Stonehenge Of Cedar City
Stonehenge of Cedar City in Cedar City, UT — inspection on March 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the kitchen was supposed to cut it up for her because it was hard for her to use both hands to cut it
depended on the type of food, but if a resident needed food cut up it would usually be cut up into
concurrent review of resident 10's meal card was conducted with the DM; there were no instructions to cut up resident 10's food.
The DM stated that there were only two cooks and they knew what the resident's preferences were.
The DM stated he thought resident 10 needed her food cut up because she had a hard time chewing. On 3/25/26 at 9:56 AM, an interview was conducted with the MDS Coordinator and she stated that resident 10 needed her food cut up and assistance with taking off lids for meal setup because it would be too hard to do that with the use of one arm.
The MDS Coordinator stated that it was not in the orders and that the nurses should have ensured that was being done. On 3/25/26 at 10:10 AM, an interview was conducted with Registered Nurse (RN) 2, who stated that resident 10 needed assistance with setup of meals and that lids should have been removed for her.
RN 2 stated that resident 10 was probably not able to cut her own food because she could only use her left hand and that she had frequent pain in her right arm. RN 2 stated resident 10 was on the diet where the kitchen cut up her food but that it was not in her physician orders. RN 2 further stated that resident 10 would not usually ask for help even when she needed it.
465153 03/26/2026
Stonehenge of Cedar City 333 West 1425 North Cedar City, UT 84721
During Normal Operations1.
Resident Acuity and Census:Regularly assess the acuity levels and needs of residents using tools like the Minimum Data Set (MDS) and Resident Assessment Instrument (RAI).Track the number of residents and their care requirements to determine the appropriate staˆng levels.2.
Shift Planning:Use a scheduling plan to determine shift scheduling based on resident needs, staˆ availability, and skill mix.Build ˆexibility into schedules to accommodate unexpected changes in resident needs or staˆ availability.3.
Communication:Conduct daily/shift huddles and shift-to-shift report to review resident needs and adjust staˆng as necessary.Implement feedback mechanisms for staˆ to report changes in real time to a change in resident condition that may require staˆng adjustments outside of the established communication processes. On 3/25/26 at 1:16 PM, an interview was conducted with the Director of Nursing (DON).
The DON stated that staffing coverage was based off of the current census of residents in the facility, not acuity.
The DON stated that the facility was currently fully staffed.
The DON stated that when the new corporation took over for the facility on 11/1/25, staffing was cut back. On 3/26/26 at 9:41 AM, a follow-up interview was conducted with the DON.
The DON stated there had been a lot of issues with call lights since staffing was cut.
The DON stated that they have trained CNAs about call lights being answered was the first priority.
The DON stated that they continue to educate staff and the facility goal is to answer call lights in under six minutes.
The DON stated that she thinks the call light average was as high as 10 minutes. On 3/26/26 at 9:57 AM, an interview was conducted with the Administrator (ADM).
The ADM stated that with the previous company the facility was staffed a lot higher and call lights were not a big issue.
The ADM stated that staffing was based on the facility census and acuity was taken into consideration.
The ADM stated that the facility floor nurses had been educated that they also needed to respond to call lights and not just the CNAs.
465153 03/26/2026
Stonehenge of Cedar City 333 West 1425 North Cedar City, UT 84721
last reviews were very good.
465153 03/26/2026
Stonehenge of Cedar City 333 West 1425 North Cedar City, UT 84721
interview was conducted with RN 2, who stated that resident 37 did not have the mental capacity to
minced and moist she would be concerned that resident 37 would choke. RN 2 stated she thought all
was the ordered diet. On 3/26/26 at 9:38 AM, an interview was conducted with the Dietary Manager (DM) and he stated that Activities did their own snacks and that they did not ensure the residents were getting the correct diets. On 3/25/26 at 2:23 PM, an interview was conducted with the DON who stated they have a speech therapist they can call when a resident needed to be screened but he worked at another job and this facility was not a high priority for him.
The DON stated they talked to the doctor about changing diet textures due to the limited availability of the speech therapist.
The DON stated that staff were expected to follow the physician's orders.