Stonehenge of Cedar City

Inspectors wroteBased 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. The facility must ensure that - S483.25(d)(1) The resident environment remains as free of accident hazards as is possible; [...]

Inspectors wroteBased 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. Resident 55 was admitted to the facility on [DATE] with diagnoses which included periprosthetic fracture hip fracture, hemiplegia and hemiparesis following cerebral infarction, artificial hip joint, major depressive disorder and anxiety. [...]

Inspectors wroteBased 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. Resident identifiers: 3, 6, 8, 10, 16, 21, 34, 54, 55 and 56.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview, for 4 of 30 sampled residents, the facility failed to ensure that a complete copy of the discharge/transfer documentation was maintained in the clinical record and a resident did not have a discharge summary. Specifically, the facility failed to document the discharge location, document what paperwork was sent with a resident to the hospital, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) and complete a discharge summary. Resident identifiers: 1, 2, 50 and 52.

Inspectors wroteBased on observation, interview and record review, for 5 of 30 sampled residents, the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, there were individual resident complaints resident council minutes and grievances regarding the food palatability. In addition, the test tray was not palatable, attractive or served at an appetizing temperature. Resident identifiers: 8, 21, 24, 46 and 54.

Inspectors wroteBased on observation, interview, and record review, it was determined, for 1 out of 30 sampled residents, that the facility failed to ensure each resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs), consistent with the resident's comprehensive assessment and plan of care. This failure included the facility not ensuring that each resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for dining-eating, including meals and snacks. Specifically, one resident was not provided with bite-sized cut food or opened food containers when they were assessed as requiring this assistance. Resident identifier: 10.

Inspectors wroteBased on observation, interview, and record review 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 assistive devices to prevent accidents. Specifically, for 1 out of 30 sampled residents, a high fall-risk resident did not have interventions put in place after falls, and interventions were repeated. Resident identifier: 7.

Inspectors wroteBased on interview and record review, for 2 out of 30 sampled residents, the facility failed to ensure each resident received food prepared in a form designed to meet individual needs. Specifically, two residents received snacks that were not pureed or minced and moist. Resident identifiers: 25 and 37.

Inspectors wroteBased on staff interview, review of medical records, and review of the policy and procedures, facility staff did not report to the State Agency bruising of unknown origin for 1 resident in the sample of 5. (Resident identifier: 1.)

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide fingernail care for 1 (Resident #15) of 2 residents sampled for activities of daily living (ADLs).

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record the review it was determined, for 2 of 15 sample residents, the facility did not ensure that patient privacy was protected. Specifically, another resident's name was used in another residents medical record. Resident identifier: 4 and 35.

Inspectors wroteBased on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not ensure that all allegations involving abuse were reported no later than 2 hour after the allegation was made but no later than 24 hours if the event that cause the allegation did not involve abuse or did not result in bodily injury. The finial investigation was provide to the State Survey Agency within 5 working days of the incident. Specifically, an incident involving a report of verbal abuse was not reported to the State Survey Agency (SSA) or investigated for 10 days after the incident. Resident identifier: 37.

Inspectors wroteBased on interview and record review it was determined, for 1 of 15 sample residents, assessment was not accurately reflect the resident's status. Specifically, a resident receiving hospice services was not reflected on the resident's assessment. Resident identifier: 9.

Inspectors wroteBased on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan. Specifically, a resident did not have a hospice care plan. Resident identifier: 9.

Inspectors wroteBased on interview and record the review, for 1 of 15 sample residents, it was determined that the facility did not ensure that the qualified staff members were providing care for residents. Specifically, a nursing student provided assistance for a resident unsupervised by staff which resulted in an avoidable fall. Resident identifier: 18.

Inspectors wroteBased on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug used without adequate monitoring. Specifically, a resident with two blood pressure medications were administered when the pulse was outside of the physician ordered parameters. Resident identifier: 23.

Inspectors wroteBased on interview and record review, it was determined that the facility did not conduct COVID-19 testing of staff as frequently as required based on the parameters set forth by the Centers for Disease Control and Prevention (CDC). In addition, the facility did not document that staff testing was completed and the results of each staff test. Specifically, a staff member that was unvaccinated was not tested twice weekly when working at the facility.