Stonehenge of Cedar City

In the surveyor’s words

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

• Actual harm, isolatedF689May 19, 2026

  Based on interview, observation and record review, the facility did not ensure that 1 of 2 sample residents were free of accident hazards as is possible; received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was burned after heat source was placed on his abdomen. This will be cited at a harm level but at past non-compliance. Resident identifier: 1. It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, [S483.25(d) Accidents. […]

• Actual harm, isolatedF550Mar 26, 2026

  Based on observation, interview and record review, for 3 of 30 sampled residents, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents reported they had incontinent episodes waiting for staff to answer their call lights. Resident 55 was cited at a harm level because she stopped drinking because staff were too busy to help her to the bathroom. Resident identifiers: 34, 54 and 55. Findings Included: 1. […]

• Actual harm, isolatedF725Mar 26, 2026

  Based on observation, interview, and record review, for the 10 of 30 sampled residents, facility did not have sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psycho-social well-being of each resident. Specifically, for 10 out of 30 sampled residents, multiple residents voiced concerns with call light wait times and not receiving assistance with the bathroom which led to incontinent episodes. In addition, concerns with regards to staffing issues and long call light times were raised as grievances and during resident council meetings on repeated occasions. This will be cited at harm level. […]

• No harm, potential for more than minimal, widespreadF882Dec 1, 2021

  Based upon interview and record review it was determined that the facility did not ensure that the Infection Preventionist (IP) had completed specialized training in infection prevention and control. Specifically, the designated IP had not completed the designated training. Findings include: On 12/01/21 at 8:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was the Infection Preventionist (IP) for the facility. The DON stated she had not completed the specialized training from the Centers for Disease Control and Prevention (CDC) as she was new to her position as DON. The DON stated that the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) nurse were also new to their positions and had not completed the specialized training either.

• No harm, potential for more than minimal, patternF585Mar 26, 2026

  Based on interview and record review, the facility failed to make prompt efforts to resolve grievances that residents might have. Specifically, grievances regarding staffing issues were not resolved. Findings included: A review of the grievances revealed the following: 1. On 10/15/25, Left waiting on my bed for the CNAs [Certified Nursing Assistant] to take me to breakfast which happens all the time. I am sick of not being on time for my breakfast or all of my meals, for that matter. This is ridiculous!!! You need more staff. Steps taken to investigate the grievance was Resident Advocate checked call light response time. Call light was on at 8:15 AM, resident did not get to breakfast until 9:30 AM. […]