Report
TheVardellReport
Millcreek Rehabilitation and Nursing
Skilled nursing facility and nursing facility
3520 South Highland Drive
Salt Lake City, UT 84106
Report
← Millcreek Rehabilitation and Nursing, free profile
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The Vardell Report.Millcreek Rehabilitation and Nursing
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Salt Lake City, UT
- Record Period
- 2021–2026
- Source Documents
- 6
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 4 inspections from September 2021 to April 2026, state surveyors documented 29 findings at Millcreek Rehabilitation and Nursing; 28 have a recorded correction and 1 awaits one; CMS lists 1 enforcement action in the window.
- Inspections
- 4
- 2021–2026, complaint and standard
- Findings
- 29
- Deficiencies cited by state inspectors
- Corrected
- 28
- Of 29 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2021 | 1 | 12 | 0 |
| 2022 | 0 | 0 | 0 |
| 2023 | 1 | 2 | 0 |
| 2024 | 0 | 0 | 0 |
| 2025 | 1 | 13 | 3 |
| 2026 | 1 | 2 | 0 |
What the Record Shows
- 28 of 29 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $25,441, its payment not published.
- 2 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, March 31, 2025, recorded 13 findings (most serious: Level J).
Report at a Glance
- Facility
- Millcreek Rehabilitation and Nursing
- Address
- 3520 South Highland Drive, Salt Lake City, UT 84106
- CMS Certification Number
- 465185
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 61
- Ownership
- Government - City/county
- Record Window
- September 30, 2021 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
2 findings
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 8, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for morePast Non-Compliance
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
13 findings
The same visit included a complaint investigation.
- F610Respond appropriately to all alleged violations.Level JImmediate jeopardyCorrected Apr 11, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Apr 11, 2025
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Apr 11, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F775Keep complete, dated laboratory records in the resident's record.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F924Put firmly secured handrails on each side of hallways.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F584Honor 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.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
Enforcement Action
Civil money penalty, $25,441 imposed March 31, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 31, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
2 findings
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Aug 4, 2023
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 4, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2021
Standard health inspection
12 findings
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Nov 19, 2021
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level ENo actual harm, potential for moreCorrected Dec 10, 2021
- F638Assure that each resident’s assessment is updated at least once every 3 months.Level ENo actual harm, potential for moreCorrected Dec 10, 2021
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level ENo actual harm, potential for moreCorrected Nov 19, 2021
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Dec 10, 2021
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Nov 15, 2021
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Nov 18, 2021
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 10, 2021
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Dec 10, 2021
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Dec 10, 2021
- F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Dec 10, 2021
- F840Employ 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.Level DNo actual harm, potential for moreCorrected Dec 10, 2021
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Infection Control, Cited in Three Inspections
Inspectors cited F880 in September 2021, June 2023 and March 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
21232526F880 across all 4 inspections, oldest to newest - 2
A Clean, Homelike Setting, Cited in Two Inspections
Inspectors cited F584 in September 2021 and March 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
21232526F584 across all 4 inspections, oldest to newest - 3
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in March 2025 and April 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
21232526F609 across all 4 inspections, oldest to newest - 4
Citation F676, Cited in Two Inspections
Inspectors cited F676 in September 2021 and June 2023. The agency describes it this way: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
21232526F676 across all 4 inspections, oldest to newest - 5
Citation F805, Cited in Two Inspections
Inspectors cited F805 in September 2021 and March 2025. The agency describes it this way: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
21232526F805 across all 4 inspections, oldest to newest - 6
Accident Hazards and Supervision, No Recorded Correction
F689 was cited in September 2021, March 2025 and April 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level J (immediate jeopardy). The April 2026 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.
21232526F689 across all 4 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
- 02
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in two inspections, most seriously at level E.
- 03
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level E.
- 04
What changed after F676 was cited, and how do you check it now?
Citation F676: cited in two inspections, most seriously at level E.
- 05
What changed after F805 was cited, and how do you check it now?
Citation F805: cited in two inspections, most seriously at level D.
- 06
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level J. The April 7, 2026 citation has no recorded correction date.
- 07
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 08
What led to the 2025 fine, and has it been paid?
A $25,441 civil money penalty was imposed March 31, 2025. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Utah state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Utah state survey agency
Inspection Sep 30, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Utah state survey agency
Inspection Jun 15, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Utah state survey agency
Inspection Mar 31, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Utah state survey agency
Inspection Apr 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 465185
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowSeptember 30, 2021 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before September 2021 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.