Stonehenge of South Jordan

In the surveyor’s words

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

• Actual harm, isolatedF693Jun 17, 2021

  Based on observation, interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications. Specifically, a resident fed by enteral means only did not have their nutrition and hydration requirements met, as identified by the Registered Dietitian (RD), which resulted in the resident being transferred to the hospital for dehydration. This resulted in a finding of harm. […]

• No harm, potential for more than minimal, widespreadF812Jun 17, 2021

  Based on observation and interview it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically, dry food was outdated in the dry food storage room and still being given to residents. Resident identifiers: All. Findings include: 1. On [DATE] at 8:30 AM, an initial tour of the facility kitchen was conducted. The following was observed: a. A package of frozen vegetables was open and exposed to air, no expiration date was on the package. b. A Blendtec mixer bottle was uncovered in the freezer with frozen fruit in the bottom of the blender, it was not labeled or dated. c. A box of single use soy sauce packets with an expiration date of [DATE] was located in the dry storage. d. […]

• No harm, potential for more than minimal, patternF882Dec 18, 2024

  Based on interview and record review, the facility did not designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's infection control program. Specifically, the previous Director of Nursing (DON) was the facilities designated IP and did not work at least part time at the facility. Findings included: On 12/18/24 at 10:54 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated she was the facility DON. The CRN stated the previous DON was the IP. On 12/18/24 at 10:55 AM, an interview was conducted with the facility Administrator. The Administrator stated the previous DON was at the facility less than 10 hours per week. On 12/18/24 at 11:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. […]

• No harm, potential for more than minimal, patternF880Jun 17, 2021

  Based on observation, interview, and record review it was determined, for 1 of 23 sample residents, that the facility did not maintain an infection prevention and control program designed to provide a sanitary environment and to prevent the development and transmission of communicable diseases and infections, including [CONDITION(S)]-CoV-2 (COVID-19). Specifically, staff did not utilize appropriate PPE when entering isolation rooms for 2 residents on contact and droplet precautions. Additionally, a resident on contact isolation precautions did not have the cautionary signs posted alerting staff and visitors of Transmission Based Precautions (TBP) and Personal Protective Equipment (PPE) was not located outside the resident's door. Resident identifiers: 80, 81, and 83. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF695Dec 18, 2024

  Based on observation, interview or record review it was determined, for 1 of 15 sampled resident, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered plan, the residents' goals and preferences. Specifically, a residents was assisted to bed and his oxygen was not turned on. Resident identifier: 74. Findings include: Resident 74 was admitted to the facility on [DATE] with diagnoses which included right pubis fracture, congestive heart failure (CHF) and chronic respiratory failure. On 12/16/24 at 12:53 PM, an interview was conducted with resident 74. Resident 74 stated he needed oxygen all the time. Resident 74 stated he did not think his oxygen was on. […]