Stonehenge of American Fork

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote2. Resident 73 was admitted to the facility on [DATE] with diagnoses that included osteoporosis with pathological fracture, sarcoidosis, repeated falls, patellofemoral disorders of left knee, weakness, myelopathy, anxiety disorder, and depression. On 10/2/23 at 10:46 AM, an interview was conducted with resident 73. Resident 73 was observed to be sitting in a wheelchair in her room at the time of the interview. Resident 73 stated that shortly after she was admitted , a Certified Nursing Assistant (CNA) and a trainee wanted to do a brief change before the end of the shift. Resident 73 stated she tried to tell the CNA that she did not need a brief change, but the CNA insisted. Resident 73 stated the CNA was unable to do a brief change while she was in her recliner so the CNA attempted to change her brief while standing and her right knee began to hurt. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.