Millard County Care and Rehabilitation

Inspectors wroteBased on record review and interview, it was found that for 4 out of 20 sampled residents, the facility failed to ensure that each resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Specifically, five residents or resident representatives were not informed of risks and benefits, treatment or treatment alternatives or options in advance of starting psychotropic medications. Resident identifiers: 4, 6, 8, and 54. 1. Resident 8's medical record was reviewed 4/27/26 through 4/30/26. [...]

Inspectors wroteBased on interview and record review, it was determined that for 3 out of 20 sampled residents, that the facility did not ensure that residents who use psychotropic drugs received gradual dose reductions and did 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. [...]

Inspectors wroteBased on interview and record review, it was found that for 4 out of 20 sampled residents, the facility failed to ensure all alleged violations of abuse, including injuries of unknown source, were reported immediately to the State Survey Agency and other officials in accordance with State law. Specifically, the facility failed to report an allegation of sexual abuse and incidents involving major injuries to the State Agency, which prevented a timely investigation and oversight of resident safety. Resident Identifiers: 3, 6, 19, and 59.1. Resident 59 was admitted to the facility on [DATE], readmitted on [DATE], and discharged [DATE] with diagnoses which included hemiplegia and hemiparesis. Review of resident 59's medical record was completed on 4/27/26 through 4/30/26. [...]

Inspectors wroteBased on interview and record review, it was found that for 3 out of 20 sampled residents, the facility failed to ensure all alleged violations involving abuse and injuries of unknown sources were thoroughly investigated. Specifically, the facility failed to initiate or document an investigation into an allegation of sexual abuse and three separate incidents involving major injuries to determine the cause, identify responsible parties, or implement corrective actions to prevent further potential abuse. Resident Identifiers: 3, 6, and 59.1. Resident 59 was admitted to the facility on [DATE], readmitted on [DATE], and discharged [DATE] with diagnoses which included hemiplegia and hemiparesisReview of resident 59's medical record was completed on 4/27/26 through 4/30/26. [...]

Inspectors wroteBased on interview and record review, it was found that for 4 out of 20 sampled residents, the facility failed to ensure that a licensed pharmacist performed a drug regimen review at least once a month and failed to act upon the pharmacist's reports of any irregularities to the attending physician and the facility's medical director and director of nursing. Irregularities included, but were not limited to, any drug that met the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that was sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. [...]

Inspectors wroteBased on record review and interview, it was determined that for 3 out of 20 sampled residents, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized. Specifically, one resident's progress notes were entered late, at least 13 times with one being documented 48 days late, and 2 resident's pharmacy reviews were not readily available. Resident identifiers: 4, 23, 54 1. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional 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. [...]

Inspectors wroteBased on record review and interview, it was determined that as part of their performance improvement activities, the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained. Specifically, the facility was cited a deficiency for 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed handling oral medications with bare hands during administration, and the facility failed to maintain documentation for tracking and investigating 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. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility had no established facility-wide system to ensure the appropriate indication, dose, and duration for antibiotic prescriptions, nor a process for monitoring usage and resistance 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. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 20 sampled residents, that based on the comprehensive assessment of a resident the facility did not provide care, consistent with professional standards of practice, to prevent pressure ulcers. In addition, a resident with pressure ulcers did not receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident had no treatment orders when a new pressure ulcer was identified. The same resident did not have wound measurements of her heel wound since November 2023 and December 2023 for two additional wounds. The heel wound increased in size and there was no re-assessment of the treatment orders. Resident identifier: 21.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, a staff member tested positive for COVID-19 and was not excluded from working in the facility.

Inspectors wroteBased on observation, interview and record review, it was determined the facility did not designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's infection control program.

Inspectors wroteBased on interview and record review, it was determined for 5 of 20 sampled residents, that the facility did not ensure that each resident's drug regimen was reviewed once a month by the licensed pharmacist, and that any irregularities were reported to the physician and were acted upon. Specifically, monthly pharmacy reviews were not being conducted between July 2023 and January 2024. Resident identifiers: 14, 19, 20, 22 and 32.

Inspectors wroteBased on interview and record review it was determined, for 5 of 20 sampled residents, that the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR), and behavioral interventions, unless it was clinically contraindicated. Specifically, residents prescribed psychotropic drugs did not have a GDR attempted. In addition, documentation for contraindication for GDR's were not documented. Resident identifier: 14, 19, 20, 22 and 32.

Inspectors wroteBased on observation and interview it was determined that the facility failed to store all drugs and biologicals in locked compartments. Specifically, two refrigerators that contained medications were unlocked.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not notify the resident's physician when there was a signigicant change in the resident's physical, mental or psychosical status or when there was a need to alter treatment significantly. Specifically, a resident developed a new wound and the physicain was not notified. In addition, the resident did not have physician's orders to treat the wound. Resident identifier: 21.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not provide or obtain routine dental services. Specifically, a resident stated her dentures did not fit and needed to be adjusted. Resident identifier: 34.

Inspectors wroteBased on interview and record review, for 1 of 20 sampled residents, it was determined the facility did not develop and implement a baseline care plan that included the instructions needed to provide effective and person centered care of the resident that met professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, the resident's care plan was developed 5 days after the resident was admitted to the facility. Resident identifier: 19.

Inspectors wroteBased on observation, interview and record review, it was determined that, for 5 of 20 sampled residents, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, care plans were not updated when there was a change in the resident's condition and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 9, 14, 21, 22, and 34.

Inspectors wroteBased on observation, interview and record review, for 2 of 20 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the resident's preferences. Specifically, a resident who had a change in her diet order was not assessed as having a change in condition, and a resident who developed pneumonia and the flu did not have his change in condition documented until it was necessary to send him to the hospital. Resident identifiers: 22 and 32.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's medications did not have a diagnoses. Resident identifier: 20.

Inspectors wroteBased on interview and record review, for 1 of 20 sampled residents, the facility did not obtain laboratory services only when ordered by a physician. Specifically, a resident had laboratory services completed without a physician's order. Resident identifier: 20.

Inspectors wroteBased on interview and record review. it was determined for 1 of 20 sampled residents, that the facility did not file in the resident's clinical record laboratory (lab) reports that were dated and contained the name and address of testing laboratory. Specifically, the lab results for 3 urinary cultures and sensitivities were not obtained or filed in the resident's medical record. Resident identifier: 19.

Inspectors wroteBased on interview and record review, it was determined for 1 of 20 sampled residents, that the facility did not file in the resident's clinical record the signed and dated reports of radiological and other diagnostic services. Specifically, a resident's chest x-ray result was not filed in the medical record. Resident identifier: 32.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not provide or obtain routine dental services. Specifically, a resident stated her dentures did not fit and needed to be adjusted. Resident identifier: 34.

Inspectors wroteBased on observation, interview and record review, it was determined for 2 of 20 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, residents were provided puree diets when their prescribed diet was mechanical soft or regular. Resident identifiers: 9 and 22.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident with a referral for cataracts to be evaluated was not completed. Resident identifier: 38.

Inspectors wroteBased on interview and record review, it was determined for 1 of 20 sampled residents, that the facility did not ensure that the hospice services met professional standards and principles that applied to providing services in the facility and to the timeliness of those services. Specifically, the facility did not obtain from the hospice provider the most recent hospice plan of care, physician re-certification of terminal illness, and all communication visit notes were not maintained in the resident's medical record. Resident identifier: 14.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not provide the right for residents to choose medical treatment. Specifically, for 4 out of 37 sampled residents, residents Physicians Orders for Life Sustaining Treatment (POLST) forms were not completely filled out. Resident identifiers: 2, 41, 202 and 23.

Inspectors wrote3. Resident 252 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy bodies, iron deficiency anemia, muscle weakness, repeated falls, rheumatoid arthritis without rheumatoid factor, epilepsy, major depressive disorder, and anxiety. Resident 252's medical record was reviewed on 5/5/22. A review of resident 252's care plan revealed the care plan to be incomplete. Resident 252's care plan was initiated on 4/25/22 with the next review date scheduled for 5/6/22. Resident 252's care plan had a focus area initiated on 4/26/22 which stated, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia, musculoskeletal impairment, weakness. This focus area had one goal, initiated on 4/26/22, which stated, The resident will improve current level of function in ADL ability through the review date. [...]

Inspectors wroteBased on observations and interviews, it was determined that the facility did not ensure that standard precautions and hand hygiene procedures were followed by staff in direct resident contact to prevent the spread of infection. Specifically, staff members did not perform hand hygiene before and after providing resident care, did not perform hand hygiene between resident encounters, and did not disinfect the weight bench before and after each resident use.

Inspectors wroteBased on interview and record review it was determined for 1 of 37 sampled residents, the facility did not conduct a periodic comprehensive, accurate, standardized, and reproducible Minimum Data Set (MDS) assessment of each resident's functional capacity. Specifically, an annual MDS assessment was not completed timely. Resident identifier: 35.

Inspectors wroteBased on interview and record review the facility did not use the quarterly review instrument once every three months for 1 of 37 sampled residents. Specifically, a Quarterly Minimum Data Set (MDS) assessment was not completed and submitted in a timely manner. Resident Identifier: 23.

Inspectors wroteBased on interview and record review, it was determined that the facility did not develop and implement a baseline care plan for each resident that included the instruction needed to provide effective and person-centered care of the resident that meets professional standards of quality care. Specifically, a baseline care plan was not completed for a newly admitted resident, which left facility staff without the needed instruction to provide the resident with effective, person-centered care. Resident identifier: 252.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not provide treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 37 sampled residents, the facility did not provide baseline monitoring of a resident's blood sugars. Resident identifier: 202.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not maintain acceptable parameters of nutrition status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible. Specifically, there was 1 of 37 sampled residents that lost weight and nutritional interventions recommended were not implemented timely. Resident identifier: 9.