D+
50/100Millcreek Rehabilitation and Nursing Inspection Report, Violations & Safety Grade (Salt Lake City, Utah)
3520 South Highland Drive, Salt Lake City, Utah 84106
Phone: 8014847638
CMS Overall:2/5
Overview & Bed Count
Certified Beds
61
Avg Residents/Day
58.9
Ownership
Government - City/county
Provider Type
Medicare and Medicaid
County
Salt Lake
Sprinkler Systems
Yes
Special Focus
None
Abuse Citation
Yes
CMS Star Ratings
Overall2/5
Health1/5
Staffing2/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Utah Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.70 | 1.24 | -0.54 |
| Total Nurse Hours per Resident per Day | 2.26 | 4.08 | -1.82 |
| CMS Staffing Rating | 2/5 | 3.2/5 | - |
| Nursing Staff Turnover | 53.5% | 50% | - |
Health Citation History
29 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-07 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-04-07 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-03-31 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | J – Immediate Jeopardy |
| 2025-03-31 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-03-31 | 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. | G – Actual Harm |
| 2025-03-31 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E – Moderate Harm Potential |
| 2025-03-31 | 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. | E – Moderate Harm Potential |
| 2025-03-31 | Administration Deficiencies | Keep complete, dated laboratory records in the resident's record. | E – Moderate Harm Potential |
| 2025-03-31 | 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. | E – Moderate Harm Potential |
| 2025-03-31 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-03-31 | Environmental Deficiencies | Put firmly secured handrails on each side of hallways. | E – Moderate Harm Potential |
| 2025-03-31 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2025-03-31 | 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. | D – Moderate Harm Potential |
| 2025-03-31 | Administration Deficiencies | Provide timely, quality laboratory services/tests to meet the needs of residents. | D – Moderate Harm Potential |
| 2025-03-31 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2023-06-15 | Quality of Life and Care Deficiencies | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D – Moderate Harm Potential |
| 2023-06-15 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2021-09-30 | 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. | E – Moderate Harm Potential |
| 2021-09-30 | Resident Assessment and Care Planning Deficiencies | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | E – Moderate Harm Potential |
| 2021-09-30 | Resident Assessment and Care Planning Deficiencies | Assure that each resident’s assessment is updated at least once every 3 months. | E – Moderate Harm Potential |
| 2021-09-30 | Quality of Life and Care Deficiencies | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | E – Moderate Harm Potential |
| 2021-09-30 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2021-09-30 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2021-09-30 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2021-09-30 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2021-09-30 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2021-09-30 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2021-09-30 | Quality of Life and Care Deficiencies | Provide or get specialized rehabilitative services as required for a resident. | D – Moderate Harm Potential |
| 2021-09-30 | Administration Deficiencies | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
16 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-21 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2025-03-31 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2025-03-31 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-03-31 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2025-03-31 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | D – Moderate Harm Potential |
| 2025-03-31 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | D – Moderate Harm Potential |
| 2025-03-31 | Construction Deficiencies | Use approved construction type or materials. | D – Moderate Harm Potential |
| 2025-03-31 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | D – Moderate Harm Potential |
| 2023-06-15 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2023-06-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2023-06-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure gas cylinders are properly stored. | D – Moderate Harm Potential |
| 2023-06-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2021-09-30 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2021-09-30 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2021-09-30 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D – Moderate Harm Potential |
| 2021-09-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
Total Penalties & Fines
$25,441
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-03-31 | Fine | $25,441 | - |
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Verified Helpline
Care & Coverage Review
Researching facilities in Salt Lake City, Utah? Speak with a licensed specialist to review your Medicare or health insurance benefits at no cost.
📞 Call (866) 227-7595
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Free, confidential consultation. We may receive referral compensation.