Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide safe and appropriate respiratory care to a resident who required oxygen therapy.
Complaint Details
The complaint investigation found that resident 74 was not provided oxygen as ordered, with the oxygen concentrator being off during care. Staff interviews revealed lack of awareness and inconsistent oxygen management. The infection preventionist role was not properly designated, with the previous Director of Nursing not working sufficient hours to fulfill the role.
Findings
The facility failed to ensure that resident 74, who required continuous oxygen therapy, had their oxygen concentrator turned on consistently. Interviews with staff confirmed lapses in oxygen management. Additionally, the facility did not designate a qualified infection preventionist responsible for the infection control program, as the previous Director of Nursing was not present part-time as required.
Deficiencies (2)
Failure to provide safe and appropriate respiratory care for a resident when needed, specifically oxygen was not turned on for resident 74.
Failure to designate a qualified infection preventionist responsible for the infection prevention and control program.
Report Facts
Residents sampled: 15
Oxygen liters: 1
Oxygen liters: 4
Oxygen saturation: 88
Previous DON hours: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurses Assistant | Observed turning on resident 74's oxygen concentrator and interviewed about oxygen management |
| CNA 2 | Certified Nurses Assistant | Interviewed regarding resident 74's oxygen use and portable oxygen tank procedures |
| Corporate Resource Nurse | Corporate Resource Nurse (CRN) and facility Director of Nursing | Interviewed about oxygen use expectations and infection preventionist designation |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) | Interviewed about previous DON as infection preventionist and training status |
| Previous Director of Nursing | Director of Nursing (DON) | Previously designated infection preventionist but worked less than part-time hours |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility Stonehenge of South Jordan.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Life Safety
Deficiencies: 5
Date: Mar 27, 2023
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found not in compliance with several fire safety requirements including fire alarm system testing, sprinkler system testing, heating/ventilation/air conditioning maintenance, fire drills, and electrical receptacle testing. Corrective actions and monitoring plans were established to address these deficiencies with compliance expected by 05/19/2023.
Deficiencies (5)
Fire Alarm System - Testing and Maintenance not maintained in accordance with NFPA 101 and NFPA 72; deficiency affected all control valve tamper switches.
Sprinkler System - Maintenance and Testing not maintained in accordance with NFPA 25 and NFPA 101; deficiency affected fire riser testing.
Utilities - Gas and Electric equipment not maintained in accordance with NFPA 70; deficiency affected fire dampers.
Fire Drills not conducted as required by NFPA 101; deficiency affected fire drills.
Electrical Systems - Maintenance and Testing not performed on receptacles at patient bed locations; deficiency affected electrical receptacles near resident beds and exam rooms.
Report Facts
Date sprinkler system last checked: Not specifically dated but referenced in findings
Number of fire drills missed: 12
Number of fire risers water flow alarm tests missed: 4
Date of compliance: Expected compliance date for all deficiencies is 2023-05-19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cole Julian | Administrator | Named in relation to the Life Safety Code survey and corrective action plan |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 17, 2021
Visit Reason
The inspection was conducted based on complaints regarding failure to notify physicians of resident falls, delayed baseline care plans, inadequate feeding tube care, unnecessary drug administration, expired food usage, and infection prevention and control deficiencies.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to failure to notify physicians of resident falls, delayed baseline care plans, inadequate feeding tube care resulting in harm, unnecessary drug administration, expired food usage, and infection prevention and control lapses.
Findings
The facility failed to immediately notify physicians of multiple resident falls, did not develop baseline care plans within 48 hours for some residents, inadequately managed a resident's feeding tube leading to dehydration and hospital transfer, administered a medication against physician parameters, served expired food items, and did not consistently implement infection prevention and control measures including proper PPE use and signage for isolation rooms.
Deficiencies (6)
Failure to immediately notify the physician when a resident sustained multiple falls.
Baseline care plans were not developed and implemented within 48 hours of admission for two residents.
A resident fed by enteral means did not have nutrition and hydration requirements met, resulting in dehydration and hospital transfer.
Resident's medication (Midodrine) was administered when it should have been held per physician's ordered parameters.
Facility did not store, prepare, distribute, and serve food in accordance with professional standards; expired dry food was still being given to residents.
Facility did not maintain an infection prevention and control program; staff did not utilize appropriate PPE when entering isolation rooms and lacked proper signage and PPE carts outside resident rooms on isolation.
Report Facts
Number of falls without physician notification: 9
Weight loss percentage: 6.29
Medication administration instances against parameters: 22
Expired food items observed: 7
Quarantine duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Interviewed regarding fall notifications and feeding tube care. |
| CRN | Corporate Resource Nurse | Interviewed regarding fall notifications and feeding tube care. |
| DON | Director of Nursing | Interviewed regarding baseline care plans, feeding tube care, medication administration, infection control, and policy implementation. |
| RD | Registered Dietitian | Interviewed regarding feeding tube nutritional assessments and recommendations. |
| NP 1 | Nurse Practitioner | Interviewed regarding feeding tube orders and medication administration. |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding blood pressure monitoring and medication administration. |
| DA 1 | Dietary Aide | Interviewed regarding food storage and handling practices. |
| DM | Dietary Manager | Interviewed regarding food storage and handling practices. |
| CNA 5 | Certified Nurse Assistant | Observed and interviewed regarding infection control practices and meal tray handling. |
| CNA 7 | Certified Nurse Assistant | Interviewed regarding infection control practices and PPE use. |
| LA 1 | Laundry Aide | Interviewed regarding handling of laundry from isolation rooms. |
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