Stonehenge of Ogden: Sexual Consent Failures - UT
Federal inspectors cited Stonehenge of Ogden in June for failing to investigate potential sexual contact between the residents, both of whom scored 7 on cognitive assessments — indicating severely impaired mental function.
The relationship began in early 2024 between Resident 151, a double amputee with vascular dementia, and Resident 13, who suffered from delusions and believed people were trying to hurt her. Both residents had cognitive scores so low they indicated severe impairment.
On February 5, the social worker noted Resident 151's "newfound friendship with a female peer" in his file.
Ten days later, a nurse found the pair in Resident 151's bed. "Pt is sitting at bedside in wheelchair with [resident 13] from room [ROOM NUMBER]A resting in his bed with a shirt on wearing no briefs," the nurse wrote at 6:30 PM. When the nurse knocked, Resident 151 "wants to be left alone with her and requested that I leave as soon as possible and shut the door."
Later that evening, another nurse found both residents partially clothed. "CNA reported that pt in room had his garments on and no bottoms," the 9:00 PM note stated.
The facility's response was to create a care plan allowing the relationship to continue. The February 16 plan stated the goal was for the "resident will show affection towards their special friend only in private." Staff were instructed to "knock and allow a few extra seconds before entering the room" if doors were closed.
But no formal assessment of either resident's capacity to consent was ever conducted.
The social worker told inspectors she "figured that the residents were both adults and they could consent to have a relationship with each other." When pressed, she admitted "no formal assessment was done to determine if resident 13 was able to consent to have a relationship."
The Director of Nursing said she and the social worker simply talked to the residents individually. "The DON stated that it would be the physician that would make the decision if a resident was able to give consent," according to the inspection report. Yet neither staff member could recall if the physician was ever notified.
Resident 151's behavior became increasingly concerning. On March 26, he "continues to verbalize paranoid statements" and described "people that had an altered physical appearance with one eye telescopic mask, and people that are coming to get him." He told staff he wanted to "get with a lady and get married and then get away from the people that are out to get him."
By May, his sexual demands escalated. On May 4, a nursing assistant reported Resident 151 "was in his wheelchair headed looking for a female resident 'to meet his needs.'" Later that evening, he asked staff if he could "have a little sex."
The facility's own abuse prevention policy explicitly prohibited staff from engaging residents "as an observer or participant in sexual acts." It required immediate reporting of sexual abuse to the administrator and mandated cooperation with investigations.
Yet when confronted with evidence of sexual contact between two severely cognitively impaired residents, staff created care plans to accommodate the relationship rather than investigate whether either resident could legally consent.
Resident 13's medical record showed she "sometimes has paranoid thoughts and believes that someone is trying to hurt me or do bad things to me." Her care plan noted she "said bizarre things at times" and was "not always alert and oriented."
The social worker acknowledged both residents were "confused" but proceeded anyway. She told inspectors the facility "was not a behavioral health facility, so she was not much concerned when the two residents started showing signs of a closer relationship."
The Director of Nursing described finding the residents "in bed together in a state of undress." When she questioned Resident 151 about the incident, he told her "it was none of your damn business."
Both residents denied sexual contact, claiming they were "just watching movies." But staff documented multiple instances of the pair being found partially clothed together.
The social worker noted that Resident 151's daughter was seeking guardianship because he was "having bad finances and making bad choices." Despite this acknowledgment of his impaired decision-making, staff never questioned his ability to consent to sexual activity.
A registered nurse told inspectors she was unaware of any resident relationships in the facility, suggesting the investigation and monitoring were inadequate.
The facility's policy required staff to report suspected abuse within 24 hours to state and local authorities. No such reports were filed regarding the sexual contact between the cognitively impaired residents.
Federal regulations require nursing homes to protect residents from sexual abuse and ensure proper investigations of any allegations. The facility's failure to assess consent capacity violated these protections.
Resident 151 died on May 19, 2024, ending the relationship that staff had allowed to continue for months without proper safeguards.
The inspection found the facility failed to develop and implement adequate policies to prevent abuse and neglect, specifically regarding the investigation of sexual contact between residents unable to consent.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
Stonehenge of Ogden in Washington Terrace, UT was cited for violations during a health inspection on June 27, 2024.
Both residents had cognitive scores so low they indicated severe impairment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Stonehenge of Ogden?
- Both residents had cognitive scores so low they indicated severe impairment.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Washington Terrace, UT, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Stonehenge of Ogden or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 465182.
- Has this facility had violations before?
- To check Stonehenge of Ogden's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.