Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Millcreek Rehabilitation and Nursing
Salt Lake City, UT · 61 certified beds · Last Life Safety survey January 21, 2026
CMS Certification Number 465185 · first certified April 2016
Ownership
Operated by BEAVER VALLEY HOSPITAL · Government - City/county
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within UT
16 citations — more than 88% of the 97 certified nursing homes in UT. Compared within UT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 5. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens August 2027 — about 11 months from now. This facility’s last Life Safety survey was January 2026. Facilities in UT are typically surveyed 19–24 months after the last one (median 21), measured over 88 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
3 of the 16 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 16 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0924 Put firmly secured handrails on each side of hallways.
How that compares
Compared with the median facility in UT, and nationally. Surveyors differ markedly between states, so the UT figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 16 |
| Median facility in UT | 3 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 30, 2021 | 4 |
| June 15, 2023 | 4 |
| March 31, 2025 | 7 |
| January 21, 2026 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-03-31 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-03-31 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2021-09-30 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2026-01-21 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2025-03-31 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2021-09-30 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-06-15 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-03-31 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Smoke Deficiencies 4
- Emergency Preparedness Deficiencies 3
- Egress Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Smoke Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 21, 2026 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 22, 2026) |
March 31, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 11, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 11, 2025) |
June 15, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 13, 2023) |
| K-0906 | Ensure gas cylinders are properly stored. | Deficient, Provider has date of correction (July 13, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (July 3, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 13, 2023) |
September 30, 2021 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 29, 2021) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 29, 2021) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 29, 2021) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (September 29, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.