WASHINGTON TERRACE, UT - Federal inspectors cited Stonehenge of Ogden for respiratory care violations and food safety failures during a June 27, 2024 complaint investigation, finding the facility administered oxygen therapy without physician orders and maintained unsanitary food storage conditions.
Unlicensed Oxygen Therapy Administration
The most serious violations involved four residents receiving oxygen therapy without proper medical authorization. Inspectors discovered that two residents were using nocturnal oxygen equipment despite having no physician orders for such treatment in their medical records.
Resident 7, who was readmitted with multiple conditions including viral intestinal infection and respiratory symptoms, told inspectors "she used nocturnal oxygen" but "had never seen her cannulas changed on either the concentrator or the portable oxygen." Federal guidelines require physician orders before any oxygen therapy can be administered to nursing home residents.
Similarly, Resident 8, admitted with compression fractures and respiratory conditions including asthma, confirmed using nocturnal oxygen therapy. However, inspectors found no physician order for oxygen therapy in her medical record.
The facility's Director of Nursing acknowledged that "in order for oxygen to be placed on a resident, an order from the doctor was required before it could be placed." She explained there were standing orders for oxygen use to maintain levels above 90%, but emphasized that medical providers needed notification to ensure proper orders were written.
Oxygen Equipment Maintenance Failures
Beyond the authorization issues, inspectors found systematic failures in oxygen equipment maintenance across multiple residents. All four residents cited had oxygen cannulas and tubing with no replacement dates, indicating the facility was not following proper infection control protocols.
Licensed Practical Nurse 1 told inspectors that "cannulas were changed on Fridays and the date was written on tape and placed on the cannula." However, observations revealed no dating on any of the oxygen equipment examined, suggesting this protocol was not being followed.
Oxygen therapy equipment requires regular replacement to prevent bacterial contamination and ensure proper function. Undated equipment creates infection risks and makes it impossible to verify compliance with manufacturer and medical safety guidelines.
Food Safety and Sanitation Violations
Inspectors also documented significant food safety violations in the facility's dining area refrigerator. During the inspection, surveyors observed multiple contaminated and improperly stored food items that posed health risks to residents and staff.
The most concerning discovery was "what appeared to be an onion in a plastic bag" that was "green, moldy, and slimy" with "liquid leaking from the bag onto the refrigerator surface." Additional violations included unmarked bags of grapes, unlabeled leftover containers, and open chip bags without dates.
The contaminated refrigerator also contained "sticky spills and debris" throughout, indicating poor cleaning protocols. Food safety regulations require all stored food items to be properly labeled, dated, and stored in sanitary conditions to prevent foodborne illness outbreaks.
Staff Protocol Breaches
The inspection revealed additional safety protocol failures when the Maintenance Director entered the kitchen area without required protective equipment. Federal regulations mandate that all personnel entering food preparation areas wear appropriate head coverings to prevent contamination.
The maintenance worker was observed checking lights and sprinkler systems in the kitchen ceiling area using a ladder, but "at no time was the MD observed to place a hair net over his hair." This violation demonstrates gaps in staff training and supervision regarding food safety protocols.
Regulatory Standards and Medical Context
Oxygen therapy administration in nursing homes falls under strict federal oversight because improper use can lead to oxygen toxicity, fire hazards, or inadequate treatment of respiratory conditions. The Centers for Medicare & Medicaid Services requires physician authorization to ensure therapy matches each resident's specific medical needs and monitoring requirements.
Food safety violations in long-term care facilities present particular risks because many residents have compromised immune systems that make them more susceptible to foodborne illnesses. Contaminated food storage and improper sanitation protocols can lead to serious outbreaks affecting vulnerable populations.
Facility Response and Oversight
Both violations were classified as causing "minimal harm or potential for actual harm," with respiratory care issues affecting "some" residents and food safety problems affecting "some" residents and staff. The facility is required to submit corrective action plans addressing each deficiency identified during the federal inspection.
The Utah Department of Health and Human Services oversees nursing home compliance and will monitor the facility's implementation of required corrections. Residents and families can contact state survey agencies for information about the facility's corrective action plans and ongoing compliance status.
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.
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