Monument Healthcare Millcreek: Drug Regimen Failures - UT
Resident 21 arrived at the facility with traumatic subdural hemorrhage, quadriplegia, spinal stenosis, and post-traumatic stress disorder. On November 2nd, his condition deteriorated rapidly.
The resident stayed in bed all day, his abdomen bloated with gas. A nurse noted he'd had watery bowel movements the previous day, and his colostomy had "exploded twice" during the night. She administered a gas pill and immediately contacted the nurse practitioner, who ordered an emergency KUB x-ray.
The x-ray was performed. Results came back showing "increased fecal material." A nursing note from 3:46 AM on November 3rd documented that the on-call doctor had been notified.
Then the results disappeared.
When federal inspectors arrived three weeks later, they couldn't find the x-ray report anywhere in the resident's medical record. The Regional Compliance Nurse admitted she was "unable to locate the KUB results" and would need to ask the unit manager to retrieve them from an online portal.
This wasn't supposed to happen. Multiple staff members described elaborate filing systems designed to prevent exactly this problem.
Licensed Practical Nurse 3 explained the process step by step. When a physician orders an x-ray, she enters it into the medical record. She fills out a lab slip, calls the x-ray company, and faxes them the physician's order. The company faxes results back. She contacts the Director of Nursing and the physician with results, enters them in the medical record, then makes copies for both the DON's office and the physician's office.
"After that she is unaware of what happens with the results after placing them in the offices," inspectors noted.
Licensed Practical Nurse 2 described a nearly identical protocol. She gets the physician's order, creates it in the medical record, calls the mobile x-ray company. When results arrive by fax, she calls the physician and gets any new orders. She makes copies - one for the physician, another for the unit manager. The unit manager reviews the results, then gives them to medical records to be scanned into the resident's chart.
The Director of Nursing confirmed this system. X-ray results get faxed to the facility. The nurse contacts the physician. The fax gets copied for the unit manager and physician. After review, it goes to medical records to be attached to the chart.
She expected this to happen "within a week from the ordered date."
The Administrator shared the same expectation. He wanted "any documentation attached to a resident's medical chart within a week of receipt date."
But for Resident 21, none of these careful protocols worked.
The inspection occurred on November 20th, eighteen days after the emergency x-ray order. Staff had multiple copies of the process, multiple checkpoints, multiple people responsible for ensuring the results made it into the medical record. The nursing note showed the results had definitely arrived - someone had documented the "increased fecal material" finding and notified the doctor.
Somewhere between the 3:46 AM nursing note and the medical record, the x-ray report vanished.
This breakdown had consequences beyond paperwork. Resident 21 lived with quadriplegia and traumatic brain injury. His bowel complications were serious enough to warrant an emergency x-ray. The results showed significant fecal impaction. Without the diagnostic report in his medical record, future caregivers wouldn't have complete information about his condition.
The facility's own staff couldn't explain what happened. LPN 3 lost track of the results after placing copies in two offices. LPN 2 assumed the unit manager would handle the final step. The Regional Compliance Nurse had to go searching through computer portals to locate results that should have been filed weeks earlier.
Federal inspectors found this violated requirements for maintaining complete medical records. Nursing homes must keep "signed and dated reports of x-rays and other diagnostic services" in each resident's file. The regulation exists because diagnostic results inform treatment decisions and provide crucial medical history.
Monument Healthcare Millcreek had policies. They had procedures. They had multiple staff members who understood their roles in the filing process.
They just couldn't produce the x-ray results when inspectors asked for them.
The case illustrates a common problem in nursing home record-keeping. Complex multi-step processes create opportunities for critical documents to fall through cracks. When diagnostic results disappear, residents lose access to important medical information that could affect their ongoing care.
For Resident 21, the missing KUB results represented more than administrative oversight. They were evidence of his body's struggle with basic functions that his injuries had compromised. The x-ray had been ordered because his colostomy was failing, his abdomen was distended, and his condition was deteriorating.
Eighteen days later, that medical evidence had simply vanished from his record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monument Healthcare Millcreek from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Monument Healthcare Millcreek in Salt Lake City, UT was cited for violations during a health inspection on November 20, 2025.
Resident 21 arrived at the facility with traumatic subdural hemorrhage, quadriplegia, spinal stenosis, and post-traumatic stress disorder.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.