Monument Healthcare Millcreek

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review it was determined, for 1 of 37 sampled residents, that the facility did not immediately inform or consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Specifically, the physician was not notified when a resident's Trulicity was held. Resident identifiers: 28.Findings included:1. Resident 28 was admitted to the facility on [DATE REDACTED] with diagnoses which included orthopedic aftercare following amputation, Type 2 DM, and morbid obesity. On 11/18/25 9:37 AM, an interview was conducted with resident 28. Resident 28 stated that when she was first admitted she missed 3 weeks of injections of her Trulicity (Dulaglutide) medication. Resident 28 stated that the nurse had to re-order the medication and it delayed her injection. Resident 28's medical records were reviewed 11/17/25 through 11/20/25. On 9/3/25, resident 28's physician ordered Dulaglutide Subcutaneous Solution Auto-injector 1.5 milligram (mg)/0.5 milliliter (ml) (Dulaglutide), Inject 1.5 mg subcutaneously one time a day every Sun (Sunday) for Diabetes.

On 10/1/25, resident 28's physician ordered Dulaglutide Subcutaneous Solution Auto-injector 1.5 mg/0.5 ml (Dulaglutide), Inject 1.5 mg subcutaneously one time a day every Wed (Wednesday) for Diabetes. Resident 28's September 2025 MAR documented a code 9 on 9/07/25, 9/21/25, and 9/28/25 for see progress note.

Resident 28's progress notes revealed the following: a. On 9/7/25 at 11:15 AM, the Medication Administration Note documented that the Dulaglutide was waiting for delivery from the pharmacy. b. On 9/7/25 at 2:21 PM, the progress note documented, Pharmacy called to report that the resident's last labs show that hgb [hemoglobin] is over 8. They will not be sending it. c. On 9/8/25 at 5:44 PM, the Medication Administration Note documented that the Dulaglutide was Given 9/8 at 1745 [5:45 PM] after patient said

she hadn't gotten it, and [provider name omitted] said it was okay to give a day late. It should be noted that

the provider notification was 24 hours after the medication was scheduled to be delivered. d. On 9/21/25 at 4:09 PM, the Medication Administration Note documented for the Dulaglutide, Resident to have family member bring it in. e. On 9/28/25 at 11:04 AM, the Medication Administration Note documented for the Dulaglutide, On order from pharmacy. On 11/19/25 at 1:28 PM, an interview was conducted with LPN 1.

LPN 1 stated that if medication was unavailable she would notify the MD and ask for orders to hold or give when available. On 11/20/25 at 10:06 AM, an interview was conducted with the DON. The DON stated that

she was not aware that resident 28 had missed 3 doses of the Dulaglutide medication. The DON stated that

the nurse should notify the MD if a medication was not available for administration and ask for new orders.

The DON stated that the nurse should then document that the MD was notified in a progress note.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Millcreek

1201 East 4500 South Salt Lake City, UT 84117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice.

Specifically, a resident was admitted with wounds and dressings on their bilateral feet and did not have wound care orders initiated until 9 days after admission. Resident identifier: 117.Resident 117 was admitted to the facility on [DATE REDACTED] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 9:07 AM, an interview was conducted with resident 117.

Resident 117 stated that he had both ankles surgically cleaned out and the left foot had MRSA. Resident 117 stated that he had 2 dressing changes completed since admission. Resident 117 stated that he was supposed to have dressing changes completed 3 times a week. Resident 117 stated that he went to the surgical doctor and had his dressing changed there one time. Resident 117's medical records were reviewed 11/17/25 through 11/20/25. On 10/24/25, resident 117's hospital history and physical documented status post left ankle incision and drainage [I & D]. The lateral aspect of the left ankle was packed with 1/4in [inch] iodoform packing and redressed. The hospital progress note documented that the left ankle was found to have MRSA septic arthritis and baceremia. The plan documented 4-6 weeks of intravenous Vancomycin treatment. Resident 117's hospital discharge orders dated 10/25/25 did not contain any orders for wound care. On 10/25/25, resident 117's nursing assessment documented under skin impairments that

the site of the right outer ankle had Septic Arthritis Wash out 10/23, Dressing intact, right toes Dressing intact covering toe. On 10/25/25, resident 117 had a care plan created for has the potential for skin breakdown/pressure ulcers r/t [related to] Infection Lt [left] foot and ankle.has surgical incision to left lateral ankle and left medial ankle and right foot great toe. Interventions identified on the care plan included to administer treatments as ordered and monitor for effectiveness. On 11/2/25, resident 117's physician ordered Left Lateral Ankle Wound Care: Cleanse with wound cleanser, pat dry. Gently pack the wound with 1/4 iodoform then cover with adaptic. Cover with kerlix then Ace bandage 3 times a week and as needed (PRN) on Monday, Wednesday, and Friday. It should be noted that the wound care orders were initiated 9 days after admission to the facility. No documentation could be found of wound care that was completed prior to 11/2/25. On 11/19/25 at 9:16 AM, an interview was conducted with Licensed Practical Nurse (LPN)

1. 1. LPN 1 stated that the floor nurse would conduct the admission assessment for newly admitted residents.

LPN 1 stated that the floor nurse along with a second staff member would review the discharge orders from

the hospital and input the orders into the resident medical records. LPN 1 stated that if the resident was admitted with wounds or dressings it would be documented on the admission assessment and the nurse that did the assessment should verify orders for wound care and refer the resident to the wound care team.

On 11/20/25 at 11:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident was admitted with wounds and dressings and did not have admission wound care orders

she would expect the admitting nurse to follow-up with the Medical Doctor for wound care orders.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Millcreek

1201 East 4500 South Salt Lake City, UT 84117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

would reorder it for the following week's administration. LPN 1 stated that she thought that the insurance was not covering it but now it was. On 11/20/25 at 9:41 AM, an interview was conducted with the Doctor of Pharmacy (PharmD) District Director of Operations for the facility. The PharmD stated that medication delivery schedules were Monday through Friday at 2:30 PM or 8:00 PM, and stat [immediate] orders were within a 4 hour delivery window from the time they received the request. The PharmD stated that the Dulaglutide was dispensed on 9/3/25 and was delivered at 8:27 PM. The PharmD stated that the medication was delivered one time per week. The PharmD stated that the next delivery was on 9/9/25 at 3:09 PM, then on 9/21/25 at 8:05 PM, and then on 9/29/25 at 3:33 PM. The PharmD stated that on 10/1/25

the medication order changed to deliver on Wednesday. On 11/20/25 at 10:06 AM, an interview was conducted with the DON. The DON stated that she was not aware that resident 28 had missed 3 doses of

the Dulaglutide medication. The DON stated that the nurse should notify the MD if a medication was not available for administration and ask for new orders. The DON stated that the nurse should then document that the MD was notified in a progress note. If it was coded 9 there should be a progress note with the documented reason the medication was not administered.3. Resident 146 was admitted to the facility on [DATE REDACTED] with diagnoses which included displaced bimalleolar fracture of right lower leg, deep tissue injury (DTI) left heel, atrial fibrillation, cardiomyopathy, congestive heart failure, hypertension, and cardiomegaly.

Resident 146's medical records were reviewed 11/17/25 through 11/20/25. On 8/12/25, resident 146's physician ordered Metoprolol Succinate Extended Release (ER) Oral Tablet 25 milligram (mg), Give 1 tablet by mouth one time a day for hypertension hold forsystolic blood pressure (BP) less than (<)110 or heart rate (HR)<60. Resident 146's August 2025 MAR revealed that Metoprolol was administered 4 times when it should have been held per the physician ordered parameters: On 8/18/25, BP was 106/57On 8/20/25, HR was 55On 8/21/25, BP was 102/60On 8/22/25, HR was 55. On 8/12/25, resident 146's physician ordered Amiodarone Hydrochloride (HCl) Oral Tablet 200 mg, Give 1 tablet by mouth two times a day [BID] for hypertension hold for systolic BP<110. Resident 146's August 2025 MAR revealed that Amiodarone was administered 6 times when it should have been held per the physician ordered parameters:8/16/25, AM BP was 100/538/18/25, AM BP was 106/578/18/25, PM BP was 109/48/21/25, AM BP was 102/60 8/21/25, PM BP was 100/608/22/25, PM BP was 100/62. On 11/20/25 at 12:03 PM, an interview was conducted with the DON. The DON stated that if the physician order said to hold for BP <110 or HR <60 then the nurse should hold the medication. The DON stated that she agreed that, based on the order parameters, the medications should have been held when they were administered.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Millcreek

1201 East 4500 South Salt Lake City, UT 84117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident was free from any significant medication errors. Specifically, multiple doses of Vancomycin were omitted from the residents scheduled medication administration. Resident identifier: 117.

Resident 117 was admitted to the facility on [DATE REDACTED] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that

he had 3 doses of Vancomycin that were missed by the facility. On 10/30/25, resident 117's physician ordered Vancomycin Hydrochloride (HCl) Solution Reconstituted, Use 1250 mg intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. The order was discontinued on 11/12/25. On 11/12/25, resident 117's physician ordered Vancomycin HCl Solution Reconstituted, Use 1 gram intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. Resident 117's Medication Administration Record (MAR) revealed the following: a. On 11/6/25 the evening dose of Vancomycin was documented as code 9. b. On 11/12/25 the morning dose of Vancomycin was documented as code 5. c. On 11/13/25 the evening dose of Vancomycin was documented as code 9. d. On 11/14/25, the evening dose of Vancomycin did not have any documentation that the medication was administered or held. The MAR legend indicated that a code 9 was see Nurse Note and a code 5 was HOLD see Nurse Note. It should be noted that no documentation was located in a nurse progress note to explain why the Vancomycin was held

on 11/6/25, 11/12/25, 11/13/25, or 11/14/25. On 11/19/25 at 1:43 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if medication was not available for the scheduled administration she would call the pharmacy to see where the medication was and why it was not delivered, and then she would call the Medical Doctor (MD) to notify that the medication was not administered. LPN 1 stated she would document a code 9 in the MAR for a medication that was unavailable and enter a progress note. LPN 1 stated that if a medication was coded 9 then it should have a progress note documented with the details of why it was not administered. LPN 1 stated that if there was no documentation in the MAR for a medication administration then it was flagged for the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) to review. LPN 1 stated that her access to the MAR did not show if prior medication was missed. On 11/20/25 at 10:42 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected that nursing staff notify the MD of any missed medication doses and then document a progress note why it was missed.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Millcreek

1201 East 4500 South Salt Lake City, UT 84117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review it was determined, for 1 of 37 residents sampled, that the facility did not notify

the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of the clinical reference ranges. Specifically, a resident's Vancomycin trough levels were high and the Medical Doctor (MD) was not notified of those high values. Resident identifier: 117.Resident 117 was admitted to the facility on [DATE REDACTED] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. Resident 117 stated that

he had 3 doses of Vancomycin that were missed by the facility. On 10/30/25, resident 117's physician ordered Vancomycin Hydrochloride (HCl) Solution Reconstituted, Use 1250 mg intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. The order was discontinued on 11/12/25. On 11/12/25, resident 117's physician ordered Vancomycin HCl Solution Reconstituted, Use 1 gram intravenously two times a day for Vancomycin therapy related to ARTHRITIS DUE TO OTHER BACTERIA, LEFT ANKLE AND FOOT and; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. Resident 117's lab results for the Vancomycin trough documented the following high results: a. On 10/27/25, the result was 14.5, high b. On 11/1/25, the result was 18.2, high; c. On 11/14/25 at 4:30 PM, the result was 12.9, high; d. On 11/14/25 at 10:50 PM, the result was 14.6, high; and e. On 11/18/25, the result was 23.2, high. No documentation could be found to indicate that the MD was notified of the high Vancomycin trough results. On 11/19/25 at 1:43 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the Vancomycin monitoring included a Vanco trough lab result that was sent to the MD for review and documentation that

the MD was notified of the results would be located in a progress note. On 11/20/25 at 10:42 AM, an

interview was conducted with the Director of Nursing (DON). The DON stated that a progress note should document that the MD was notified of trough results and pharmacy recommendation of medication dose adjustment. The DON stated that nursing staff would notify the MD by phone of critical lab results and when

the MD came to the building they would sign the all lab report to verify that they had seen the results.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Millcreek

1201 East 4500 South Salt Lake City, UT 84117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0779

Keep signed and dated reports of x-rays and other diagnostic services in the residents record.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not file

in the resident's clinical record signed and dated reports of radiological and other diagnostic services.

Specifically, a resident 21's Kidney, Ureter, and Bladder (KUB) was not in the medical records. Resident identifier 21. Resident 21 was admitted to the facility on [DATE REDACTED] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder.Review of resident 21's medical record was completed on 11/17/25 through 11/20/25.On 11/2/25,

a physician's order documented an immediate (STAT) KUB radiograph (x-ray).On 11/2/25 at 12:48 pm, a nursing progress alert note stated the following: 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 patient stated that he had a watery bowel movement yesterday and last night his colostomy exploded twice. The nurse reported to the Nurse Practitioner at which time a KUB was ordered.On 11/3/25 at 3:46 am, a nursing progress radiology results note revealed the following. Abdomen x-ray. Impression: increased fecal material. The doctor on call was notified. No new orders.It should be noted that no documentation of the x-ray results could be located in resident 21's medical record.On 11/20/25 at 1:15 pm, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated once a physician gaves an order, the LPN would enter the order into the resident's medical record. LPN 3 stated a lab slip/request would be filled out and a call to the x-ray company to get a technician dispatched to the facility. LPN 3 stated she will fax the x-ray company the physician's order for their records. LPN 3 stated the x-ray company will fax over the results. LPN 3 stated that when she gets the results, she will contact the Director of Nursing (DON) and the physician. LPN 3 stated she will enter the results on to the resident's medical record and any additional orders from the physician. LPN 3 stated that she will then make a copy of the results and put one in the DON's office and the other in the physician's office. LPN 3 stated after that she is unaware of what happens with the results after placing them in the offices.On 11/20/25 at 1:54 pm, an interview was conducted with LPN 2. LPN 2 stated she will get an order from the physician. LPN 2 stated that she will then create an order on the resident's medical record. LPN 2 stated that she will call the mobile x-ray company. LPN 2 stated that the x-ray company will fax the results to the facility. LPN 2 will call the physician regarding the results and get any new orders. LPN 2 will make a copy of the fax, one goes to the physician, and the other one goes to the unit manager. LPN 2 stated that once the unit manager reviews the results, they will give it to medical records to be scanned and put on the resident's medical record.On 11/20/25 at 3:06 pm, an

interview was conducted with the Regional Compliance Nurse (RCN). The RCN stated that she was unable to locate the KUB results for resident 21 on their medical chart. The RCN stated that she needed to ask the unit manager to retrieve it from the portal to be able to provide it to the State Surveyor.On 11/20/25 at 3:07 pm, an interview was conducted with the DON. The DON stated that x-ray results are faxed to the facility.

The DON stated that the nurse will contact the physician with the results. The DON stated that the received fax is copied and given to the unit manager and the physician for review. The DON stated that after the results are reviewed the fax is forwarded to medical records to be attached to the resident's medical chart.

The DON stated that management expects that to be done within a week from the ordered date.On 11/20/25 at 3:07 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he expects to have any documentation attached to a resident's medical chart within a week of receipt date.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Millcreek

1201 East 4500 South Salt Lake City, UT 84117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

will change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves are removed and hand hygiene performed before leaving the room. c. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving

the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The guidance was last updated on February 1, 2024. The Centers for Disease Control and Prevention (CDC) documented under Infection Control Basics for Health Care Providers to Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. The recommendations included to wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. The guidance further stated that donning PPE upon room entry and properly discarding before exiting the room was done to contain pathogens. The guidance also recommended limiting transport and movement of patients outside the room to medically necessary purposes. The guidance stated to use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs) or to disinfect equipment before use on another patient. The guidance was last updated on April 3,

1. 2024. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html The CDC

guidance on Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities documented that healthcare providers should follow contact precautions when caring for patients with MRSA (colonized or carrying and infected). The guidance was last updated on June 27,

2. 2025. https://www.cdc.gov/mrsa/hcp/infection-control/index.html

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Millcreek

1201 East 4500 South Salt Lake City, UT 84117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and interview it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff area for toilet facilities. Specifically, the facility had seven public bathrooms that were accessible by residents and were not equipped with a call light system. On 11/20/25, an observation was made of the public bathroom facilities. The 300 hallway bathroom near room [ROOM NUMBER] was observed and did not contain a call light inside. The 400 hallway bathroom near the nurse's station was observed and did not contain a call light inside. The bathroom next to the staff break room was observed and did not contain a call light inside. The bathroom next to the Human Resource office and front desk was observed and did not contain a call light inside. None of the public bathrooms were locked. On 11/20/25 at 2:36 PM, an interview was conducted with the Director of Maintenance (DOM). The DOM stated that the facility had 7 public bathrooms. The DOM stated that technically anyone could use any of the bathrooms at any time, including residents. The DOM stated that they had two bathrooms in the Administration hallway, one bathroom in the 400 hallway west, one bathroom in the 400 hallway east, one bathroom in the activities room, one bathroom in the 300 hallway, and one bathroom next to the front office. The DOM stated that he just replaced all the bathroom doorknobs and removed the dead bolt. The DOM stated that he never thought to put call lights in those bathrooms and did not know that they needed to have a call light.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet