Monument Healthcare Millcreek: Infection Control Gaps - UT
Resident 21 arrived at the facility with traumatic brain injury, quadriplegia, spinal stenosis, and post-traumatic stress disorder. On November 2nd, nursing notes documented his deteriorating condition: "The patient decided to stay in bed all day today. The nurse noted that the patient's abdomen was blooded with a lot of gas and administered a gas pill."
The situation worsened overnight.
"The patient stated that he had a watery bowel movement yesterday and last night his colostomy exploded twice," the nurse wrote. Staff immediately contacted the nurse practitioner, who ordered an emergency kidney, ureter, and bladder x-ray.
The mobile x-ray technician arrived and performed the diagnostic test. Results came back at 3:46 a.m. on November 3rd showing "increased fecal material" in the resident's abdomen — a potentially serious finding for someone with his medical conditions. The on-call doctor was notified but issued no new orders.
Then the paperwork vanished.
Federal inspectors conducting a complaint investigation on November 20th found no trace of the x-ray results in Resident 21's medical record. The diagnostic report that revealed dangerous fecal impaction had disappeared somewhere in the facility's chaotic filing system.
Licensed Practical Nurse 3 described the supposed process during interviews with inspectors. After receiving physician orders, she would contact the mobile x-ray company and fax them the request. When results arrived by fax, she would notify the Director of Nursing and physician, enter findings into the medical record, then make copies for both the nursing director's office and physician's office.
"After that she is unaware of what happens with the results after placing them in the offices," inspectors wrote.
Licensed Practical Nurse 2 offered a different version. She claimed results went to the physician and unit manager, who would then forward them to medical records for scanning into the resident's chart.
The Regional Compliance Nurse admitted during her November 20th interview that she couldn't locate the KUB results anywhere in Resident 21's medical chart. She told inspectors she would need to ask the unit manager to retrieve the results from some unspecified "portal" to provide them to state surveyors.
Three different staff members described three different procedures for handling diagnostic results.
The Director of Nursing claimed x-ray results were copied and distributed to the unit manager and physician for review, then forwarded to medical records for attachment to the resident's chart. She said management expected this process completed "within a week from the ordered date."
The Administrator echoed this timeline, stating he expected documentation attached to residents' medical charts within a week of receipt.
But nearly three weeks had passed since the emergency x-ray, and the critical diagnostic results remained missing from the quadriplegic resident's medical record.
The November 2nd incident began when staff noticed the resident's distended, gas-filled abdomen. His description of the overnight colostomy explosions prompted immediate medical concern. For someone with quadriplegia and traumatic brain injury, fecal impaction poses serious health risks including bowel obstruction, perforation, or sepsis.
The emergency x-ray confirmed staff suspicions — dangerous fecal buildup requiring medical attention. Yet this crucial diagnostic information disappeared into the facility's dysfunctional record-keeping system.
Federal regulations require nursing homes to maintain signed and dated reports of all diagnostic services in residents' medical records. These documents provide essential continuity of care, allowing doctors and nurses to track residents' conditions and make informed treatment decisions.
Monument Healthcare Millcreek's missing x-ray results represent more than paperwork problems. When diagnostic findings vanish, medical staff lose critical information needed to monitor residents' health and prevent complications.
The facility's confused procedures revealed systemic problems beyond one missing report. Three nurses described three different processes for handling x-ray results, suggesting widespread confusion about basic medical record management.
Licensed Practical Nurse 3's admission that she was "unaware of what happens" after placing copies in various offices highlighted the breakdown. Results entered a black hole of competing filing systems with no clear accountability.
The Regional Compliance Nurse's need to retrieve results from an external "portal" during the inspection suggested the facility relied on outside systems rather than maintaining complete internal medical records as required by federal law.
For Resident 21, the missing x-ray results meant his dangerous fecal impaction findings were unavailable to guide ongoing care decisions. His complex medical conditions — traumatic brain injury, quadriplegia, spinal stenosis — require careful monitoring and prompt response to complications like the colostomy explosions that triggered the emergency diagnostic test.
The November 3rd x-ray results showing "increased fecal material" should have remained permanently accessible in his medical record for future reference by doctors, nurses, and specialists managing his care.
Instead, those critical findings joined the chaos of Monument Healthcare Millcreek's record-keeping system, where emergency diagnostic results disappear and staff members can't explain what happens to essential medical information after they file it away.
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 21, 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 brain injury, 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.