Stonehenge Of Ogden

informed the Administrator (ADM), and they proceeded to inform the residents' families.

The SSW

talked to a resident about what the resident knows about consent, how to be safe when with a close

allow the relationship to continue by the interviews with resident 151 and resident 13.

The SSW stated that she does not recall if the physician was ever notified of resident 151 and resident 13's relationship, and that it would have been the DON that would have contacted the physician.

The SSW stated that since both residents were confused, she had initiated a care plan, and she also initiated a care plan in case the relationship progressed further.

The SSW stated that when she spoke with resident 151 and resident 13, they both replied they liked being with each other.

On 6/27/24 at 12:35 PM, an interview with the DON was conducted.

The DON stated she was informed that resident 13 and resident 151 were found in bed together in a state of undress.

The DON stated that she and the SSW went together to talk to the residents individually.

The DON stated that resident 151 told her it was none of your damn business.

The DON stated that both residents denied being undressed with each other, stating nothing happened, and they were just watching movies.

The DON stated that she encouraged both residents to let staff know if anything did happen or may happen.

The DON stated that during the investigation, due to the residents being under the blankets the Certified Nurse Assistant (CNA) thought they saw the residents without clothing on.

The DON stated that resident 151 was alert to himself and was alert and oriented x 3 or 4.

The DON stated that resident 151 was showing signs of terminal aggressions.

The DON stated that the did not do any cognitive assessments on resident 13 or resident 151, and that the assessment was her and the SSW talking to the residents.

The DON stated she is unsure if the incident between resident 13 and resident 151 went to an interdisciplinary team (IDT) meeting, and that she recalled it was her and the SSW that talked most about it.

The DON stated that it would be the physician that would make the decision if a resident was able to give consent.

The DON stated that either she or the SSW would contact the physician.

The DON stated that resident 13 was not always alert and oriented, and this behavior tended to be worse at night.

The DON stated if patients were alert and oriented then the facility had to respect their choices to have a relationship.

The DON stated there was no policy in regards to residents and relationships that she was aware of. [Cross refer to F-F600]

• Resident 19 was admitted to the facility on [DATE] with diagnoses which included chronic

essential hypertension, gastro-esophageal reflux, and personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits. Resident 19's medical record was reviewed 6/24/24-6/27/24.

On 6/24/24 at 9:46 AM, an interview was conducted with resident 19. Resident 19 stated that she used nocturnal oxygen. Resident 19 stated that she was unsure when her cannulas got changed.

On 6/24/24 at 9:50 AM, an observation was made of resident 19's oxygen cannulas. It was observed that there were no dates on the oxygen cannula or tubing.

• Resident 20 was admitted to the facility on [DATE] with diagnoses which included chronic

diastolic (congestive) heart failure, paroxysmal atrial fibrillation, thrombocytopenia, unspecified protein-calorie malnutrition, chronic respiratory failure with hypoxia, unspecified osteoarthritis, trigeminal neuralgia, pulmonary hypertension, peripheral vascular disease, and history of falling. Resident 20's medical record was reviewed 6/24/24-6/27/24.

On 6/24/24 at 11:19 AM, an interview was conducted with resident 20. Resident 20 stated that she was not aware that her cannulas required changing. Resident 20 stated that she used a concentrator and portable oxygen.

On 6/24/24 at 11:20 AM, an observation was made of resident 20's oxygen concentrator and portable oxygen.

There were no dates on the nasal cannulas for the concentrator or portable oxygen.

On 6/26/24 at 12:01 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated nurses were in charge of changing out residents' cannulas weekly. LPN 1 stated that cannulas were changed on Fridays and the date was written on tape and placed on the cannula.

On 6/26/24 at 1:16 PM, an interview was conducted with the Director of Nursing [DON].

The DON stated that oxygen tubing was changed weekly and required a nurse to sign on the treatment administration record [TAR].

The DON stated that tubing was dated when it was replaced.

The DON stated that in order for oxygen to be placed on a resident, an order from the doctor was required before it could be placed.

The DON stated that there were standing orders for oxygen use in order to maintain oxygen levels above 90%, but the medical provider needed to be notified of this to ensure an order was written.

465182 06/27/2024

Stonehenge of Ogden 5648 South Adams Avenue Washington Terrace, UT 84405

serve food in accordance with professional standards.

accordance with professional standards for food service safety.

Specifically, an employee was

undated and unlabeled food.

Findings include:

• On 6/24/24 at 12:51 PM, the Maintenance Director (MD) was observed to enter the facility kitchen.

The MD was observed to check several lights and sprinkler heads on the kitchen ceiling. At 12:52 PM, the MD left the kitchen, obtained a ladder that had been placed near the dining room entrance, and re-entered the kitchen. At no time was the MD observed to place a hair net over his hair.

• On 6/24/24 at 12:57 PM, an observation was made of the refrigerator in the dining room.

The following was noted: a. An open bag of grapes with no date or label b. A styrofoam container of what appeared to be leftovers.

This container was not dated or labeled. c. An open bag of chips with no date or label d.

What appeared to be an onion in a plastic bag.

The onion was green, moldy, and slimy.

There was liquid leaking from the bag onto the refrigerator surface. e.

Five open plastic containers of soda with no date or label. f.

Several areas with sticky spills and debris.

On 6/24/24, at 1:00 PM, an interview was conducted with Housekeeper (HSK) 1. HSK 1 stated she thought that the refrigerator in the dining room was for both residents and employees, but was unsure. HSK 1 stated that it was the dietary department's responsibility to clean the refrigerator in the dining room.

On 6/24/24 at 1:02 PM, an interview was conducted with the Dietary Manager (DM).

The DM stated that she though that the refrigerator in the dining room was for both residents and employees, but that it was mostly the therapy department that used it.

The DM stated that the dietary department and the housekeeping department took turns cleaning the refrigerator in the dining room.

465182 06/27/2024

Stonehenge of Ogden 5648 South Adams Avenue Washington Terrace, UT 84405

Findings included:

1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included viral intestinal infection, hypokalemia, hypercalcemia, unspecified protein-calorie malnutrition, dyspnea, essential hypertension, insomnia, generalized anxiety disorder, major depressive disorder, and gastro-esophageal reflux disease.

Resident 7's medical record was reviewed 6/24/24-6/27/24.

On 6/24/24 at 10:27 AM, an interview was conducted with resident 7. Resident 7 stated that she used nocturnal oxygen. Resident 7 stated that she had never seen her cannulas changed on either the concentrator or the portable oxygen.

On 6/24/24 at 10:28 AM, an observation was made of the portable oxygen's nasal cannula which was yellowish in color and draped across the back of the wheelchair. An observation was made that there was no date on the cannula attached to the portable oxygen. An observation was made that there was no date on the nasal cannula attached to the concentrator.

Review of resident 7's medical record revealed no order for oxygen therapy.

2. Resident 8 was admitted to the facility on [DATE] with diagnoses which included wedge compression fracture of unspecified lumbar vertebra, history of falling, unspecified asthma, sepsis, major depressive disorder, generalized anxiety disorder, essential hypertension, chronic kidney disease stage 3, gastro-esophageal reflux disease, and cardiac murmur.

Resident 8's medical record was reviewed 6/24/24-6/27/24.

On 6/24/24 at 12:50 PM, an interview was conducted with resident 8. Resident 8 stated that she used nocturnal oxygen. Resident 8 stated she was unsure how often her cannulas were changed.

On 6/24/24 at 12:52 PM, an observation was made of resident 8's oxygen cannula and tubing. It was observed that there was no date on the cannula or oxygen tubing.

Review of resident 8's medical record revealed no order for oxygen therapy.

465182

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 465182 B.

Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonehenge of Ogden 5648 South Adams Avenue Washington Terrace, UT 84405

Findings included:

The facility's Abuse Prohibition Policies, dated 2024, was reviewed and documented the following information:

The Provider Code of Conduct is to protect vulnerable clients (residents) from abuse, neglect, maltreatment and exploitation .

Abuse, sexual-abuse and sexual exploitation, neglect, exploitation, and maltreatment are prohibited.

A. No .individual . shall abuse, sexually abuse or sexually exploit, neglect, exploit or maltreat any client .

1. No person shall cause physical Injury to any client.

All Injury to clients (explained or unexplained) shall be documented in writing and immediately reported to supervisory personnel.

2. No person by acting, failing to act, encouragement to engage In [sic], or failure to deter from will cause any client to be subject to abuse, sexual abuse or sexual exploitation, negleh, [sic] exploitation, or maltreatment.

3. No person shall engage any client as an observer or participant in sexual acts.

4. No person shall make unjust or Improper [sic] use of a client or their resources for profit or advantage.

B.

Failure to comply with this Code of Conduct may result in corrective action, probation, suspension, and/or termination of contract, license or certification, in accordance with administrative procedures act and Department of Human Services' regulations.

POLICY: Our facilities will not condone any form of client/resident abuse or neglect. To assist In abuse prevention, all, csonnel[sic] are to report any signs and symptoms of abuse/neglect to their supervisor or to the Administrator .,mediately[sic].

A.

Abuse of clients may include, but is not limited to:

465182

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 465182 B.

Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonehenge of Ogden 5648 South Adams Avenue Washington Terrace, UT 84405