Stonehenge of Springville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease with late onset, lymphedema, morbid obesity, abnormalities of gait and mobility, chronic pain, and epilepsy. Resident 35's medical record was reviewed 3/4/25 through 3/5/25. An…

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, for 1 of 24 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident who had multiple falls had repeated interventions implemented after falls and staff were not aware of the interventions that were on the care plan. Resident identifier: 29. Findings include: On 3/3/25 at 10:30 AM, an observation was made of resident 29 in his room. Resident 29 was observed to be in bed with his bed in a low position and the call light within reach. There was a call don't fall sign on his wall. Resident 29's medical record was reviewed 3/3/25 through 3/5/25. Resident 29 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, epilepsy, major…

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, for 1 of 24 sampled residents, that the facility did not ensure that a resident who was continent of bladder on admission received services and assistance to maintain continence. Specifically, a resident was assessed a candidate for scheduled toileting and was not provided the services. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting non-dominate side. On 3/3/25 at 11:31 AM, an interview was conducted with resident 25. Resident 25 stated after she pushed her call light she wet her pants while waiting for staff. Resident 25 stated she was not on a toileting schedule but would like to be on one especially in the evenings and at night time because there were less staff to help her to the bathroom. Resident 25's medical record was reviewed 3/3/25 through 3/5/25. A quarterly Minimum Data Set (MDS) dated [DATE] revealed…

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, for 1 of 24 residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for the use of oxygen, and residents did not have properly labeled oxygen tubing. Resident identifiers: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with diagnoses of pericardial effusion, chronic obstructive pulmonary disease, morbid obesity, chronic respiratory failure with hypoxia, interstitial pulmonary disease, chronic respiratory failure with hypercapnia, obstructive sleep apnea and chronic congestive heart failure. Resident 20's medical record was reviewed 3/4/25 through 3/5/25. On 3/4/25 at 9:31 AM, an interview was conducted with resident 20. Resident 20 stated his oxygen did not work when it was going through 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 interview, observation, and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure residents who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident diagnosed with depression and anxiety who verbalized she wanted to die and was ready to die, refused medications, displayed crying episodes, and threatened another resident with physical harm was not offered or provided behavioral health services. Resident identifier: 28. Findings include: On 3/3/25 at 10:41 AM, an interview and observation was conducted with resident 28. Resident 28 was in her bed with her eyes closed. Resident 28 opened her eyes, she answered interview questions with one to two word answers. Resident 28 was withdrawn and displayed a flat affect throughout the interaction. On 3/3/25 at 11:11…

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, for 2 of 23 sampled residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, resident's blood pressure (BP) support medication was administered outside of the physician's ordered parameters. Resident identifier: 20 and 238. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses of essential hypertension. Resident 20's medical record was reviewed 3/4/25 through 3/5/25. A physician's order dated 11/27/24 documented, Toprol XL (extended release)Tablet 24 Hour 25 MG (milligram) (Metoprolol Succinate ER (extended release) Give 1 tablet by mouth one time a day for HTN (hypertension) HOLD FOR SBP…

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, 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. The DM stated the facility had a Registered Dietitian (RD) consultant that came to the facility at least once per week, sometimes more frequently. The DM stated the RD participated in weekly skin and weight meetings at the facility. On 8/3/21 at approximately 4:00 PM, the date of hire and certifications…

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, 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. Resident 8 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, adjustment disorder with depressed mood, pseudobulbar affect, morbid obesity, anxiety disorder, osteoarthritis, dry eye syndrome,…

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, 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 SARS-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 (CPAP) machines were not cleaned by staff, staff were observed not performing hand hygiene and changing gloves during wound care, and staff were observed not performing hand hygiene during meal delivery. Resident identifiers: 11, 14, 22, and 24. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not…

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, for 2 out of 28 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident that included the services that were to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, two resident's utilized a Continuous Positive Airway Pressure (CPAP) machine and did not have a care plan in place to address this aerosol generating procedure. Resident identifiers: 14 and 22. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral palsy, acute respiratory failure, obstructive sleep apnea, morbid obesity, atrial fibrillation, and hypertension. On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new CPAP machine because his current one was on recall. Resident 14 stated that he operated the machine…

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, for 2 out of 28 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, two residents who utilized a Continuous Positive Airway Pressure (CPAP) machine did not have orders for their CPAP equipment and treatment, and there was no resident monitoring for the use of the devices in place. Resident identifiers: 14 and 22. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral palsy, acute respiratory failure, obstructive sleep apnea (OSA), morbid obesity, atrial fibrillation, and hypertension. On 8/02/21 at 2:52 PM, an interview was conducted with resident 14. Resident 14 stated that he needed a new CPAP machine because his current one was on recall.…

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, for 2 out of 28 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose (including duplicate therapy); 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 of these combinations. Specifically, medications were not administered per the physician ordered parameters and a resident was not monitored for complications associated with an anticoagulant use. Resident identifiers: 2 & 11. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, essential hypertension, type 2 diabetes with hyperglycemia, dementia without behavioral disturbance, chronic kidney disease, gastro-esphageal reflux…

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.