Millcreek Rehabilitation and Nursing LLC
3520 South Highland Drive, Salt Lake City, UT 84106
At or above the 2024 benchmark — elevated deficiency count.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.78 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced.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 |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
27
Outstanding
0
Actual harm or worse (G–L)
3
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★★★ (5/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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47/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
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 27 total deficiencies. 27 corrected.
Most recent inspection (March 31, 2025)
Provide timely, quality laboratory services/tests to meet the needs of residents.
Administration Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025
Keep complete, dated laboratory records in the resident's record.
Administration Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025
Put firmly secured handrails on each side of hallways.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025
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
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
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2025
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
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
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
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
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
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
Inspection cycle 2 (June 15, 2023)
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 4, 2023
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)
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
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2021
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
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
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2021
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
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
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
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
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
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
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