Stonehenge of American Fork

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. The cook's hair had fallen out of the hat and was not covered by the hairnet.At 12:05 PM, an observation was made of a kitchen aide who had her hair clipped up in the back. The hair net was observed to only be covering the hair in the hair clip not on her scalp.At 12:07 PM, the cook was observed to touch the face of the plates with gloved hands that had touched her face and hair. At 12:08 PM, the dietary manager was observed to enter the cooking area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents had the right to make choices about aspects of his or her life in the facility that were significant to the resident. Specifically, 1 out of 37 sampled residents, a resident was not administered medications timely. Findings included:Resident 18 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic congestive heart failure, morbid obesity, major depressive disorder, weakness, acquired absence of left leg above knee, and essential hypertension.On 7/21/25 at 11:14 AM, an interview was completed with resident 18. Resident 18 stated that she did not receive her nighttime medications until around 11:00 PM, and that was just too late to get them. Resident 18 stated the staff had woken her up last night to administer the medications and it was close to or after midnight. Resident 18 stated that it did not happen with every nurse but it did happen quite a bit. Resident 18 stated she did not want to be woken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 1 out of 3 sampled residents, a resident did not receive a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) when the beneficiary intended to continue services that might not have been covered under Medicare. Resident identifier: 14.Findings included:A SNF Beneficiary Notification Review, completed by the Social Services Director (SSD) for resident 14, dated 7/23/25, indicated, Medicare Part A Skilled Services Episode Start Date: 01/31/25. Last covered day of Part A Service: 04/19/25. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. It further indicated, 1. Was a SNF ABN, Form CMS [Centers for Medicare & Medicaid Services] 10055 provided to the resident? . No . Discussed with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, 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 were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, for 1 out of 37 sampled residents, a resident's heels were observed to not be floated while in bed when it was indicated as needed on the care plan. Resident identifier: 88.Findings included:Resident 88 was admitted to the facility on [DATE] with diagnoses which included a second degree atrioventricular block, dementia, weakness, and hypertension.On 7/22/25 at 1:45 PM, an observation was made of resident 88 laying in bed on his back, his heels were not floated.Resident 88's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and would not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 37 sampled residents, a resident who had blanchable redness on the left heel was observed to not have their heels floated when in bed. Resident identifier: 88.Findings included:Resident 88 was admitted to the facility on [DATE] with diagnoses which included a second degree atrioventricular block, dementia, weakness, and hypertension.On 7/22/25 at 1:45 PM, an observation was made of resident 88 laying in bed on his back, his heels were not floated.Resident 88's medical record was reviewed on 7/21/25 through 7/23/25.A physician's order dated 7/9/25 at 12:18 PM, indicated, Float Heels for protection of skin integrity .An admission Nursing Comprehensive assessment dated [DATE] at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The walk-in freezer was observed to have a box of pre-cut carrots was open to air, a box of cookie dough was open to air, a box of puff pastry was open to air, a box of egg omelets was open to air, and a box of frozen waffles was open to air. On 10/10/23 at 11:47 AM, a second walkthrough of the kitchen was conducted. a. The dry storage room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 2 out of 31 sampled residents, the tube feeding did not have the bag labeled with the formula type, rate of infusion, resident identification information, date and time of administration, or the nurse initials who initiated the infusion. Resident identifier: 16 and 26. Findings Include: 1. Resident 16 was initially admitted to the facility on [DATE] and again on 6/24/23 with diagnoses which included pneumonia, metabolic encephalopathy, urinary tract infection, sepsis, acute kidney failure, multiple sclerosis, weakness, left hand contracture, essential hypertension, anxiety disorder, dysphagia, pseudobulbar affect, major depressive disorder, unspecified convulsions, and mood disorder. On 10/3/23 resident 16's care plan was reviewed. Resident had a care plan with a Focus that stated, I require tube feeding related to: Weight loss. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 (CPAP) machine was in use without the appropriate personal protective equipment (PPE). Resident identifier: 5 Findings included: 1. On 11/17/21 at 9:25 AM, an observation was made of Licensed Practical Nurse (LPN) 2. LPN 2 did not use hand sanitizer or wash her hands before gathering medications for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined 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, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility and to other officials. Specifically, for 1 out of 23 sampled residents, an incident where a resident was improperly transferred by staff that resulted in a fracture was not reported to the State Survey Agency or adult protective services. Resident identifier: 55. Findings included: Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to displaced fracture of base of neck of left femur subsequent encounter for closed fracture with routine healing, hemiplegia and hemiparesis following cerebral infarction affecting right dominant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not ensure assessments accurately reflected the resident's status. Specifically, for 2 out of 23 sampled residents, Minimum Data Set (MDS) assessments did not accurately reflect the resident's status. One resident was not accurately assessed to receive tube feedings and one resident was not accurately assessed to have a Preadmission Screening and Resident Review (PASRR) Level II in place. Resident identifiers: 14 and 45. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with medical diagnoses that included but not limited to, dementia with behavioral disturbances, schizoaffective disorder, type 2 diabetes mellitus, anxiety disorder, manic episodes, major depressive disorder, pyoderma gangrenosum, hypertension, and atherosclerotic heart disease. A review of resident 14's medical record was completed on 11/17/21. On 12/13/18, a PASRR Level I was completed which read, Level I screen indicates referral for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 23 sampled residents, the facility did not hold hypertensive medications when the blood pressure (BP) and/or pulse measurements were outside of the physician ordered parameters. Resident identifiers: 9 and 13. Findings include: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to polyneuropathy, idiopathic peripheral autonomic neuropathy, convulsions, cerebral aneurysm, protein-calorie malnutrition, essential hypertension (HTN), hypokalemia, dehydration, metabolic encephalopathy, and retention of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility did not ensure that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, for 1 out of 23 sampled residents, a resident was prescribed an antipsychotic medication without a diagnosis to support the use of an antipsychotic medication. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to polyneuropathy, idiopathic peripheral autonomic neuropathy, convulsions, cerebral aneurysm, protein-calorie malnutrition, essential hypertension, hypokalemia, dehydration, metabolic encephalopathy, and retention of urine. Resident 13's medical record was reviewed on 11/17/21. Physician's orders were reviewed and the following were documented: a. On 7/13/21, Seroquel 25 milligrams (mg) at bedtime (QHS) for hallucinations and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not promptly notify the ordering physician; physician assistant; nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges. Specifically, for 1 out of 23 sampled residents, notification was not made when a resident had critical lab values. Resident identifiers: 10. Findings include: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia without behavioral disturbance, fracture of head and neck of right femur, orthopedic aftercare, encephalopathy, essential hypertension, anxiety, sepsis, and urinary tract infection. On 11/15/21, resident 10's medical record was reviewed. On 10/13/21, a Comprehensive Metabolic Panel (CMP) was ordered. The CMP was not collected until 10/14/21. The results were available on 10/15/21. The lab report revealed the following: a. Sodium level was High at 154 [Note: Normal sodium values were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility did not maintain medical records on each resident that were complete, accurate, and readily accessible. Specifically, for 1 out of 23 sampled residents, a residents Neurology Clinical notes were not readily accessible. Resident identifier: 13. Findings included: Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to polyneuropathy, idiopathic peripheral autonomic neuropathy, convulsions, cerebral aneurysm, protein-calorie malnutrition, essential hypertension, hypokalemia, dehydration, metabolic encephalopathy, and retention of urine. Resident 13's medical record was reviewed on 11/17/21. Physician's orders were reviewed and the following were documented: a. On 7/13/21, Seroquel 25 milligrams (mg) at bedtime (QHS) for hallucinations and insomnia. Order discontinued on 9/16/21. b. On 9/16/21, Seroquel 25 mg QHS for adjunct to antidepressant therapy. On 7/13/21 at 3:28 PM, a Nurses Note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.