Monument Healthcare Millcreek: Notification Failures - UT
The complaint-driven inspection found that staff were not consistently wearing gowns and gloves when entering the rooms of residents known to carry or be infected with MRSA. Inspectors documented that workers failed to don protective equipment upon room entry and did not always discard it properly before leaving, the two steps most critical to keeping the pathogen from traveling room to room on clothing and hands.
The failures affected a small number of residents.
Contact precautions for MRSA exist because the bacteria spreads through direct touch, not air. A staff member who enters a room without a gown, adjusts a resident's blanket, removes their gloves, and then touches a door handle or a blood pressure cuff on the way out can carry the infection to the next resident they touch. Monument's inspectors found evidence that this kind of lapse was occurring.
Inspectors also noted concerns about equipment. Dedicated or disposable patient-care items are supposed to be used for residents on contact precautions, or thoroughly disinfected before being used on anyone else. A shared blood pressure cuff that moves between an MRSA-positive resident and others without disinfection is a direct transmission route.
CMS rated the violation at the minimal harm level, meaning inspectors did not find evidence that another resident had already acquired MRSA as a result. That distinction matters less than it might seem. MRSA colonization can go undetected for weeks, and residents in nursing homes, many of them elderly with compromised immune systems and open wounds, face severe consequences if the infection takes hold.
The facility's plan of correction was not included in the inspection document.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Monument Healthcare Millcreek in Salt Lake City, UT was cited for violations during a health inspection on November 20, 2025.
The failures affected a small number of residents.
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.