Millard County Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Millard County Care and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 7, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Feb 7, 2024

  Based 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. Findings include: On 2/5/24 upon entering the facility, an interview was conducted with the Administrator. The Administrator stated the Maintenance Director tested positive for COVID-19 that morning. The Administrator stated he fixed the facility washing machine and then tested positive. The Administrator stated he was not feeling well and he was sent home. […]

• No harm, potential for more than minimal, widespreadF882Feb 7, 2024

  Based 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. Findings include: The facility's Infection control documentation was requested. No Infection Control Surveillance Logs were available from the previous survey 5/5/22 to current. On 2/6/24 at 4:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had not had an IP since the previous survey. The DON stated she had not completed the IP training. The DON stated she was unable to fill the IP position because then it would take a nurse from patient care. The DON stated she did not have infection control tracking or trending. […]

• No harm, potential for more than minimal, patternF552Apr 30, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF605Apr 30, 2026

  Based 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. […]