Millcreek Rehabilitation and Nursing
3520 South Highland Drive, Salt Lake City, UT 84106 · All homes in Salt Lake City
Millcreek Rehabilitation and Nursing, a 61-bed government - city/county nursing facility in Salt Lake City, UT, holds a 2-star CMS overall rating - below the 3.0-star national average, ranking #80 of 96 rated homes in UT on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 8014847638
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- 2 / 5
- Below average · CMS overall · nat'l 3.0
- #80 of 96
- In-state rank among rated UT homes
- 2.25
- Well below average · nurse hrs/day · nat'l 3.86
- 29
- Inspection findings · 3 serious
If a nursing-home resident is in immediate danger, call 911.
For elder abuse or neglect concerns, contact your state's Adult Protective Services (search "APS" + your state) or call the Eldercare Locator at 1-800-677-1116. For facility advocacy, reach your Long-Term Care Ombudsman. CMS ratings and inspection data below are a research screen, not an emergency channel.
The verdict
Millcreek Rehabilitation and Nursing, a 61-bed government - city/county nursing facility in Salt Lake City, UT, holds a 2-star CMS overall rating - below the 3.0-star national average, ranking #80 of 96 rated homes in UT on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
- 2 / 5
- CMS overall · national 3.0
- #80 of 96
- In-state rank among rated UT homes
- 2.25
- Nurse hrs/resident-day · national 3.86
- 29
- Inspection findings · 3 serious
CMS force-curves overall stars within each state; read health, staffing, and quality sub-ratings alongside the headline.
In-state ownership mix · peer inventory
How 97 UT nursing homes split by ownership sector
This facility is recorded as Government - City/county. Sector buckets collapse CMS ownership_type into For-profit, Nonprofit, and Government, orthogonal to the RN/LPN/CNA hour bar below.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 465185
- Ownership
- Government - City/county
- Provider Type
- Medicare and Medicaid
- Beds
- 61
- Residents
- 58
- In Hospital
- No
- County
- Salt Lake
- Last Inspection
- Mar 31, 2025
Staffing Data
How the 2.25 total nursing hours per resident-day are staffed:
- RN Hours
- 0.69 (nat'l avg: 0.69)
- LPN Hours
- 0.16
- CNA Hours
- 1.39
- Total Nursing Hours
- 2.25 (nat'l avg: 3.86)
- PT Hours
- 0.01
- Nursing Turnover
- 52.4%
- RN Turnover
- 30.8%
What the CMS Record Reveals About Millcreek Rehabilitation and Nursing
According to CMS Nursing Home Compare, Millcreek Rehabilitation and Nursing ranks #80 of 96 rated nursing homes in UT on overall stars (tie-broken by health+staffing+quality, then fewer fines). Millcreek Rehabilitation and Nursing operates 61 certified beds in Salt Lake City, UT with approximately 58 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars (health inspection 1★ · staffing 2★ · quality 5★).
The inspection file contains 29 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. CMS enforcement records show 1 penalty totaling $25K levied against this facility. Per resident day, this facility reports 2.25 total nursing hours (national average 3.86) and 0.69 RN hours.
Classified as "Government - City/county" ownership and operating as a "Medicare and Medicaid" provider, Millcreek Rehabilitation and Nursing falls into a category where comparative context matters. Reported nursing staff turnover at this facility is 52.4% (CMS payroll-based measure).
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify the same record on Medicare.gov Care Compare and with the facility or your state survey agency before making placement decisions.
Deficiency History (29 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 8, 2026
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 11, 2025
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Apr 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.
Category: Resident Rights Deficiencies
Corrected: Apr 11, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Apr 11, 2025
Put firmly secured handrails on each side of hallways.
Category: Environmental Deficiencies
Corrected: Apr 11, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 11, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 11, 2025
Keep complete, dated laboratory records in the resident's record.
Category: Administration Deficiencies
Corrected: 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.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 11, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 11, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 11, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 11, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 11, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 4, 2023
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 4, 2023
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.
Category: Administration Deficiencies
Corrected: Dec 10, 2021
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 10, 2021
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 10, 2021
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Dec 10, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 10, 2021
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 18, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 15, 2021
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Dec 10, 2021
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 19, 2021
Assure that each resident’s assessment is updated at least once every 3 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 10, 2021
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 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.
Category: Resident Rights Deficiencies
Corrected: Nov 19, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 5.9% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.7% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.6% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 9.9% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | N/A | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.9% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.7% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 12.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 15.2% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 96.3% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
Penalty History 1 penalties totaling $25K
| Date | Type | Amount |
|---|---|---|
| Mar 31, 2025 | Fine | $25K |
Nationwide facilities with similar scale or staffing
Two data-derived peer sets for Millcreek Rehabilitation and Nursing, both outside UT so the neighborhoods are not the same-state geography list below.
Similar bed count
Nearest CMS certified bed counts outside UT (61 beds here).
Similar staffing hours
Nearest CMS adjusted total nurse hours per resident day outside UT (2.27 here).
Nearby Nursing Homes in UT
96 other nursing homes are on record in UT; 6 are shown here.
Advanced Health Care of Salem
Salem, UT
Advanced Health Care of St. George
St George, UT
Alpine Meadow Rehabilitation and Nursing
West Valley City, UT
Aspen Ridge of Utah Valley
Orem, UT
Aspen Ridge Transitional Rehab
Murray, UT
Aspen Ridge West Transitional Rehab
Murray, UT
Understanding Nursing Home Data
What the CMS records show for Millcreek Rehabilitation and Nursing
The health, staffing, and quality sub-ratings above often diverge from the CMS overall headline. Use those components and the inspection findings to read the full file, not the overall star alone.
- The UT registry aggregates state averages and the highest-rated homes in this cohort. View UT registry
- Peer homes near 61 beds show how CMS stars vary at a similar scale in UT. Compare a similar-size peer
- CMS publishes separate fields for inspections, nurse staffing hours, and quality measures; the guide explains how each star is computed. How CMS ratings work
CMS refreshes Nursing Home Compare quarterly (current extract: August 2026). PlainNursing describes published records; it does not establish suitability, availability, admissions, or individual outcomes.
Frequently Asked Questions
What is the overall CMS rating for Millcreek Rehabilitation and Nursing?
Where does Millcreek Rehabilitation and Nursing rank among nursing homes in UT?
What are the staffing levels at Millcreek Rehabilitation and Nursing?
How many beds does Millcreek Rehabilitation and Nursing have?
Does Millcreek Rehabilitation and Nursing have any deficiencies on record?
Has Millcreek Rehabilitation and Nursing received any fines or penalties?
Who owns Millcreek Rehabilitation and Nursing?
When was Millcreek Rehabilitation and Nursing last inspected?
What quality measures are tracked for Millcreek Rehabilitation and Nursing?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Verify the same CCN on Medicare.gov Care Compare and with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
