Stonehenge of American Fork

In the surveyor’s words

From the most serious findings on record at Stonehenge of American Fork, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 10, 2023

  Based on observation, interview and record review it was determined, for 2 out of 31 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a fall from occurring which resulted in a fracture and care planned interventions were not implemented, adequate, or timely. Additionally, the facility did not provide adequate supervision or assistance during incontinence care which resulted in a dislocation of the resident's knee. The identified deficiencies were determined to have occurred at a harm level. Resident identifiers: 66 and 73. […]

• Actual harm, isolatedF684Nov 18, 2021

  Based on observation, interview, and record review it was determined the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 2 out of 23 sampled residents, a resident with a change of condition had a delay in treatment. In addition, a resident that was transferred improperly sustained a fracture. Resident identifiers: 10 and 55. Findings include: 1. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . anxiety disorder, and [CONDITION(S)]. On 11/15/21 at 2:29 PM, an interview was conducted with resident 55. […]

• No harm, potential for more than minimal, widespreadF812Oct 10, 2023

  Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards of food service safety. Specifically, food items in the walk-in freezer, walk-in refrigerator, reach-in freezer, and dry food storage were open to air. Findings include: On 10/2/23 at 8:05 AM, an initial walkthrough of the kitchen was conducted. a. The reach-in freezer was observed to have a box of beef patties open to air, a box of country fried steak was open to air, and a box of egg rolls was open to air. b. The dry storage room was observed to have a box of buttermilk biscuit mix that was open to air. c. The walk-in refrigerator was observed to have a box of [brand name] sausage links was open to air. d. […]

• No harm, potential for more than minimal, patternF812Jul 23, 2025

  Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the staff wore hairnets incorrectly, cell phones were in the food preparation area, a dirty rag was used to clean a plate that was used for a resident's lunch, a spoon was repeatedly touched with dirty gloves then placed on the food. Findings included:On 7/23/25 at 12:18 PM, the following were observed during lunch service: At 12:03 PM, an observation was made of the Cook. The cook wore a hat with a hairnet over the top of it that was not covering her hair. […]

• No harm, potential for more than minimal, patternF880Nov 18, 2021

  Based on observation and interview, the facility did not establish and 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. Specifically, staff were observed without eye protection during an outbreak, staff did not sanitize their hands while passing food trays to residents, used meal trays were taken from resident rooms and placed back on the food cart next meal trays that had not been delivered, staff did not sanitize hands between passing medications to different residents, and staff entered a resident's room while a continuous positive airway pressure ([CONDITION(S)]) machine was in use without the appropriate personal protective… […]