01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-31 | 15 | 2025-03-31 | 8 |
| Cycle 2 | 2023-06-15 | 2 | 2023-06-15 | 4 |
| Cycle 3 | 2021-09-30 | 12 | 2021-09-30 | 4 |
CMS CCN 4651852026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Millcreek Rehabilitation And Nursing
3520 South Highland Drive · Salt Lake City, UT 84106 · Salt Lake County
Certified beds61CMS provider file
Recent citation rows45current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
45 rows in the current release
3 rows carry G–L scope/severity codes; 2 carry J–L. 8 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-07 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2026-04-08 · complaint2026-04-07 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · complaint2026-01-21 · FIREK0211Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2026-01-22 · complaint2025-03-31 · FIREE0004Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · FIREE0039Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2025-04-11 · complaint2025-03-31 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-04-11 · complaint2025-03-31 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-04-11 · complaint2025-03-31 · HEALTHF0610Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-04-11 · complaint2025-03-31 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-04-11 · complaint2025-03-31 · HEALTHF0770Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0775Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Keep complete, dated laboratory records in the resident's record.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0805Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · HEALTHF0924Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · FIREK0161Severity D · isolated; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · FIREK0225Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · FIREK0712Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-31 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-04-112023-06-15 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2023-07-1303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-03-31 | Fine | $25,441 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LANGFORD, SCOTTIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2017
- COTTONWOOD HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/10/2016
- MILLCREEK REHABILITATION AND NURSING LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/11/2025
- CLARK, BRENDANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/03/2025
- MYERS, WALTERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/04/2016
- STUBBS, RACHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/03/2025
- MYERS, KATIEIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- SWAIN, HOLLYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- SWAIN, JAREDIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- COTTONWOOD HEALTHCARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/03/2025
- MILLCREEK REHABILITATION AND NURSING LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- CLARK, BRENDANIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/03/2025
- STUBBS, RACHAELIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/03/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.25per resident day
RN hours0.69per resident day
Weekend nurse hours1.95per resident day
Staff turnover52.4%CMS reported field
06 / LOCAL RECORDS
Open the Salt Lake City ledger →Other published facilities nearby
City Creek Post Acute108 beds · CMS overall 3/521 citation rowsHolladay Healthcare Center120 beds · CMS overall 3/534 citation rowsMaple Ridge Rehabilitation And Nursing36 beds · CMS overall 1/547 citation rowsMeadow Brook Rehabilitation And Nursing41 beds · CMS overall 2/565 citation rowsMidtown Manor82 beds · CMS overall 1/542 citation rowsMonument Healthcare Cottonwood Creek77 beds · CMS overall 3/529 citation rowsMonument Healthcare Millcreek120 beds · CMS overall 4/518 citation rowsMonument Healthcare South Salt Lake140 beds · CMS overall 1/560 citation rows