Inspection Reports for
Stonehenge of Orem
435 West Center Street, Orem, UT, 84057
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Mar 13, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with pharmacy services, emergency preparedness, life safety code, fire alarm system, sprinkler system, and fire drills.
Findings
The facility was found noncompliant with pharmacy services related to narcotic medication handling and recordkeeping. Life safety deficiencies were identified including failure to maintain hazardous area separation, fire alarm system testing, sprinkler system maintenance, and fire drill documentation. Corrective actions and plans of correction were accepted for all deficiencies.
Deficiencies (5)
F755 Pharmacy Services: The facility did not provide pharmaceutical services assuring accurate acquiring, receiving, dispensing, and administering of drugs. Narcotic medication cards were improperly handled with taped back pockets and unclear disposal procedures.
K321 Hazardous Areas - Enclosure: The facility did not maintain hazardous areas to be fire and smoke separated as required by NFPA 101 19.3.2.1. One smoke compartment was affected.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain the fire alarm system in accordance with NFPA 101. One of two required tests was missed, including documentation of battery testing.
K353 Sprinkler System - Maintenance and Testing: The facility did not maintain the fire sprinkler system per NFPA 101. Six required escutcheons were missing and a sprinkler head was leaking.
K712 Fire Drills: The facility failed to verify transmission of the fire alarm signal during fire drills held at unexpected times. All required fire drills were affected.
Report Facts
Deficiencies cited: 5
Date of Compliance: Mar 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cole Julian | Administrator | Signed approval of plan of correction |
| Licensed Practical Nurse 1 | Interviewed regarding narcotic medication handling | |
| Registered Nurse 1 | Interviewed regarding narcotic medication disposal procedures | |
| Director of Nursing | Director of Nursing | Interviewed regarding narcotic medication policies and corrective actions |
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