Stonehenge of Ogden

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, 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, the residents goals, and preferences. Specifically, for 4 out of 27 sample residents the facility was not dating the change of oxygen tubing and nasal cannulas, nor ensuring there was a physician order for the use of oxygen for two residents (residents 7 and 8). Resident Identifiers: 7, 8, 19, and 20. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included viral intestinal infection, hypokalemia, hypercalcemia, unspecified protein-calorie malnutrition, dyspnea, essential hypertension, insomnia, generalized anxiety disorder, major depressive disorder, and gastro-esophageal reflux disease. Resident 7's medical record was reviewed 6/24/24-6/27/24. On 6/24/24 at 10:27 AM, an interview was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, an employee was observed in the kitchen area without a hair net; and a refrigerator was observed to have spoiled, undated and unlabeled food. Findings include: 1. On 6/24/24 at 12:51 PM, the Maintenance Director (MD) was observed to enter the facility kitchen. The MD was observed to check several lights and sprinkler heads on the kitchen ceiling. At 12:52 PM, the MD left the kitchen, obtained a ladder that had been placed near the dining room entrance, and re-entered the kitchen. At no time was the MD observed to place a hair net over his hair. 2. On 6/24/24 at 12:57 PM, an observation was made of the refrigerator in the dining room. The following was noted: a. An open bag of grapes with no date or label b. A styrofoam container of what appeared to be leftovers. This container was not dated or labeled. c. An open bag of chips with no date or label d. What appeared to be an onion in a plastic bag. The onion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 27 sampled residents, that the facility did not ensure that residents remained free from abuse, neglect, and misappropriation of property. Specifically, there were residents in a relationship that had not been evaluated to have the capacity to consent. Resident identifiers: 13 and 151. Findings include: A. Resident 151 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, unspecified severity, with agitation, acquired absence of right leg below knee, acquired absence of left leg below knee, occlusion and stenosis of bilateral carotid arteries, and duodenal ulcer, without hemorrhage or perforation. Resident 151's medical records were reviewed between 6/24/24 and 6/27/24. An admission Minimum Data Set (MDS) dated [DATE] revealed that resident 151 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severely impaired cognition. A review of resident 151's care plan initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. In addition, the facility did not established polices and procedures to investigate any such allegations. Specifically, for 2 out of 27 sample residents, investigations and evaluations of ability to consent were not conducted after two residents were found to be in bed together. Resident identifiers: 13 and 151. Findings included: The facility's Abuse Prohibition Policies, dated 2024, was reviewed and documented the following information: The Provider Code of Conduct is to protect vulnerable clients (residents) from abuse, neglect, maltreatment and exploitation . Abuse, sexual-abuse and sexual exploitation, neglect, exploitation, and maltreatment are prohibited. A. No .individual . shall abuse, sexually abuse or sexually exploit, neglect, exploit or maltreat any client . 1. No person shall cause physical Injury to any client.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure the resident's right to formulate an advanced directive. Specifically, for 1 out of 24 sampled residents, the resident's electronic medical record documented that the resident was a Do not attempt or continue any resuscitation (DNR) and Do not attempt to intubate (DNI) while the Physician Orders for Life-Sustaining Treatment (POLST) form documented the resident's wishes as Attempt to resuscitate, full treatment. Resident identifier: 136. Findings included: Resident 136 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, pneumonia, shortness of breath, pressure ulcer unspecified stage, pressure-induced deep tissue damage of sacral region, Parkinson's disease, anxiety disorder, and hypertension. Resident 136's electronic medical record dashboard documented the code status as DNR/DNI. On 1/5/23, resident 136's POLST documented Attempt to resuscitate, full treatment. On 1/10/23 at 9:40 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure that when a resident was transferred or discharged that the appropriate information was communicated to the receiving health care institution or provider. Specifically, for 2 out of 24 sampled residents, residents were transferred to the hospital and no documentation could be found that the receiving institution was provided the contact information of the practitioner, resident representative information, advanced directives information, comprehensive care plan, and all other necessary information to ensure a safe and effective transition of care. Resident identifiers: 15 and 137. Findings included: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, fall, peripheral neuropathy, chronic obstructive pulmonary disease, Crohn's disease, major depressive disorder, bipolar disorder, anxiety disorder, history of pulmonary embolism, hypothyroidism, hyperlipidemia, and post-traumatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene. Specifically, for 1 out of 24 sampled residents, a resident who required bathing assistance was not provided a shower since admission. Resident identifier: 141. Findings included: Resident 141 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure, pneumonia, severe sepsis, congestive heart failure, chronic kidney disease, hyperparathyroidism, rheumatoid arthritis, and metabolic encephalopathy. On 1/9/23 at 9:13 AM, an interview was conducted with resident 141. Resident 141 stated that she had not had a shower since she had been admitted . Resident 141 stated it had been over a week since she had a shower. Resident 141 stated that she would need staff assistance with the shower. Review of resident 141's bathing task…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, for 1 out of 24 sampled residents, an observation was made of wound care to a resident's coccyx pressure ulcer that was not consistent with the physician's orders for wound care. Resident identifier: 136. Finding included: Resident 136 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, pneumonia, shortness of breath, pressure ulcer unspecified stage, pressure-induced deep tissue damage of sacral region, Parkinson's disease, anxiety disorder, and hypertension. On 1/9/23 at 10:52 AM, an observation was made of resident 136 lying supine in bed with bilateral feet elevated. An air mattress was noted on the bed. Resident 136's physician's order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment. Specifically, for 1 out of 24 sampled residents, a resident's tube feeding was not infusing at the prescribed infusion rate. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, myelodysplastic syndrome, severe protein-calorie malnutrition, type 2 diabetes mellitus without complications, bacteremia, sepsis, atherosclerotic heart disease, ascites, chronic systolic (congestive) heart failure, and acute kidney failure. On 1/9/23 at 10:55 AM, an observation was made of resident 17's tube feeding (TF). Resident 17's TF was infusing at a rate of 70 milliliters per hour (ml/hr) with a flush of 30 milliliters (ml) every (Q) four hours. The TF bag was labeled Glucerna 1.2 and dated 1/9/23 at 10:45 AM. Resident 17's medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not maintain an infection prevention and control program that was designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 24 sampled residents, observations were made of staff exiting a resident's room that was on contact precautions and then entering another residents room without performing hand hygiene after having touched environmental surfaces in both rooms. Additionally, observations were made during wound care of staff not performing hand hygiene and cross contamination. Resident identifiers: 136. Findings included: 1. On 1/9/23 at 9:04 AM, an observation was made of Student Certified Nurse Assistant (SCNA) entering room [ROOM NUMBER]. room [ROOM NUMBER] was observed with signs posted on the door that stated contact precautions. The sign documented to perform hand hygiene before entering and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not prevent misappropriation of resident's medications for 5 of 17 sample residents. Specifically, one nurse misappropriated narcotic medications from the electronic medication dispenser without administering the medications to the residents, and another nurse misappropriated medications from residents' narcotic prescriptions. Additionally, 17 residents who had been discharged from the facility had medications misappropriated. Resident identifiers: 8, 15, 19, 21, and 37. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses which included nondisplaced intertrochanteric fracture of left femur, major depressive disorder, acute kidney failure, morbid obesity, pulmonary hypertension, nonrheumatic mitral valve disorder, chronic kidney disease, hypertension, gastro-esophageal reflux disease, venous thrombosis, anxiety, and pulmonary embolism. On 9/2/21, resident 37s medical record review was completed. Nursing notes revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to prevent the transmission of communicable diseases for 1 of 17 sample residents. Specifically, a staff member entered and exited a newly admitted resident's room, who was on 14 day isolation, without donning and doffing appropriate personal protective equipment (PPE). Resident identifier: 137 Findings include: Resident 137 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse, hypotension, chronic inflammatory demyelinating polyneuritis, polyneuropathy, major depressive disorder, bipolar II disorder, atherosclerotic heart disease, and chronic kidney disease. Resident 137 was designated as a new admit, requiring isolation and transmission-based precautions for 14 days due to the COVID-19 pandemic. On 8/30/21 at 7:14 AM a small plastic cart with PPE was observed outside resident 137's room. A transmission based precautions (TBP) sign was observed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.