SALT LAKE CITY, UT - Federal health inspectors identified 8 deficiencies at Monument Healthcare Millcreek following a complaint investigation completed on November 20, 2025, including a failure to maintain properly signed and dated diagnostic reports in resident medical records.
Diagnostic Records Missing Required Documentation
The investigation found that Monument Healthcare Millcreek did not consistently keep signed and dated reports of x-rays and other diagnostic services in resident records, a violation of federal regulatory tag F0779 under the Administration category of nursing home regulations.
The deficiency was classified at Scope/Severity Level D, meaning inspectors found an isolated incident with no documented actual harm but determined there was potential for more than minimal harm to residents. While this represents the lower end of the federal severity scale, missing diagnostic documentation in a healthcare setting carries meaningful clinical risk.
When x-ray results, lab reports, or other diagnostic findings are not properly filed in a resident's medical record, the consequences can cascade through every aspect of care. A physician reviewing an incomplete chart may not be aware that a diagnostic test was performed, potentially leading to duplicate testing that exposes residents to unnecessary radiation or repeated blood draws. More critically, unsigned or misfiled results may mean that abnormal findings go unreviewed and unaddressed.
Why Diagnostic Record Integrity Matters
In a skilled nursing facility, residents typically have multiple chronic conditions managed by several providers. The medical record serves as the central communication tool between physicians, nurses, therapists, and specialists. When diagnostic reports are not properly maintained, the integrity of that communication breaks down.
For example, if a chest x-ray reveals early signs of pneumonia but the signed report is not placed in the resident's record, nursing staff may not implement appropriate monitoring protocols. Similarly, bone density scan results that never reach the chart could mean a resident at high risk for fractures does not receive fall prevention interventions.
Federal regulations require that all diagnostic reports be signed by the interpreting professional and dated before being filed in the resident's medical record. This requirement exists to ensure that a qualified provider has reviewed the results and that care teams can verify when the interpretation occurred relative to the resident's treatment timeline.
Facility Received 8 Total Deficiencies
The diagnostic record-keeping violation was one of 8 deficiencies identified during the complaint investigation, indicating broader compliance concerns at the facility. When inspectors find multiple deficiencies during a single survey, it often points to systemic issues in a facility's quality assurance and administrative oversight processes.
Monument Healthcare Millcreek reported correcting the diagnostic records deficiency as of December 26, 2025, approximately five weeks after the inspection. The facility's correction plan would have been submitted to the Centers for Medicare & Medicaid Services (CMS) for review.
Industry Standards for Record Management
Accreditation organizations and federal guidelines establish clear expectations for diagnostic record management in long-term care facilities. Best practices include maintaining a tracking system for all ordered diagnostic tests that monitors whether results have been received, reviewed by a physician, signed, and filed in the appropriate resident record. Many facilities use electronic health record systems with built-in alerts that flag outstanding diagnostic reports.
Facilities are also expected to conduct regular audits of medical records to identify documentation gaps before they affect care. When a facility lacks these quality controls, isolated documentation failures can become patterns that compromise resident safety.
What Families Should Know
Family members of nursing home residents can request to review their loved one's medical record at any time. Verifying that diagnostic test results are present, signed, and dated is one way to confirm that the facility is meeting basic documentation standards.
The full inspection report for Monument Healthcare Millcreek, including details on all 8 cited deficiencies, is available through the CMS Care Compare database and on NursingHomeNews.org's [facility page for Monument Healthcare Millcreek](/facility/monument-healthcare-millcreek-salt-lake-city-ut).
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.