Stonehenge of Springville

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 5, 2025

  Based on observation, interview, and record review it was determined, for 2 of 24 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident that was dependent on staff and required maximum assistance for bed mobility and toilet use was left alone, rolled out of the bed, and received a laceration and bilateral femur fractures. In addition, staff were not educated on how to keep a resident safe from choking who had a risk versus benefit signed. Resident identifiers: 5 and 35. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF801Aug 5, 2021

  Based on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings included: On 8/2/21 at approximately 11:28 AM, an interview was conducted with the facility's DM. The DM stated he was enrolled in classes to complete the certification for Dietary Manager. He stated he was enrolled in a fast track program that would take about 5 months to be completed. The DM stated he had been at the facility for 2 ½ years. […]

• No harm, potential for more than minimal, patternF756Aug 5, 2021

  Based on interview and record review it was determined, for 3 out of 28 sampled residents, that the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and any irregularities were reported to the attending physician, the facility's medical director and the Director of Nursing (DON) and these reports were acted upon. Additionally, the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Specifically, the pharmacist made recommendations to the attending physician that were not acted upon nor documented in the resident's medical record. Resident identifier: 2, 8, and 28. Findings included: 1. […]

• No harm, potential for more than minimal, patternF880Aug 5, 2021

  Based on observation, interview, and record review it was determined, for 4 out of 28 sampled residents, 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 [CONDITION(S)]-CoV-2. Specifically, observations were made of staff entering rooms on Transmission Based Precautions (TBP) without determining if aerosolized generating procedures (AGP) were in use and the necessary Personal Protective Equipment (PPE) was not donned, resident's Continuous Positive Airway Pressure ([CONDITION(S)]) machines were not cleaned by staff, staff were observed not performing hand hygiene and changing gloves during… […]

• No harm, potential for more than minimal, isolatedF609Mar 5, 2025

  Based on interview, and record review, for 3 of 24 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, a resident had an assisted fall out of bed during cares, the same resident had a fall which resulted in a bilateral femur fractures, a resident threatened another resident with physical harm, and a resident choked on a plastic ring and the State Survey Agency was not notified after the allegation was identified. Resident identifiers: 5, 28, 35, Findings include: 1. […]