A list of the most recent deficiencies for Stonehenge of Springville. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2023-05-16 | 2023-07-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-16 | 2023-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-05 | 2021-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-09-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-05 | 2021-09-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-05 | 2021-09-30 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-05 | 2021-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-09-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-03 | 2021-09-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-06-06 | 2019-08-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-08-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-06 | 2019-08-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-06 | 2019-08-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-06 | 2019-08-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-06 | 2019-08-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-13 | 2019-08-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-13 | 2019-08-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-13 | 2019-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-06-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-06 | 2019-06-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-06 | 2019-06-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-06 | 2019-06-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-06 | 2019-06-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-06 | 2019-06-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-06 | 2019-06-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-06-13 | 2019-06-27 | N |
