Stonehenge of Ogden

In the surveyor’s words

From the most serious findings on record at Stonehenge of Ogden, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jul 1, 2026

  Based on observation, and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, gloves were not changed and hand hygiene was not performed after touching dirty surfaces in the kitchen prior to touching food while plating the lunch meal. Findings included:On 6/30/26 at 11:33 AM, an observation and simultaneous interview were conducted with [NAME] 1 during the lunch meal service. [NAME] 1 stated that she had prepared a chicken salad sandwich with apples and celery for lunch. The Dietary Manager (DM) washed hands with soap and water and donned gloves. The DM placed the fruit container containing cantelope, honeydew, pineapple, orange, and grapes on a rolling cart on top of a cutting board. […]

• No harm, potential for more than minimal, patternF695Jun 27, 2024

  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. […]

• No harm, potential for more than minimal, patternF812Jun 27, 2024

  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. […]

• No harm, potential for more than minimal, patternF602Sep 2, 2021

  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 [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/2/21, resident 37s medical record review was completed. Nursing notes revealed the following: a. […]

• No harm, potential for more than minimal, isolatedF605Jul 1, 2026

  Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 2 out of 31 sampled residents, the facility did not attempt a GDR for psychotropic medications in two separate quarters (with at least one month between attempts) and clinical contraindications were not documented in the resident medical records. Resident identifiers: 30 and 31.Findings included:1. […]