Stonehenge of Ogden

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, staff were applying a PureWick external urinary catheter device without orders or training on how to use the device. Resident identifier: 28.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.