Resident 7 told inspectors she used nocturnal oxygen but had never seen her cannulas changed on either the concentrator or portable oxygen equipment. When inspectors examined her equipment on June 24, they found yellowish nasal cannulas with no replacement dates marked anywhere.
Her medical record contained no order for oxygen therapy.
The same day, Resident 8 confirmed she also used nocturnal oxygen but was unsure how often her cannulas were changed. Inspectors found no dates on her cannula or oxygen tubing either.
Her medical record also lacked any oxygen therapy order.
Two other residents received oxygen with proper physician orders, but the facility failed to date their equipment changes as required. Resident 19 used nocturnal oxygen but told inspectors she was unsure when her cannulas got changed. Resident 20 said she wasn't aware her cannulas required changing at all.
None of the four residents had dated equipment despite facility policy requiring weekly changes.
Licensed Practical Nurse 1 told inspectors that nurses changed residents' cannulas every Friday and wrote the date on tape placed on the cannula. But the Director of Nursing acknowledged that oxygen required a doctor's order before placement and that medical providers needed notification to ensure proper orders were written.
The facility had standing orders allowing oxygen use to maintain levels above 90 percent, the nursing director said, but physicians still needed to authorize individual treatment.
The oxygen violations represented just one safety breakdown inspectors documented during their June 27 visit.
In the dining room, inspectors found a refrigerator containing spoiled, undated and unlabeled food that posed contamination risks to residents and staff. The discovery occurred while the maintenance director worked in the kitchen area without required hair protection.
At 12:51 PM on June 24, inspectors watched the maintenance director enter the kitchen to check lights and sprinkler heads on the ceiling. He left to get a ladder, then returned to continue his work. At no point did he wear a hair net while working above food preparation areas.
Six minutes later, inspectors opened the dining room refrigerator and found multiple food safety violations.
An open bag of grapes sat unlabeled and undated. A styrofoam container held what appeared to be leftovers, also without dates or labels. An open chip bag lacked any identification.
Most disturbing was a plastic bag containing what appeared to be an onion that had turned green, moldy and slimy. Liquid leaked from the bag onto the refrigerator surface.
Five open plastic soda containers sat without dates or labels. Sticky spills and debris covered several areas inside the refrigerator.
Housekeeper 1 told inspectors she thought the refrigerator was for both residents and employees but wasn't sure. She said the dietary department was responsible for cleaning it.
The dietary manager said she thought the refrigerator was used by both residents and employees, but mostly by the therapy department. She claimed the dietary and housekeeping departments took turns cleaning it.
The confusion over responsibility left the refrigerator in a state that could contaminate food and spread illness to vulnerable nursing home residents.
Federal regulations require nursing homes to procure food from approved sources and store, prepare, distribute and serve food according to professional standards. The moldy onion and unlabeled containers violated those requirements.
The oxygen violations were equally serious. Respiratory care must follow professional standards, comprehensive care plans, and resident goals and preferences. Providing oxygen without physician orders bypassed essential medical oversight.
Oxygen therapy requires careful monitoring because too much oxygen can damage lungs and too little can cause organ failure. Physicians must evaluate each resident's specific respiratory needs, underlying conditions, and medication interactions before authorizing treatment.
The facility's failure to date equipment changes also created safety risks. Nasal cannulas and oxygen tubing can harbor bacteria and cause infections if not replaced regularly. The yellowish color of Resident 7's cannula suggested extended use beyond recommended replacement schedules.
Both violations affected residents who depend on the facility for basic safety protections. Nursing homes must maintain higher standards because residents often cannot advocate for themselves or leave if care becomes dangerous.
The inspection found additional minor violations but classified the oxygen and food safety problems as having minimal harm or potential for actual harm to residents.
Resident 7 was admitted with multiple serious conditions including viral intestinal infection, malnutrition, breathing difficulties, high blood pressure, anxiety, depression and acid reflux. Her readmission suggested ongoing health challenges requiring careful medical supervision.
Resident 8 arrived with a spinal compression fracture, history of falls, asthma, sepsis, depression, anxiety, high blood pressure, kidney disease, acid reflux and a heart murmur. Her complex medical needs made unauthorized oxygen therapy particularly concerning.
The other two residents had conditions requiring oxygen but received it through proper medical channels, highlighting the facility's inconsistent approach to respiratory care.
Stonehenge of Ogden operates at 5648 South Adams Avenue in Washington Terrace, serving residents who require skilled nursing care and rehabilitation services. The facility must submit correction plans to state and federal regulators addressing each violation.
The inspection occurred as nursing homes nationwide face increased scrutiny over safety practices and medical oversight. Facilities that provide medical treatments without proper authorization risk losing Medicare and Medicaid funding that supports most nursing home operations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonehenge of Ogden from 2024-06-27 including all violations, facility responses, and corrective action plans.