Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monument Healthcare Millcreek during CMS and state inspections, most recent first.
A resident with complex cardiac, renal, and nutritional conditions received evening TPN ordered with pharmacy instructions that conflicted between the electronic order summary and the pharmacy label regarding total volume, rate, and duration. An agency RN initiated the TPN, reported not finding an IV pump, and manually regulated the infusion via roller clamp instead of using the pump that was later confirmed to be in the room. The TPN, which was ordered to infuse over many hours with tapering, was instead delivered over roughly 3 hours, and the oncoming RN later found the bag empty and connected directly to the PICC line without the pump. Subsequent documentation showed marked changes in the resident’s neuro status and vital signs, including lethargy, altered mental status, elevated HR and BP, hyperglycemia, and complaints of chest pain, leading to EMS transfer and hospital admission. The facility’s investigation substantiated that the TPN was administered incorrectly as a bolus, and the PN policy requiring controlled, tapered infusion was not followed, while the transfer documentation did not note the TPN bolus when the resident was sent to the hospital.
A resident with sepsis and kidney stones was managed on PRN morphine for pain, but two concurrent PRN orders for morphine 15 mg (0.5 tablet q3h and 1 tablet q3h) were entered, creating a potential daily dose of up to 180 mg without clarification. Despite documentation of slurred speech, lethargy, low O2 sats, cough, and shortness of breath, and a provider note attributing intermittent dysarthria to morphine and indicating the need to reduce dosing unless pain exceeded 4, no updated morphine order was found. Nursing staff continued to administer 15 mg doses based largely on the resident’s requests and subjective pain scores, without resolving the conflicting orders or consistently consulting the provider, and the resident was ultimately transferred to the ED in critical condition, where opiate toxicity was diagnosed and treated with naloxone.
Three residents experienced deficiencies in medication management, including administration of blood pressure medications outside of physician-ordered parameters and missed doses of a diabetes medication due to pharmacy and documentation issues. The DON and LPN confirmed that medications were given when they should have been held or were not administered as scheduled, and that proper physician notification and documentation were lacking.
Seven public bathrooms accessible to residents were observed to lack call light systems, preventing residents from being able to call for staff assistance while using these facilities. The Director of Maintenance confirmed that these bathrooms were accessible to residents and did not have call lights installed, stating he was unaware of the requirement.
A resident with diabetes and other complex medical needs missed several scheduled doses of Trulicity due to pharmacy and supply issues, but the physician was not immediately notified of these missed doses. Documentation showed delays in both medication administration and provider notification, and staff interviews confirmed that the required immediate communication with the physician did not occur.
A resident admitted with surgical wounds and dressings on both feet did not receive wound care orders until nine days after admission, despite having a care plan noting the risk for skin breakdown and documented wounds. The admitting nurse did not obtain or verify wound care orders upon admission, and no wound care was documented until orders were finally received from the physician.
A resident with multiple serious health conditions did not receive several scheduled doses of IV Vancomycin, as ordered for treatment of bacterial arthritis and MRSA. The MAR showed missed or undocumented doses, with no corresponding nurse notes to explain the omissions. Nursing staff confirmed that missed doses should be documented and reported, but this was not done, resulting in a significant medication error.
A resident with multiple health conditions receiving IV Vancomycin had several high trough lab results, but there was no documentation that the physician was notified of these abnormal values. Staff interviews confirmed that the process required physician notification and documentation, but records did not show this occurred.
A resident with multiple complex diagnoses had a STAT KUB x-ray ordered and performed due to abdominal symptoms, but the signed and dated x-ray report was not filed in the clinical record. Staff interviews revealed inconsistencies in the process for handling and filing diagnostic results, resulting in the required documentation being unavailable in the resident's chart.
A resident with MRSA, wounds, and a PICC line was not placed on appropriate contact precautions, as required by facility policy and CDC guidance. Staff were unclear about the differences between Enhanced Barrier Precautions and Contact Precautions, and the resident participated in therapy sessions outside their room without proper signage or PPE protocols in place, resulting in a breakdown of the infection prevention and control program.
Unsafe TPN Administration via Gravity Drip and Order Discrepancies
Penalty
Summary
The deficiency involves the unsafe and inappropriate administration of TPN/IV fluids to a cognitively intact resident with multiple complex medical conditions, including CHF, chronic pulmonary edema, chronic kidney disease, kidney transplant status, malnutrition, intestinal fistula, and electrolyte disorders. The resident had an order for evening TPN with pharmacy instructions specifying a compounded volume of 1800 ml, including start and end taper periods, and a total run period of 16 hours. However, the pharmacy label on the TPN bag directed infusion of 1800 ml at 125 ml/hr over 12 hours, and there were discrepancies between the pharmacy order summary (with tapering start and end rates and volumes) and the label directions. The DON later acknowledged that the label directions did not match the calculated infusion time for the stated volume and rate and that there was confusion in how the order was written. On the evening of the incident, an agency RN initiated the resident’s ordered TPN infusion between approximately 7:30 PM and 8:00 PM. The agency RN reported that an IV pump was not present in the room and manually calculated the drip rate, regulating the infusion via the roller clamp and counting drips per minute, rather than using an IV pump. It was later confirmed that an IV pump was in fact present in the room. The agency RN did not document or report the duration of infusion used to calculate the drip rate. Between 10:00 PM and 10:30 PM, the agency RN reported that the TPN bag was about half full before leaving the shift. At around 10:00 PM, the oncoming facility RN assumed care of the hallway and later, at approximately 11:01 PM, entered the resident’s room and found the TPN bag empty, connected directly to the PICC line and not routed through the IV pump. The progress note documented that the resident had already received the full TPN volume even though it was scheduled to run over 12 hours, and the facility’s abuse investigation determined that the TPN had infused over about 3 hours and 15 minutes instead of the ordered 12 hours. Following the rapid infusion, the resident’s condition changed. At about 11:01 PM, the resident’s blood sugar was documented as 450, and vital signs and neuro checks were performed, with subsequent neurological assessments showing elevated HR, elevated BP, increased RR, and progressive changes in level of consciousness and motor response from baseline over the night and into the morning. The resident became lethargic with altered mental status, was more difficult to arouse, and later complained of chest pain, headache, nausea, and confusion. A physiatry follow-up note described the resident as lethargic, arousable only to loud voice and tactile stimulation, and reporting constant sharp chest pain. EMS was called later that morning due to chest pain, low BP, fever, and high HR, and the resident was transferred to the hospital, where she was noted to be febrile, tachycardic, initially hypotensive, and confused, with differential diagnoses including sepsis and line sepsis. The facility’s emergency transfer form did not document that the resident had received a TPN bolus the prior night, and the hospital documentation did not reflect that the TPN bolus and associated change in condition had been communicated. The facility’s own investigation substantiated that the resident received TPN incorrectly as a bolus over a short period rather than as ordered. The facility’s PN policy required that PN be tapered up over 1–2 hours, run at a set rate for a determined time, and then tapered down over 1–2 hours, and specifically stated that PN should never be stopped suddenly and that tapering is needed to prevent hypoglycemia. The pharmacy order summary for this resident’s TPN included start and end taper periods and a total run period of 16 hours, but the pharmacy label and the way the order was presented created inconsistencies in the documented volume, rate, and duration. The DON acknowledged that the nurse should have clarified the discrepancies with the pharmacy and followed up with the physician. The DON also confirmed that the TPN label indicated infusion at 125 ml/hr with a total volume and duration that did not mathematically align, and that there was confusion with the order as written. Despite these documented inconsistencies and the presence of an IV pump in the room, the TPN was administered via gravity drip and infused in a fraction of the intended time, leading to a substantiated medication administration error and associated change in the resident’s condition.
Failure to Manage PRN Morphine Orders Safely Resulting in Opiate Toxicity
Penalty
Summary
The deficiency involves the facility’s failure to provide pain management in accordance with professional standards of practice for a resident receiving morphine, resulting in opiate toxicity and hospitalization. The resident was admitted with sepsis, obstructive and reflux uropathy, and kidney stones, and had an existing order for immediate-release morphine 7.5 mg every 6 hours as needed for dorsalgia. On admission, medication reconciliation was completed with the family and primary care physician records. Shortly after admission, the resident complained of ongoing pain and requested more morphine than he was receiving. On 1/3, nursing documentation reflected instructions to give 0.5 tablet by mouth every 3 hours for pain and 1 tablet by mouth every 3 hours as needed for pain, and physician orders were entered for morphine sulfate 15 mg, both 0.5 tablet every 3 hours PRN and 1 tablet every 3 hours PRN, creating two active PRN orders for the same opioid at different doses and the same frequency. The new morphine orders significantly increased the potential daily morphine exposure. Based on the prescribed frequency and dosage, there was a potential for up to 180 mg of morphine to be administered in a 24-hour period, representing an increase of 150 mg per 24 hours from the prior regimen. On 1/5, the physician documented that the resident’s family reported slurred speech, and the physician assessed that there was intermittent dysarthria likely caused by morphine and stated that the morphine should be reduced unless needed for pain levels higher than 4; however, no updated morphine order reflecting this change was found in the medical record. Subsequent nursing notes documented clinical changes, including lethargy, slurred or unclear speech, low oxygen saturations, cough, shortness of breath, and the need for supplemental oxygen and nebulizer treatments. Despite these changes and the physician’s concern about morphine-related dysarthria, the dual PRN morphine orders remained, and there was no documented clarification or consolidation of the opioid orders. In the days leading up to the resident’s transfer to the hospital, the MAR showed administration of 15 mg morphine tablets with pain scores of 10, 7, and 4, totaling 45 mg in a 24-hour period. On the morning of transfer, nursing documented that the resident appeared lethargic, had cold extremities, and that oxygen saturation could not be obtained despite oxygen being titrated up to 5 L/min, with staff reporting a significant decline compared to the prior day. The resident was transferred to the ED for further evaluation. In the ED, the provider documented that the resident arrived critically ill with hypoxia, slow respiratory rate, confusion, and minimal responsiveness, and noted that the resident had been receiving extra doses above the 0.5 tablet of morphine he was supposed to be getting at least once or twice a day. The ED provider diagnosed opiate toxicity along with hypoxia and sepsis, and the resident responded to naloxone with improvement in respiratory rate, oxygenation, and blood pressure. Interviews with an LPN and the DON revealed that nurses relied heavily on resident request and subjective pain reports to administer morphine, did not consistently question high-frequency opioid orders, and did not obtain provider clarification when two different PRN orders for the same opioid existed, contributing to the unsafe pain management that led to opiate toxicity. Interviews further clarified the facility’s practices and expectations around opioid administration and order management. The LPN stated that when receiving a physician order, he would repeat it back and then enter it into the record, and that he typically would follow up with a provider if he encountered a morphine order more frequent than every 4–6 hours. However, in this case, he did not follow up with the provider regarding the every-3-hour morphine orders because the resident had been on morphine for some time and appeared to be tolerating it. He also stated that he administered morphine based on resident request, even when pain levels were low, and that on the day of the resident’s decline he gave the higher dose at the resident’s request despite lethargy. The DON stated she expected nurses to use nursing judgment and to contact the physician when there were two different orders for the same opioid, and acknowledged that the morphine order should have been written as a range (0.5 to 1 tablet every 3 hours). The combination of unclarified duplicate PRN morphine orders, lack of documented adjustment after the physician’s concern about morphine-related dysarthria, and reliance on resident preference without adequate clinical reassessment or provider consultation led to excessive morphine dosing and the resident’s opiate toxicity.
Failure to Adhere to Physician-Ordered Medication Parameters and Timely Administration
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as defined by administration outside of physician-ordered parameters, missed doses, and lack of adequate monitoring. For three residents, there were documented instances where blood pressure medications were administered despite vital signs being outside the prescribed hold parameters. Specifically, one resident with hypertensive chronic kidney disease, hemiplegia, and atrial fibrillation received Metoprolol Tartrate on six occasions when either systolic blood pressure or heart rate was below the physician’s specified threshold for holding the medication. Another resident with diagnoses including orthopedic aftercare, diabetes, and morbid obesity did not receive her prescribed Dulaglutide injections as scheduled for three weeks following admission. The delay was attributed to pharmacy delivery issues and insurance coverage, with documentation showing missed doses and late administration. The resident reported the missed doses, and the nurse confirmed difficulties in obtaining the medication, but there was inconsistent documentation of physician notification and follow-up. A third resident with multiple cardiac conditions, including atrial fibrillation and congestive heart failure, received both Metoprolol Succinate ER and Amiodarone HCl on several occasions when blood pressure or heart rate was below the ordered parameters for holding the medications. Interviews with the DON confirmed that medications should have been held according to the physician’s orders, and that the administration outside of these parameters was not in compliance with the prescribed regimen.
Lack of Call Light Systems in Public Bathrooms
Penalty
Summary
The facility was found to be inadequately equipped to allow residents to call for staff assistance in public bathrooms, as none of the seven public bathrooms accessible to residents were equipped with a call light system. Observations on 11/20/25 revealed that multiple public bathrooms, including those in the 300 and 400 hallways, near the nurse's station, staff break room, Human Resource office, front desk, Administration hallway, and activities room, did not contain call lights. These bathrooms were not locked, making them accessible to residents at any time. During an interview, the Director of Maintenance confirmed the absence of call lights in these bathrooms and stated that he was unaware of the requirement to have them installed.
Failure to Immediately Notify Physician of Missed Diabetes Medication
Penalty
Summary
A deficiency was identified when the facility failed to immediately inform or consult with a resident's physician regarding a significant change in the resident's treatment, specifically related to the administration of Trulicity (Dulaglutide) for diabetes management. The resident, who had diagnoses including orthopedic aftercare following amputation, Type 2 diabetes mellitus, and morbid obesity, reported missing three weeks of Trulicity injections upon admission. Medical record review showed that the medication was not administered as scheduled on multiple occasions due to pharmacy delivery issues and lab results, with documentation indicating delays and missed doses. Despite these missed doses, there was no immediate notification to the resident's physician at the time the medication was unavailable. Provider notification occurred 24 hours after a scheduled dose was missed, and in other instances, the medication was either awaited from the pharmacy or arrangements were made for a family member to bring it in. Interviews with facility staff, including an LPN and the DON, confirmed that the physician was not promptly notified as required when the medication was not available, and the DON was unaware that multiple doses had been missed.
Delay in Initiation of Wound Care Orders for Newly Admitted Resident
Penalty
Summary
A deficiency was identified when a resident was admitted with wounds and dressings on both feet, but did not have wound care orders initiated until nine days after admission. The resident had a complex medical history, including arthritis due to bacteria in the left ankle and foot, MRSA, diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. Upon admission, the resident's hospital discharge orders did not include wound care instructions, but the nursing assessment documented the presence of surgical incisions and dressings. The care plan noted the potential for skin breakdown and included interventions to administer treatments as ordered and monitor for effectiveness. Despite these documented needs, there was no evidence that wound care was provided or that orders were obtained until nine days after admission, when a physician finally ordered specific wound care procedures. Interviews with staff revealed that the admitting nurse is responsible for reviewing discharge orders, documenting wounds, and obtaining necessary wound care orders, but this process was not followed in this case. The Director of Nursing confirmed that the expectation is for the admitting nurse to follow up with the physician for wound care orders if they are not present at admission.
Missed Vancomycin Doses and Lack of Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including bacterial arthritis, MRSA, diabetes, chronic kidney disease, and congestive heart failure, did not receive several scheduled doses of Vancomycin as ordered by their physician. The resident, who had a PICC line for intravenous antibiotics, reported that three doses of Vancomycin were missed. Review of the Medication Administration Record (MAR) showed that on four occasions, Vancomycin doses were either marked with codes indicating 'see Nurse Note' or 'HOLD see Nurse Note,' or lacked any documentation of administration or reason for omission. No corresponding nurse progress notes were found to explain why the medication was not given or held on these dates. Interviews with nursing staff and the Director of Nursing revealed that the expected protocol was to notify the physician of any missed medication doses and document the reason in a progress note. The LPN interviewed stated that a code indicating a missed dose should be accompanied by a detailed progress note, and that missing documentation in the MAR should be flagged for review by nursing leadership. Despite these expectations, there was no documentation to account for the missed Vancomycin doses, resulting in the resident not being free from significant medication errors.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
A deficiency was identified when the facility failed to notify the ordering physician of laboratory results that were outside the clinical reference ranges for one resident. The resident, who had a complex medical history including bacterial arthritis, MRSA, diabetes, chronic kidney disease, congestive heart failure, pain, and edema, was receiving intravenous Vancomycin therapy via a PICC line. Multiple Vancomycin trough levels were reported as high on several occasions, but there was no documentation that the physician was notified of these abnormal results. Interviews with staff confirmed that the process required notification of the physician and documentation in the progress notes when lab results were abnormal. However, review of the resident's records did not show any evidence that the physician was informed of the high Vancomycin trough levels, nor was there documentation of any pharmacy recommendations for dose adjustment. The DON confirmed that such notifications and documentation should have occurred.
Failure to File Signed and Dated Diagnostic Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated report of a radiological diagnostic service in a resident's clinical record. The resident, who had a history of traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder, was admitted to the facility and later had a physician's order for an immediate (STAT) Kidney, Ureter, and Bladder (KUB) x-ray due to abdominal symptoms. Although nursing notes referenced the x-ray and its impression, the actual documentation of the x-ray results could not be located in the resident's medical record during the review period. Interviews with multiple staff members, including LPNs, the Regional Compliance Nurse, the DON, and the Administrator, revealed that the process for handling x-ray results involved receiving faxed reports from the x-ray company, notifying the physician, and distributing copies to various offices before forwarding the results to medical records for scanning and attachment to the resident's chart. However, there was a lack of clarity and consistency in the process, and the KUB x-ray result for the resident in question was not found in the clinical record as required.
Failure to Implement Proper Contact Precautions for Resident with MRSA
Penalty
Summary
A deficiency was identified when a resident with a history of MRSA septic arthritis, bacteremia, and a PICC line for intravenous antibiotics was not placed on proper contact precautions. The resident had undergone surgical cleaning of both ankles, with the left foot confirmed to have MRSA. Despite the presence of a PPE cart in the room and a magnet indicator on the doorframe, there was no signage specifying the type of transmission-based precautions required. The resident's medical records indicated orders for both Enhanced Barrier Precautions (EBP) and Contact Precautions due to wounds and the PICC line, and the care plan included interventions for EBP related to these conditions. Interviews with staff revealed confusion and lack of clarity regarding the implementation and distinction between EBP and Contact Precautions. An LPN was unable to clearly differentiate between the two types of precautions or specify the required PPE for each. The Director of Rehabilitation was unaware that the resident was on any transmission-based precautions and allowed the resident to participate in therapy sessions in the gym, stating that if the wound was contained, gym attendance was permitted. The DON confirmed that a number 6 magnet was used to indicate EBP, but that Contact Precautions would require additional signage, which was not present for this resident. Facility policies and CDC guidance reviewed during the survey specified that residents with MRSA infections should be placed on Contact Precautions, with clear signage and appropriate use of gowns and gloves upon room entry. The lack of proper signage, inconsistent staff knowledge, and failure to implement the correct precautions for a resident with an active MRSA infection led to the deficiency. The resident was observed participating in group therapy without the required precautions in place, further demonstrating the facility's failure to maintain an effective infection prevention and control program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Murray Creek | 1.1 mi | ★★★★★ | 2 | 0 |
| Spring Creek Healthcare Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Paramount Health And Rehabilitation | 1.3 mi | ★★★★★ | 1 | 0 |
| Rocky Mountain Care - Cottage On Vine | 2.1 mi | ★★★★★ | 1 | 0 |
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