Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonehenge Of Cedar City during CMS and state inspections, most recent first.
A resident with paraplegia and no sensation below the chest sustained an abdominal burn after a CNA placed a heated item, wrapped in plastic and a T-shirt, on his stomach for spasms and discomfort. The resident did not realize it was too hot until the next day, when the burn and blisters were discovered.
The facility failed to provide sufficient nursing staff with appropriate skills to respond promptly to call lights and assist residents with toileting, resulting in multiple residents experiencing incontinence and being left unattended on the toilet. Several residents with significant mobility and medical issues reported waiting long periods, including up to 30–45 minutes or more, for call lights to be answered, particularly during evenings, nights, shift changes, and weekends. Surveyors directly observed call lights sounding for 8–13 minutes before staff responded. Staff reported that CNA hours had been cut after a change in ownership, many staff had quit, and they were unable to complete all care tasks due to understaffing. Grievances and resident council notes over several months documented repeated complaints about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals, while leadership acknowledged staffing was based on census rather than acuity despite the written facility assessment describing an acuity-based approach.
Delayed Toileting Assistance and Incontinence Episodes: A resident with mobility limitations reported waiting 35 minutes for help to the bathroom and becoming incontinent, another resident reported waiting an hour for her call light to be answered and urinating in her brief, and a third resident said she had to get herself off the toilet and back to bed because staff were unavailable. Records showed mixed continence documentation and CNA task entries reflecting incontinence episodes, while staff described routine 2-hour checks and call light use between rounds.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
A resident grievance pattern showed delayed responses to call lights and staffing concerns, including residents waiting long periods for breakfast, toileting assistance, snacks, and other help. Several complaints described slow or unanswered call lights, and one resident was left on the toilet for almost 3 hours. The RA and DON were aware of the repeated concerns, and the records noted ongoing issues with timely assistance and call light response.
Incomplete discharge and transfer documentation: The facility failed to keep complete discharge/transfer records for several residents. For one resident discharged after aspiration-related illness, the chart lacked the discharge location; for another resident transferred to the ED, the chart did not show what paperwork accompanied the transfer; for a third resident discharged with HH, the chart did not document what documents or meds were sent; and for a fourth resident discharged after a femur fracture, the chart lacked a discharge summary. The DON stated the discharge progress notes were believed to cover the required information, but the paperwork could not be located in the medical record.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Repeated Fall Interventions for a High-Risk Resident: A resident with dementia, severe cognitive impairment, and gait impairment had multiple falls with injuries, including a fracture, head bruising, abrasions, and a skin tear. Staff documented repeated or unchanged interventions after several falls, such as neurological checks, call light reminders, and routine safety checks, and in some cases no new fall-prevention intervention was implemented despite staff acknowledging the resident was forgetful and could not reliably use the call light.
Facility staff did not report bruising of unknown origin for a resident to the State Agency as required. The bruising was noted on the resident's neck, back, and sides, with explanations attributing it to a shirt and a new diagnosis of hemophilia. Admin 1 did not consider the bruising as unknown origin and failed to report it within the required timeframe, contrary to the facility's Abuse Reporting Policy.
Burn from Improper Heat Pack Use
Penalty
Summary
A resident with paraplegia, osteomyelitis, and neuromuscular dysfunction of the bladder sustained a burn to the abdomen after a heat source was placed on his skin. The resident stated he had asked staff for a heating pad because he was having muscle spasms and difficulty breathing in his abdominal area, and a staff member wrapped something in a shirt and placed it on his abdomen. Because the resident did not have sensation below his chest, he did not realize the item was too hot until the next day, when he noticed the burn. On assessment, the resident’s abdomen showed a pinkened area with blisters, and nursing documentation described a burn measuring 9 x 5 cm with blisters, including one that had popped. The resident reported that the item had been brought by an aide and that he did not know what it was, only that it was in plastic and wrapped in a shirt. The facility’s investigation stated that the resident had requested a heating pack from the night CNA, who later returned with a heat pack and placed it on the resident’s stomach. The investigation further indicated that the resident could not feel heat below his chest and could not detect the burn. The ADON later stated that the burn appeared to be a first-degree burn initially, with additional blisters developing afterward, and that the pattern suggested a towel had been heated, wrapped in plastic, then wrapped in a T-shirt before being placed on the resident’s abdomen. The resident’s lack of sensation and the staff member’s use of a heat source on the resident’s body were directly associated with the accident hazard cited under F689.
Insufficient Nursing Staff and Delayed Call Light Response Leading to Incontinence and Unattended Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skills to meet residents’ needs, particularly in timely response to call lights and assistance with toileting, which resulted in incontinent episodes and residents being left unattended. Multiple residents reported long call light wait times, especially during evening and night shifts and on weekends, when there were as few as three CNAs for the entire building. Residents with significant physical limitations, including recent hip fractures, hemiplegia, and other serious conditions, described being unable to get to the bathroom without staff assistance and experiencing incontinence because staff did not respond promptly to their call lights. One resident with a periprosthetic hip fracture, hemiplegia, an artificial hip joint, major depressive disorder, and anxiety reported that from 6:00 PM to 6:00 AM there were only three CNAs for three hallways, resulting in long waits for call light responses. This resident stated she had incontinent bladder episodes when she first arrived because she could not hold her urine while waiting for help, including one instance where she waited 35 minutes for a response. Another resident with a left femur fracture, chronic pain, lupus, and epilepsy reported waiting an hour for her call light to be answered, leading to urinating in her brief because staff did not arrive in time to take her to the bathroom. A third resident with metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, UTI, and end-stage renal disease on dialysis stated she had been left on the toilet and had to get herself off and back to bed due to lack of staff. CNA documentation showed multiple incontinent episodes for these residents despite staff describing them as continent of bowel and bladder. Additional residents and a family member reported frequent long call light wait times, including waits of 30–45 minutes, particularly during shift changes and on weekends. The Resident Council President reported that since a change in ownership, residents complained that call lights took 30–40 minutes to be answered and that there were not enough CNAs on the night shift to handle residents’ needs during evening and bedtime hours. Direct observations by surveyors documented call lights sounding for 8 to 13 minutes before being answered on multiple occasions. Staff interviews confirmed that CNA hours had been cut after the ownership change, that many staff had quit, and that staff were asked to work a lot of overtime and were sometimes unable to complete showers due to understaffing. One staff member reported a resident had an incontinent episode after waiting about 45 minutes for a call light response. Grievance records and resident council notes showed a repeated pattern of complaints over several months about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals due to insufficient staff. Grievances included reports of residents waiting over an hour to be taken to breakfast, feeling ignored when requests were not fulfilled, and being left on the toilet for almost three hours, causing discomfort. Resident council notes repeatedly documented concerns about call lights taking a long time to be answered, not enough CNAs in the dining room at mealtimes, and residents being left on the toilet or not getting to breakfast on time. Although the facility’s written facility assessment and staffing plan referenced using acuity and tools such as the MDS and RAI to determine staffing, the DON stated that in practice staffing coverage was based on census rather than acuity and acknowledged there had been many issues with call lights since staffing was cut after the change in ownership.
Delayed Toileting Assistance and Incontinence Episodes
Penalty
Summary
The facility failed to treat residents with dignity and to provide care in a manner that supported their quality of life when residents reported long waits for assistance with toileting and call lights. Resident 55, who had diagnoses including periprosthetic hip fracture, hemiplegia and hemiparesis following cerebral infarction, artificial hip joint, major depressive disorder, and anxiety, stated she sometimes waited a long time after ringing her call light and described one occasion when she waited 35 minutes for staff. She reported that because she could not use her leg and had to wait for help to the bathroom, she had incontinent episodes and felt miserable when she wet the bed. Resident 54, admitted with diagnoses including trochanteric fracture of the left femur, chronic pain, lupus, and epilepsy, stated she waited an hour for her call light to be answered and staff did not get to her in time to take her to the bathroom, causing her to urinate in her brief. She stated she did not like lying in a wet brief and reported that a night nurse had told management there were not enough staff. Resident 34, admitted with diagnoses including metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, urinary tract infection, and end stage renal disease with dialysis, stated she had been left on the toilet and had to get herself off the toilet and back to bed because there were not enough staff. Record review showed inconsistencies between resident interviews, nursing documentation, and CNA task records regarding continence status and toileting needs. Resident 55 had a bowel and bladder evaluation stating she was continent, yet CNA documentation showed bladder incontinence episodes on multiple dates and her care plan identified her as at risk for bowel/bladder incontinence related to impaired mobility. Resident 54 was also documented as continent in some nursing notes and evaluations, while CNA tasks showed daily bladder incontinence episodes and a prior MDS indicated frequent urinary incontinence. Resident 34 had documentation showing both continence and incontinence, and the bowel and bladder evaluation identified her as a good candidate for retraining, while CNA tasks showed bladder and bowel incontinence episodes. Staff interviews reflected that residents on the 100 hallway were generally checked every 2 hours and used call lights between rounds, but staff also stated they were not aware of any residents on a bowel and bladder retraining program in that hallway.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
Delayed Response to Resident Grievances About Call Lights and Staffing
Penalty
Summary
The facility failed to make prompt efforts to resolve resident grievances related to staffing and call light response times. Multiple grievances documented residents reporting long waits for assistance, including being left waiting on a bed for breakfast, not receiving requested items, concerns that there were not enough CNAs on the floor, being left on the toilet for almost 3 hours, and repeated complaints that call lights were not answered in a timely manner. In several instances, the grievance findings noted that staff response times were slower than expected, with call lights reportedly active for 10 to 15 minutes and one grievance documenting a call light on at 8:15 AM with the resident not getting to breakfast until 9:30 AM. The grievance records also showed that residents and a spouse reported dissatisfaction with slow call light response and lack of timely assistance. The Resident Advocate stated grievances were documented on a grievance form and discussed with the DON, and that the facility tracked call light response times after a trend of complaints emerged following a change in ownership and staffing decrease. The report also states the DON reviewed staffing schedules and staff were fully staffed at one point, while residents continued to report slow response times and unmet needs.
Incomplete discharge and transfer documentation
Penalty
Summary
The facility failed to maintain complete discharge and transfer documentation in the clinical record for 4 of 30 sampled residents, and one resident did not have a discharge summary. The missing documentation included the discharge location, what paperwork was sent with a resident to the hospital, a reconciliation of pre-discharge medications with post-discharge medications, and a complete discharge summary. The deficiencies were identified through record review and staff interviews. Resident 1 was admitted with diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, and chronic kidney disease stage 3, and was later discharged. The discharge nursing note stated that the resident's daughter was present during discharge paperwork and teaching, and that medications were sent with the resident and faxed to a pharmacy, but the record did not document the discharge location. The DON stated she believed the discharge progress note covered the required information and could not locate the discharge paperwork in the medical record. Resident 50 was transferred to the ED for further evaluation after oxygen saturations would not rise above 90% on 5 LPM nasal cannula, and the record did not show which documents accompanied the resident during the hospital transfer or contain a transfer notice. Resident 2's discharge nursing note stated the resident was discharged with home health, transported by his daughter, and sent home with all medications including cream, but the facility did not document what documentation or medication was sent with the resident and could not locate the discharge paperwork. Resident 52 was discharged after a displaced right femur fracture, fall, diabetes mellitus, anxiety, and cirrhosis of the liver, and the record contained a nursing note that the resident went home with gabapentin, but there was no discharge summary with a recapitulation of the resident's stay; the DON stated the resident should have had a discharge summary in addition to the notes.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
Repeated Fall Interventions for a High-Risk Resident
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that adequate supervision and assistive devices were provided to prevent accidents for a resident with severe cognitive impairment and a high fall risk. The resident was admitted and readmitted with diagnoses including unspecified dementia, muscle weakness, and other abnormalities of gait and mobility. Her care plan identified fall risk related to confusion, abnormal gait, and opioid use, and her MDS showed a BIMS score of 3, indicating severe cognitive impairment. The resident experienced multiple falls, including unwitnessed and witnessed events in her room, bathroom, dining room, and near her bed and recliner. Documentation showed that after some falls, interventions were repeated rather than changed, such as neurological checks, call light reminders, call light within reach, and continuing existing at-risk plan interventions. In several instances, no new interventions were implemented after the fall. One fall resulted in a right humeral head fracture, and other falls involved head injuries, bruising, abrasions, and a skin tear. The resident was also observed with oxygen tubing on the floor and later became caught in the tubing while ambulating in her room with a shuffling gait. The record review and interviews showed that staff understood the resident was a high fall risk and that she was forgetful, overestimated her ability to walk unassisted, and sometimes could not use a call light because of her cognition. Staff also stated that neurological checks were not interventions to prevent falls and that interventions should not be repeated. The facility’s fall policy required appropriate interventions to prevent future falls, but the documentation for this resident showed repeated use of the same interventions and, in some cases, no new interventions after falls.
Failure to Report Bruising of Unknown Origin
Penalty
Summary
Facility staff failed to report bruising of unknown origin for a resident to the State Agency as required. A nursing note dated January 27, 2025, documented that staff found bruising on the resident's neck, back, and sides. During an interview on February 5, 2025, Admin 1 explained that the bruising on the resident's back and sides was present upon admission and attributed the neck bruising to a shirt the resident was wearing. Additionally, the resident was diagnosed with hemophilia, which contributed to the bruising. Admin 1 concluded that the bruising was not of unknown origin and did not report it as a critical incident to the State Agency within the required timeframe. The facility's Abuse Reporting Policy mandates notification to the state agency within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. However, the incident was not reported as required.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Health And Rehabilitation | 0.1 mi | ★★★★★ | 0 | 0 |
| Garfield County Nursing Home | 26.7 mi | ★★★★★ | 0 | 0 |
| Hurricane Health And Rehabilitation | 37.7 mi | ★★★★★ | 7 | 0 |
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