (CCN)
465185
Certification
Medicare and Medicaid
Ownership
Government - City/county
Certified beds
61
Phone
(801) 484-7638
CMS data as of
July 1, 2026
D

What the records show

CMS rates Millcreek Rehabilitation and Nursing 2 out of 5 stars overall, with 1 of 5 for health inspections, 2 of 5 for staffing, 5 of 5 for quality measures. Federal inspectors cited 29 health deficiencies across the last three survey cycles, most recently surveyed in 2025, 3 at actual-harm level or higher. CMS enforcement records list 1 fine totalling $25,441.

Facility Assessment Inspectors recorded 3 citations at the actual-harm level or worse in the last three survey cycles. This facility is operated by COTTONWOOD HEALTHCARE, which scores 15 points below the national average.

Reviews, Ratings and Official Records

This page reviews Millcreek Rehabilitation and Nursing using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.

At or above the 2024 benchmark — elevated deficiency count.

Ratings and Grade Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
 0.69 — At or above the repealed 0.55 hr benchmark

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 29
Outstanding 0
Actual harm or worse (G–L) 3
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
Overall: ★★☆☆☆ (2/5)
Health inspection: ★☆☆☆☆ (1/5)
Quality: ★★★★★ (5/5)
Staffing: ★★☆☆☆ (2/5)
NursingHomeGrade Score
 40/100

Loaded into NursingHomeGrade on August 7, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.

Staffing Compared With State and National Levels

This facility0.69 hrs
UT median1.04 hrs
National average0.69 hrs

Registered nurse turnover: 30.8% · Total nursing staff turnover: 52.4%

Staffing figures are the values CMS published in its file processed July 1, 2026, drawn from payroll-based journal reporting.

Audit and Inspection Reports

Millcreek Rehabilitation and Nursing is a Government - City/county facility. The records on this page are the federal health-inspection and enforcement records CMS publishes. We do not hold, and have not reviewed, any separate financial or performance audit issued by a county, state or independent auditor — if one exists for this facility, it is not part of the data described below.

Source records: CMS Care Compare profile for provider 465185 ↗ · the federal files we load and when.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

2 immediate jeopardy, 1 actual harm issues found among 29 total deficiencies. 29 corrected.

Most recent inspection (March 31, 2025)

E Potential harm — pattern F0775 Status: Corrected

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

Administration Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

D Potential harm — isolated F0770 Status: Corrected

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

Administration Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

E Potential harm — pattern F0924 Status: Corrected

Put firmly secured handrails on each side of hallways.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

D Potential harm — isolated F0609 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 8, 2026

J Immediate jeopardy — isolated F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

G Actual harm — isolated F0600 Status: Corrected

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 — Deficient, Provider has date of correction, corrected April 11, 2025

E Potential harm — pattern F0609 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

D Potential harm — isolated F0805 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

D Potential harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Past Non-Compliance

J Immediate jeopardy — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

E Potential harm — pattern F0656 Status: Corrected

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 — Deficient, Provider has date of correction, corrected April 11, 2025

E Potential harm — pattern F0842 Status: Corrected

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 — Deficient, Provider has date of correction, corrected April 11, 2025

D Potential harm — isolated F0561 Status: Corrected

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025

D Potential harm — isolated F0584 Status: Corrected

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 — Deficient, Provider has date of correction, corrected April 11, 2025

Inspection cycle 2 (June 15, 2023)

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 4, 2023

D Potential harm — isolated F0676 Status: Corrected

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 — Deficient, Provider has date of correction, corrected August 4, 2023

Inspection cycle 3 (September 30, 2021)

D Potential harm — isolated F0840 Status: Corrected

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 — Deficient, Provider has date of correction, corrected December 10, 2021

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2021

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2021

D Potential harm — isolated F0805 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021

E Potential harm — pattern F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021

D Potential harm — isolated F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021

E Potential harm — pattern F0676 Status: Corrected

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 — Deficient, Provider has date of correction, corrected November 19, 2021

D Potential harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021

D Potential harm — isolated F0825 Status: Corrected

Provide or get specialized rehabilitative services as required for a resident.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021

E Potential harm — pattern F0636 Status: Corrected

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 — Deficient, Provider has date of correction, corrected December 10, 2021

E Potential harm — pattern F0638 Status: Corrected

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021

E Potential harm — pattern F0584 Status: Corrected

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 — Deficient, Provider has date of correction, corrected November 19, 2021

Fines and Enforcement Actions

Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.

Date Action Amount or length
March 31, 2025 Fine $25,441

1 fine totalling $25,441.

Source: CMS Penalties file (dataset g6vv-u9sr).

Ownership and Contact Information

Facility name
Millcreek Rehabilitation and Nursing
Legal business name
BEAVER VALLEY HOSPITAL
Address
3520 South Highland Drive, Salt Lake City, UT 84106
Phone
(801) 484-7638
Provider number (CCN)
465185
Ownership type
Government - City/county
Operator
COTTONWOOD HEALTHCARE · 22 facilities
Medicare/Medicaid certified since
April 4, 2016
Official record
CMS Care Compare profile ↗
Details verified against CMS data dated
July 1, 2026

The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.

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Sources and Methodology

The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.

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