Monument Healthcare Millcreek: Lab Test Failures - UT
Resident 21 arrived at the facility with traumatic brain injury, quadriplegia, and spinal stenosis. On November 2nd, his colostomy exploded twice overnight after a day of severe abdominal bloating and gas. A nurse administered medication and contacted the facility's nurse practitioner, who immediately ordered a kidney, ureter, and bladder X-ray.
The imaging revealed "increased fecal material" in his abdomen. A nursing note from 3:46 AM on November 3rd documented the results and stated the on-call doctor had been notified. No new orders followed.
But when federal inspectors arrived weeks later, the X-ray results had vanished from the resident's medical record.
"She was unable to locate the KUB results for resident 21 on their medical chart," inspectors wrote about their interview with the facility's Regional Compliance Nurse. The nurse told inspectors she would need to ask the unit manager to retrieve the results "from the portal" to provide them to state surveyors.
Monument Healthcare Millcreek operates a complex system for handling diagnostic results that involves multiple handoffs between staff members. Licensed Practical Nurse 3 described the process: after receiving faxed X-ray results, she contacts the Director of Nursing and the attending physician, enters results into the resident's medical record, then makes copies for both the nursing director'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.
A second nurse, LPN 2, described a slightly different procedure. She said X-ray results go to the physician and unit manager, who reviews them before forwarding to medical records for scanning into the resident's chart.
The facility's Director of Nursing told inspectors that management expects all documentation to be attached to residents' medical charts within one week of the ordered date. The Administrator echoed that timeline, stating he expects any documentation in a resident's medical chart within a week of receipt.
Yet nearly three weeks after the November 2nd X-ray order, the results remained missing from Resident 21's file.
The case illustrates how administrative failures can compromise medical care for vulnerable residents. Resident 21's condition required careful monitoring - his traumatic brain injury, complete paralysis, and post-traumatic stress disorder made him entirely dependent on staff for medical management. His colostomy complications represented a serious medical concern that warranted immediate diagnostic imaging.
The missing X-ray results meant that any healthcare provider reviewing his medical record would have no documentation of the abdominal imaging, the findings of increased fecal material, or the medical team's response to those findings. This gap could affect future treatment decisions and continuity of care.
Federal regulations require nursing homes to maintain complete medical records for all residents, including signed and dated reports of radiological and diagnostic services. The rule exists to ensure healthcare providers have access to complete medical histories when making treatment decisions.
Monument Healthcare Millcreek's violation affected one resident out of 37 sampled during the November inspection. Inspectors classified the harm level as "minimal harm or potential for actual harm," but the case reveals systemic problems with the facility's record-keeping procedures.
The facility's staff members demonstrated knowledge of proper procedures during interviews, yet the system failed to ensure critical medical documentation reached the resident's permanent record. The multiple handoffs and unclear final responsibility created opportunities for important medical information to fall through administrative cracks.
LPN 3's statement that she was "unaware of what happens with the results after placing them in the offices" suggests a breakdown in the facility's chain of custody for medical documents. Despite having established procedures and timeline expectations, the facility lacked effective oversight to ensure completion of the documentation process.
The resident's medical complexity made complete record-keeping particularly crucial. Managing quadriplegia, traumatic brain injury, and colostomy care requires careful coordination between multiple healthcare providers. Missing diagnostic results could lead to duplicated testing, delayed treatment, or medical decisions made without complete information about the resident's condition.
Federal inspectors noted that staff could eventually locate the X-ray results "from the portal," indicating the information existed somewhere in the facility's systems. But the failure to incorporate those results into the resident's official medical record violated federal requirements and potentially compromised his ongoing care.
The case occurred during a complaint investigation at Monument Healthcare Millcreek, suggesting broader concerns about the facility's operations prompted the federal review. The missing X-ray results represented just one finding among the inspection team's discoveries at the Salt Lake City nursing home.
Monument Healthcare Millcreek's administrative breakdown left a vulnerable resident's emergency medical results floating in bureaucratic limbo, demonstrating how even well-intentioned procedures can fail without proper oversight and accountability.
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 brain injury, quadriplegia, and spinal stenosis.
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.