Millard County Care And Rehabilitation

resident's ability to function.

interview and record review, it was determined that for 3 out of 20 sampled residents, that the facility

not ensure that PRN (as needed) orders for anti-psychotic drugs were limited to 14 days.

Specifically, the facility did not document a gradual dose reduction attempt of psychotropic medications for two residents prior to January 2026 and one resident had an antipsychotic medication prescribed for more than 14 days.

Resident identifiers: 4, 8, and 54. 1. Resident 4 was admitted on [DATE], and readmitted on [DATE] with diagnoses including, but not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder unspecified.Resident 4's medical record was reviewed from 4/27/26 through 4/30/26.

The facility completed a psychotropic medication review and gradual dose reduction attempt in January

• There were no other documented gradual dose reduction attempts in the residents medical

record.2. Resident 54 was admitted on [DATE], and readmitted on [DATE] with diagnoses including, but not limited to Alzheimer's disease with early onset, dementia in other diseases classified elsewhere mild with anxiety, and psychotic disorder with hallucinations due to known physiological conditions.Resident 54's medical record was reviewed from 4/27/26 through 4/30/26.

The facility completed a psychotropic medication review and gradual dose reduction attempt in January 2026.

There were no other documented gradual dose reduction attempts in the residents medical record.On 4/29/26 at 9:34 AM, an interview was conducted with the Director of Nursing (DON).

The DON stated that the most recent psychotropic review and gradual dose reduction attempts at the facility were conducted in January 2026.

The DON stated that the facility did not complete any gradual dose reduction attempts or psychotropic reviews prior to January 2026, but that they should be completed quarterly. 3. Resident 8's medical record was reviewed 4/27/26 through 4/30/26.Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, psychotic disorder with delusions due to known physiological condition, dementia, and major depressive disorder.A physician's order dated 2/8/26 at 9:10 AM indicated haloperidol lactate (an antipsychotic/antimanic agent) injection solution 5 MG/ML (milligrams/milliliter).

Inject 0.2 ml intramuscularly every 12 hours as needed (PRN) for delusions, hallucinations, paranoia, and agitation.

No end date was given in the order.The medication administration record (MAR) was reviewed for the months of February 2026, March 2026, and April 2026 the MARs indicated resident 8 received the PRN haloperidol lactate injection on 2/8/26 at 9:15 AM and 4/21/26 at 4:35 PM. No end date was documented on the MAR.On 4/30/26 at 8:48 AM, an interview was conducted with the Director of Nursing (DON) who stated her PRN haldol was more than 14 days because it was only used for extreme reasons, but that it should have been limited to 14 days and that the doctor did not document a reason for the extended order.

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Millard County Care and Rehabilitation 150 South White Sage Avenue Delta, UT 84624

interviewed resident 19 and she denied it and that nobody had touched her.

The ADM stated that

19 if a man had groped her breast and she said no.

The ADM stated that resident 19 had said a

said, no, it was up in [City name redacted].

The ADM stated he did not report it because he felt it was not a credible allegation of abuse because there was more story to it, about resident 19's sister's dementia progressing and that he could not get anymore information out of resident 19's sister and because resident 19 denied it.

The ADM stated that resident 19's nephew had told him that resident 19 had been assaulted at another facility in [City name redacted] when resident 19's sister was her POA and that resident 19's nephew thought resident 19's sister was just reliving that and getting that confused.

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Millard County Care and Rehabilitation 150 South White Sage Avenue Delta, UT 84624

Review of resident 3's medical record was completed on 4/27/26

indicated severely impaired cognition.On 4/6/25 at 3:31AM, an Incident Nursing Note revealed the following, 0310 [3:10 AM] resident bed alarm went off, when staff went down, resident found in kneeling [sic] position leaning into her recliner. resident [sic] states her walker didn't go where she was going. resident [sic] states she was getting up from bed to go to bathroom [sic]. able to stand, c/o [complaint of] left knee, left elbow pain- no visible injury, right pinky pain no visible injury, right ring finger abrasion.On 4/16/25 at 4:24 PM, a Nursing Note revealed the following, Resident had ORIF [Open Reduction and Internal Fixation] to R [right] 4/5 [fourth and fifth] MC [metacarpal] Fx [fractures], at [name redacted] this AM.

She returned to [name redacted] from surgery at 12:50.On 4/30/26 at 12:44 PM, an interview was conducted with the ADM.

The ADM stated that he was made aware of resident 3's fractures to her right wrist.

The ADM stated that resident 3 is very independent and she would want to be able to wander the facility at her leisure.

The ADM stated that he did not feel there was any neglect or abuse that caused the major injury.

The ADM stated that he did not investigate the cause of the injury.

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Millard County Care and Rehabilitation 150 South White Sage Avenue Delta, UT 84624

can only be for 14 days and that he recommended an alternative option by a low dose of Seroquel

indicated quetiapine fumarate [generic name for Seroquel; an antipsychotic/antimanic medication]

Practical Nurse (LPN) 1 and she stated that she did not talk to the doctor about the recommendation from the pharmacist in November 2025 because resident 8 had not needed PRN haldol around that time.An interview was conducted on 4/30/26 at 1:14 PM with the Director of Nursing (DON) and she stated that it did not look like the pharmacist's recommendation from November 2025 was completed until February 2026 when a nurse mentioned it to the physician.

The DON stated that she does not have time to stay on top of that because she was too busy.

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Millard County Care and Rehabilitation 150 South White Sage Avenue Delta, UT 84624

Based on observation and interview, it was determined that the facility failed to ensure all drugs and

principles.

Specifically, two open insulin pens were not labeled with a resident's name.

Resident identifier: 56. On 4/29/26 at 10:50 AM, an observation of the south medication fridge was made where a plastic bin with resident 56's first name written on it was located, two open insulin pens were loose in the plastic bin and there was no resident name labeled on the medications. A concurrent interview was conducted with Registered Nurse (RN) 1 who stated the two insulin pens belonged to resident 56 and that they always put the names of the resident on the pen. RN 1 stated they were unsure why the labels had not been affixed. RN 1 was observed to place resident 56's identification label on both insulin pens.On 4/29/26 at 2:17 PM, an interview was conducted with the Director of Nursing (DON) who stated she threw the two previously unlabeled insulin pens away to avoid any medication errors and that the insulin pens should have been labeled.

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Millard County Care and Rehabilitation 150 South White Sage Avenue Delta, UT 84624

corrective plans of action.

improvement activities, the facility failed to take actions aimed at performance improvement and,

improvements were realized and sustained.

Specifically, the facility was cited a deficiency for F-F756 when it failed to maintain documentation in the medical records to demonstrate that a pharmacist reviewed the residents' medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents which was identified as a deficiency in the previous health survey in 2024.On 4/30/26 at 1:14 PM, an interview was conducted with the Director of Nursing and she stated that she did not have time to maintain documentation in the medical records to demonstrate that a pharmacist reviewed the residents' medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents because she did not have time.

This was cited during the previous survey at F-F756 and again on the current surveyOn 4/30/26 at 2:07 PM, an interview was conducted with the Administrator (ADM) and he stated that he did not have a performance improvement project but he had QAPI minutes that captured some of the improvement plans that they had worked on.

The ADM further stated that he felt they did achieve compliance with F-F756, which was cited during the previous survey, and that it should have been corrected.Documents to show compliance were requested at that time but were not received as of 5/13/26.

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Millard County Care and Rehabilitation 150 South White Sage Avenue Delta, UT 84624

infections.

Specifically, staff were observed handling oral medications with bare hands during

infections to identify patterns or trends.

Resident identifier: 23.1. On 4/30/26 at 11:47 AM, an observation of Licensed Practical Nurse (LPN) revealed that while preparing medications for resident 23, LPN 1 popped a pill directly into her bare hand before placing it into a medication cup. LPN 1 was then observed administering the contaminated medication to resident 23. On 4/30/26 at 1:29 PM, an interview with the DON was conducted.

The DON stated that staff members were expected to pop pills directly from blister packs into medication dispenser cups and to never touch medications with bare hands.

The DON stated that if a medication came in contact with a staff member's bare hand, that medication was to be disposed of and replaced with a newly dispensed dose. 2. On 4/29/26 at 8:20 AM, the facility's Infection Control Surveillance Logs were requested.

The DON stated that the facility had several residents contract influenza during the 2025 holiday season due to increased number of visitors.The DON stated that she kept those residents with symptoms contained to their room to reduce further spreading.

The DON stated that she did not have a list of residents or rooms affected regarding the influenza outbreak. It should be noted, the requested Infection Control Surveillance Logs were unavailable for review. On 4/30/26 at 12:28 PM, an interview with the Director of Nursing (DON) was conducted.The DON stated that she also served as the facility's designated Infection Preventionist (IP).

The DON stated that the facility lacked an infection control surveillance manual or organized tracking system.

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Millard County Care and Rehabilitation 150 South White Sage Avenue Delta, UT 84624

Specifically, the facility had no established facility-wide system to ensure the appropriate indication,

data.On 4/29/26 at 8:20 AM, the facility's Infection Control Surveillance Logs were requestedIt should be noted the facility's Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, were unavailable.On 4/30/26 at 12:28 PM, an interview with the Director of Nursing (DON) was conducted.

The DON stated that she also served as the facility's designated Infection Preventionist.

The DON stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment.