Stonehenge of Springville

Inspectors wroteBased 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.

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.