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/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 18, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with healthcare regulations and standards at Stonehenge of South Jordan nursing home.
Findings
The facility was found deficient in providing safe and appropriate respiratory care to a resident requiring oxygen therapy and failed to designate a qualified infection preventionist responsible for the infection control program.
Deficiencies (2)
F 0695: The facility did not ensure a resident requiring respiratory care had oxygen turned on as ordered, resulting in oxygen saturation below prescribed levels.
F 0882: The facility did not designate a qualified infection preventionist responsible for the infection control program; the previous Director of Nursing was the designated IP but worked less than part-time hours.
Report Facts
Residents sampled: 15
Residents affected: 1
Residents affected: Few
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Assistant (CNA) 1 | Observed turning on oxygen concentrator for resident 74 | |
| Certified Nurses Assistant (CNA) 2 | Interviewed regarding oxygen use for resident 74 | |
| Corporate Resource Nurse (CRN) | Interviewed regarding oxygen use and infection preventionist designation; stated she was the facility DON | |
| Licensed Practical Nurse (LPN) 1 | Interviewed regarding infection preventionist training and previous DON role | |
| Previous Director of Nursing (DON) | Designated infection preventionist who worked less than part-time hours |
Inspection Report
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The inspection was conducted as a regulatory 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 a Life Safety Code survey conducted on 03/27/2023 to assess compliance with fire safety regulations and emergency preparedness at Stonehenge of South Jordan, LLC.
Findings
The facility was found not to be in compliance with several Life Safety Code requirements related to fire alarm system testing, sprinkler system maintenance, utilities and gas equipment, fire drills, and electrical system maintenance. Corrective actions and monitoring plans were established to ensure compliance by 05/19/2023.
Deficiencies (5)
K-345 Fire Alarm System testing and maintenance was not maintained in accordance with NFPA 101 and NFPA 72. The deficiency affected all control valve tamper switches and documentation of semiannual testing was missing.
K-353 Sprinkler System maintenance and testing was not maintained per NFPA 25 and NFPA 101. The facility failed to provide documentation that the fire risers water flow alarm test was conducted quarterly as required.
K-511 Utilities - Gas and Electric equipment did not maintain heating, ventilating, and air conditioning systems in accordance with NFPA 101. The facility failed to provide an itemized list of fire/smoke damper locations and testing documentation.
K-712 Fire drills were not conducted quarterly on each shift as required. Documentation of required 12 fire drills and orientation training was missing, and drills were held at unexpected times.
K-914 Electrical Systems maintenance and testing was not performed on patient bed receptacles. Receptacles near resident beds and exam rooms were not hospital grade and were not tested annually as required.
Report Facts
Date of Compliance: May 19, 2023
Survey Date: Mar 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cole Julian | Administrator | Present during the Life Safety Code survey and named in the corrective action plans. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 17, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify physicians of resident falls, delayed baseline care plans, improper feeding tube care, unnecessary drug administration, expired food usage, and infection prevention and control deficiencies.
Complaint Details
The investigation was complaint-driven, focusing on issues including failure to notify physicians of falls, delayed care plans, feeding tube care deficiencies, medication errors, expired food usage, and infection control lapses. Substantiation status is not explicitly stated.
Findings
The facility failed to immediately notify physicians of resident falls, did not develop baseline care plans within 48 hours of admission for some residents, inadequately managed a resident's feeding tube leading to dehydration and hospital transfer, administered a medication against physician parameters, used expired food products in meal service, and did not consistently implement infection prevention and control measures including proper PPE use and signage for isolation rooms.
Deficiencies (6)
F580: The facility did not immediately notify the physician of multiple falls for resident 7, resulting in minimal harm.
F655: Baseline care plans were not developed and implemented within 48 hours of admission for residents 75 and 81.
F693: Resident 24, fed by enteral means, did not receive appropriate nutrition and hydration, resulting in dehydration and hospital transfer.
F757: Resident 20 was administered Midodrine despite physician orders to hold the drug if systolic blood pressure was greater than 90.
F812: The facility stored and served expired food items including peanut butter, jams, soy sauce, and cereals to residents.
F880: Staff failed to consistently use appropriate PPE and post required signage for residents on isolation precautions, risking infection transmission.
Report Facts
Resident sample size: 23
Falls for resident 7: 9
Weight loss: 6.29
Midodrine administration instances: 22
Expired food items: 6
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 physician communication |
| DON | Director of Nursing | Interviewed regarding care plans, medication administration, infection control, and facility policies |
| RD | Registered Dietitian | Interviewed regarding feeding tube nutrition and hydration recommendations |
| NP 1 | Nurse Practitioner | Interviewed regarding feeding tube orders and medication management |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding blood pressure monitoring and infection control procedures |
| CNA 5 | Certified Nurse Assistant | Observed and interviewed regarding infection control and meal tray handling |
| CNA 7 | Certified Nurse Assistant | Observed and interviewed regarding PPE use in isolation rooms |
| DA 1 | Dietary Aide | Interviewed regarding food handling and expiration date monitoring |
| DM | Dietary Manager | Interviewed regarding food storage and expiration date policies |
| DC | Dietary Cook | Interviewed regarding food preparation and expiration date awareness |
| LA 1 | Laundry Aide | Interviewed regarding handling of laundry from isolation rooms |
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