Millard County Care and Rehab: Antipsychotic Failures - UT
The resident, identified in inspection records only as Resident 8, was admitted to Millard County Care and Rehabilitation with a history that included dementia, major depressive disorder, and a psychotic disorder with delusions following a stroke that left one side of the body weakened. On February 8, a physician ordered haloperidol lactate, an antipsychotic and antimanic drug, to be injected intramuscularly every 12 hours as needed for delusions, hallucinations, paranoia, and agitation. The order carried no end date.
Inspectors reviewed medication administration records for February, March, and April. The resident actually received the injection twice during that span, once on February 8 and once on April 21. The order, though, sat open the entire time. No end date appeared on the order. No end date appeared on the medication administration record.
When inspectors spoke with the Director of Nursing on the morning of April 30, she acknowledged the problem directly. She said the order had run past 14 days because the drug was used only for extreme situations. She also said the physician had never documented a reason for allowing the order to extend beyond that point.
The haloperidol finding was one of three psychotropic medication failures inspectors documented across 20 sampled residents.
Two others, Resident 4 and Resident 54, had gone without documented gradual dose reduction attempts for months. Gradual dose reduction is a process meant to periodically test whether a resident still needs a psychotropic drug at its current dose, or whether it can be lowered or stopped. For residents with dementia, the process carries particular weight. These drugs carry serious risks in older adults with cognitive impairment, including sedation, movement disorders, and increased risk of stroke and death.
Resident 4 carried diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Resident 54 had Alzheimer's disease with early onset, dementia with anxiety, and a psychotic disorder with hallucinations. Both residents had their most recent psychotropic review and gradual dose reduction attempt completed in January 2026. Inspectors, reviewing records through the end of April, found no documentation of any attempt before or after that date.
The Director of Nursing confirmed it on April 29. She told inspectors that the facility had not completed any gradual dose reduction attempts or psychotropic reviews prior to January 2026, and that those reviews are supposed to happen quarterly.
That means, by the DON's own account, the facility was already behind before January. The January reviews appear to have been the first ones done. Then nothing followed.
Quarterly means four times a year. The inspection found evidence of once.
For residents like Resident 4 and Resident 54, living with dementia in a care facility, the purpose of those reviews is to ask a basic question at regular intervals: does this person still need this drug, at this dose, or has something changed? The question was not being asked.
The inspection classified the violations at a level of minimal harm or potential for actual harm, meaning inspectors did not document that residents suffered a concrete injury traceable to the missed reviews or the open-ended haloperidol order. What the record shows is a facility where the oversight structure for some of its most vulnerable residents, those on antipsychotics for dementia-related symptoms, was not functioning. Reviews that should have happened every three months happened once. An injection order that should have expired in two weeks ran for over two months with no physician explanation and no end date written anywhere.
Resident 8 received that injection for the second time on April 21. Nine days later, inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Millard County Care and Rehabilitation from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 7, 2026 · Our methodology
Millard County Care and Rehabilitation in Delta, UT was cited for violations during a health inspection on April 30, 2026.
Inspectors reviewed medication administration records for February, March, and April.
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.