Millcreek Rehabilitation and Nursing LLC

3520 South Highland Drive
Salt Lake City, UT, 84106
8014847638
CCN: 465185
2
Overall
1
Health
2
Staffing
5
Quality
ChainBEAVER VALLEY HOSPITAL
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
BEAVER VALLEY HOSPITAL5% OR GREATER DIRECT OWNERSHIP INTEREST100%
LANGFORD, SCOTTCORPORATE OFFICERNOT APPLICABLE
MILLCREEK REHABILITATION AND NURSING LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MYERS, WALTEROPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
STUBBS, RACHAELOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
CLARK, BRENDANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
COTTONWOOD HEALTHCARE LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2025-03-31Fine$25K
Health Deficiencies (27)
2025-03-31 · Health
E
F924 · Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F842 · 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.
D
F805 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
E
F775 · Administration Deficiencies
Keep complete, dated laboratory records in the resident's record.
D
F770 · Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F656 · 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.
J
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
E
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
G
F600 · 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.
D
F584 · 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
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
2023-06-15 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F676 · 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.
2021-09-30 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F840 · 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
F825 · Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F805 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F676 · 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
F638 · Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
E
F636 · 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
F584 · 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.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
2.21
3.68
RN Hrs/Resident/Day
0.78
0.54
LPN Hrs/Resident/Day
0.07
0.81
CNA Hrs/Resident/Day
1.36
2.33
PT Hrs/Resident/Day
0.01
0.12
Data as of 2026-03-01