Stonehenge of South Jordan
For profit - Limited Liability company
32 Beds
STONEHENGE OF UTAH
Data: November 2025
Trust Grade
85/100
#24 of 97 in UT
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Stonehenge of South Jordan has a Trust Grade of B+, indicating it is above average and recommended for families considering care options. It ranks #24 out of 97 nursing homes in Utah, placing it in the top half of facilities in the state and #10 out of 35 in Salt Lake County, which means there are only nine local options that are better. The facility is improving, as the number of reported issues decreased from six in 2021 to two in 2024. Staffing is a clear strength with a 5/5 star rating and only 39% turnover, which is well below the state average, suggesting staff are experienced and familiar with residents. Notably, there have been no fines imposed, and the facility offers more RN coverage than 90% of Utah facilities. However, there are some concerns. One serious incident involved a resident who was not given the appropriate treatment for their feeding needs, leading to hospitalization for dehydration. Additionally, there were issues with outdated food items being served and a lack of a designated infection preventionist, which could pose risks to resident safety. These findings highlight the need for ongoing improvements despite the overall positive rating.
- Trust Score
- B+
- In Utah
- #24/97
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 39% turnover. Near Utah's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Utah facilities.
- Skilled Nurses ✓ Good
- Each resident gets 111 minutes of Registered Nurse (RN) attention daily — more than 97% of Utah nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ○ Average
- 8 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
85/100
Top 24%
Needs review
6 → 2 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2021: 6 issues
2024: 2 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below Utah average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 39%
Near Utah avg (46%)
Typical for the industry
Chain: STONEHENGE OF UTAH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 8 deficiencies on record
1 actual harm
Dec 2024
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview or record review it was determined, for 1 of 15 sampled resident, the facility did not ensure th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview or record review it was determined, for 1 of 15 sampled resident, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered plan, the residents' goals and preferences. Specifically, a residents was assisted to bed and his oxygen was not turned on. Resident identifier: 74.
Findings include:
Resident 74 was admitted to the facility on [DATE] with diagnoses which included right pubis fracture, congestive heart failure (CHF) and chronic respiratory failure.
On 12/16/24 at 12:53 PM, an interview was conducted with resident 74. Resident 74 stated he needed oxygen all the time. Resident 74 stated he did not think his oxygen was on. Resident 74 stated he needed to have his oxygen turned on. At 1:05 PM, an observation was made of Certified Nurses Assistant (CNA) 1. CNA 1 was observed to place a pulse oximeter on resident 74 and then went into resident 74's bathroom and turned on his oxygen concentrator. Resident 74's oxygen was at 88% after a minute.
Resident 74's medical record was reviewed.
A physician's order dated 12/7/24 revealed O2 [oxygen] 1-4 L [liters] per NC [nasal cannula]
PRN [as needed] to keep Sat [saturations] > [greater than] 90% until stable RA [room air] every shift.
A care plan dated 12/7/24 revealed I use Oxygen Therapy: CHF, Respiratory illness. The goal was I will have no s/sx [signs and symptoms] of poor oxygen absorption during my stay. The interventions included Change oxygen cannula and humidification bottle (if used) weekly; Give medications as ordered; Monitor for s/sx of respiratory distress and report to MD [medical doctor] PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color; Position resident to facilitate ventilation/perfusion matching: Use upright, high Fowlers position when possible to allow for optimal diaphragm use, When on side, the good side should be down (e.g., damaged lung should be up); and Provide reassurance and allay anxiety if in distress. Stay with patient during episodes of respiratory distress.
On 12/17/24 at 2:38 PM, an interview was conducted with CNA 2. CNA 2 stated resident 74 was on continual oxygen using 3 to 4 liters. CNA 2 stated when a resident required oxygen a portable oxygen tank was used when the resident was being transported. CNA 2 stated resident 74 was not able to go without oxygen. CNA 2 stated when a resident was connected to a different oxygen tank or concentrator, she always checked to make sure the tubing was hooked up and the oxygen was on.
On 12/17/24 at 3:25 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated if a resident required oxygen, then she would expect that the resident had the oxygen on at all times. The CRN stated a resident used a portable oxygen tank when the resident was not in their room. The CRN stated a resident used an oxygen concentrator when the resident was in their room.
On 12/17/24 at 12:35 PM, an interview was conducted with CNA 1. CNA 1 stated she was not aware resident 74's oxygen concentrator was off. CNA 1 stated if she knew the oxygen concentrator was off she would have turned in on. CNA 1 stated the oxygen concentrator was usually turned off when a resident was not using it. CNA 1 stated she did not realize the concentrator was off.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's infection control program. Speci...
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Based on interview and record review, the facility did not designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's infection control program. Specifically, the previous Director of Nursing (DON) was the facilities designated IP and did not work at least part time at the facility.
Findings included:
On 12/18/24 at 10:54 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated she was the facility DON. The CRN stated the previous DON was the IP.
On 12/18/24 at 10:55 AM, an interview was conducted with the facility Administrator. The Administrator stated the previous DON was at the facility less than 10 hours per week.
On 12/18/24 at 11:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the previous DON was the IP. LPN 1 stated that she was unsure how often the previous DON came to the facility. LPN 1 stated that she had not done the training to be the IP even though she signed and completed the infection surveillance for the facility.
Jun 2021
6 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Tube Feeding
(Tag F0693)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications. Specifically, a resident fed by enteral means only did not have their nutrition and hydration requirements met, as identified by the Registered Dietitian (RD), which resulted in the resident being transferred to the hospital for dehydration. This resulted in a finding of harm. Resident identifier 24.
Findings include:
Resident 24 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, cerebral infarction, severe protein-calorie malnutrition, dyskinesia of esophagus, acute kidney failure (AKF), history of transient ischemic attack (TIA), gastrostomy, tremor, gastro-esophageal reflux disease (GERD), hypertension (HTN), overactive bladder, anemia, Parkinson's disease, chronic pain, major depressive disorder, esophageal obstruction, fibromyalgia, gastritis, osteoporosis, chronic kidney disease (CKD), and disorder of the thyroid.
On 6/14/21 at 11:23 AM, an observation was made of resident 24 lying in bed supine with the head of the bed (HOB) elevated greater than 30 degrees. The resident had a tube feed (TF) at the side of the bed. The TF was observed not connected to the resident and was not infusing. The bag of formula was labeled Vital AF 1.2 via percutaneous endoscopic gastrostomy (PEG) tube and was dated 6/13/21 at 12:30 PM. Resident 24 stated that the TF runs in the morning and she did not like it. It's hard to breathe with it running. At 11:38 AM an observation was made of Licensed Practical Nurse (LPN) 2 reconnecting the TF tubing to resident 24's peg tube at a rate of 48 milliliters (ml)/hour (hr) with the water flush set at a rate of 20 ml/hr. The water flush bag did not have a label with the resident information or the date and time it was hung. Resident 24 complained of pressure in the abdomen and was able to point to the area of concern. LPN 2 stated she would go get a stethoscope to listen. LPN 2 was observed to give a 30 cubic centimeter (cc) water flush with the medication administration.
On 6/16/21 at 11:41 AM, an observation was made of resident 24's TF infusing at a rate of 49 ml/hr. with a water flush set at a rate of 20 ml/hr. The bag of formula was labeled Vital AF 1.2 and was dated 6/14/21 at 7:30 PM. The TF bag was observed to have approximately 250 ml of formula remaining. An interview was conducted with resident 24 and their family member. Resident 24 was still complaining of stomach pain and stated that the TF was causing the pain and tightness. Resident 24 stated she had a bowel movement Monday and it somewhat relieved the pressure and pain. Resident 24's family member reported that the TF caused fullness and difficulty with breathing. Resident 24 stated that the pain was currently an 8/10 (on a scale of 1 to 10 with 10 being the highest), was located in the stomach, was described as pressure and tightness, and with reports of hard to breathe. The resident pushed the call light and at 12:16 PM it was answered by Registered Nurse (RN) 2. The resident reported the pain to RN 2. RN 2 assessed resident 24's pain and stated that she would inform Nurse Practitioner (NP) 1 as he was still in the building.
On 6/15/21 resident 24's medical records were reviewed.
Review of resident 24's census revealed that the resident was admitted to the facility on [DATE], transferred to the hospital on 6/3/21 with an expected stay of less than 24 hours, and returned to the facility on 6/4/21.
Review of resident 24's physician orders revealed the following:
a. Enteral Feed, every shift CONTINUOUS FEED: Tube Feeding Vital AF Run at 40 ml/hr; flush 17 cc/hr. The order was initiated on 5/31/21 and discontinued on 6/3/21.
b. Enteral Feed, every shift CONTINUOUS FEED: Tube Feeding Vital AF Run at 55 ml/hr (Goal Rate); flush 20 cc/hr. The order was initiated on 6/3/21.
c. Enteral Feed, every shift Flush tube with 20-30 ml(cc) of water before and after administration of medication pass. The order was initiated on 5/31/21.
d. Enteral Feed at bedtime Graduate cylinder and 60 cc syringe change out, add date at bedtime. The order was initiated on 5/31/21.
e. Elevate HOB 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped. The order was initiated on 5/31/21.
f. NPO (nothing by mouth). The order was initiated on 5/31/21.
Review of resident 24's weights revealed the admission weight (wt.) on 6/1/21 was 105 lbs (pounds), and current wt. on 6/15/21 was 98.4 lbs. This was a 6.29% wt loss in 15 days.
Resident 24's progress notes were reviewed and revealed the following:
a. On 6/1/21 at 1:31 AM, the note documented, Pt (patient) is new admit to facility for failure to thrive, pt is thin and skin is fragile. Pt is alert and oriented x 3 to person, place and situation but not time. Pt has intermittent confusion during shift. Pt wears glasses. Pts heart sounds were WNL (within normal limits), no evidence of irregular heart rate noted during assessment, no peripheral edema and CRTS (capillary refill times) to extremities less than 3 seconds. Lung sounds clear throughout, HOB (head of bed) maintained at least 30 degrees once feeding initiated. No cough present. Bowel sounds active in all quadrants and LBM (last bowel movement) was 5/28, no distention noted and pt is continent of bowel. Pt is incontinent of bladder and needed brief change upon admit. SN (skilled nurse) performed this while assessing skin. Blanching redness to bottom and groin. Pt has PEG tube to LUQ (left upper quadrant), PEG line is patent and flushing well, Sn (skilled nurse) changed dressing to peg tube site upon admission. Blanching redness to bilateral heels, heels floated. Bp (blood pressure) -140/73, P (pulse) -89, O2 (oxygen saturation) -94%2l (liters), temp (temperature) -97.8F (Fahrenheit), R (respirations) -16. pt was stretcher admit last reported weight and height from hospital was 105lbs and 5'4 (inches). Pt adjusting to room well and utilizes call light/voices concerns. VSS (vital signs stable), WCTM (will continue to monitor).
b. On 6/1/21 at 12:00 PM, the note documented that the resident was seen by NP 1 for initial assessment. History of present illness documented that resident 24 was a [AGE] year old female with a past medical history of stroke, chronic pain, depression, fibromyalgia, gastritis, chronic kidney disease, hypothyroidism, opioid addiction who was admitted following hospitalization for confusion, rigidity, tingling with urination, right thalamic acute cerebrovascular accident, PEG tube feeds, esophageal dysmotility, esophageal stenosis, acute kidney injury, protein/calorie malnutrition, refeeding syndrome and stress leukocytosis. The physical exam documented a&o (alert and oriented) x 2, well-nourished elderly _male lying comfortably in bed. The assessment and plan of care documented for protein calorie malnutrition to continue with TF and obtain weekly complete blood counts (CBC), comprehensive metabolic panel (CMP), magnesium (mag), and Phosphate (Phos.) levels. COVID-19 vaccine was documented as given on 2/13/21 and 3/13/21.
c. On 6/1/21 at 5:04 PM, the note documented, Last Recorded Vitals of: T (temperature) 97.7 - 6/1/2021 11:07 Route: Temporal Artery , P 96 - 6/1/2021 11:08 Pulse Type: Regular , R 18.0 -6/1/2021 11:10, BP 112/50 - 6/1/2021 11:04 Position: Lying r/arm , , O2 89.0 % - 6/1/2021 11:11 Method: Oxygen via Nasal Cannula ,Liters of Oxygen:2, W 105.0 lb - 6/1/2021 01:24 Scale: Bath . The Capillary Refill was documented as less than 3 seconds. Patient's nutritional intake requires use of feeding tube. Isolation is required for active infection with all services provided within room. J-Peg LLQ (left lower quadrant). It should be noted that the resident did not have an active infection and was not on isolation precautions. COVID vaccination status was addressed in NP 1 progress note and resident 24 did not require quarantine.
d. On 6/1/21 at 9:52 PM, the note documented that the lab results were received and NP 1 was made aware.
e. On 6/1/21 at 11:58 PM, the note documented that NP 1 ordered for resident 24 to have a basic metabolic panel (BMP) drawn in the morning.
f. On 6/2/21 at 1:46 PM, the note documented that the BMP was drawn.
g. On 6/2/21 at 3:54 PM, the note documented, Last Recorded Vitals of: T 98.2 - 6/2/2021 10:19 Route: Temporal Artery , P 104 - 6/2/2021 10:22 Pulse Type: Regular , R 16.0 -6/2/2021 10:24, BP 100/45 - 6/2/2021 10:15 Position: Lying r/arm , , O2 90.0 % - 6/2/2021 10:25 Method: Oxygen via Nasal Cannula ,Liters of Oxygen:2, W 105.0 lb - 6/1/2021 01:24 Scale: Bath Patient's nutritional intake requires use of feeding tube. Isolation is required for active infection with all services provided within room. J-Peg LLQ The progress note was authored by the same nurse on 6/1/21 at 5:04 PM.
h. On 6/3/21 at 2:09 PM, the note documented, Per Dietitian: enteral feeding rate goal is 55 ml/hr, pt is currently at 47 ml/hr and is tolerating rate well at this time. if pt continues to tolerate rate of 47 ml/hr for the rest of the day, will attempt to increase rate up to 55 ml/hr on 6/4/21. pt is tolerating h2o (water) rate of 20 ml/hr without issue
i. On 6/3/21 at 2:13 PM, the note documented to discontinue the Lisinopril, Amlodipine, and Oxybutynin.
j. On 6/4/21 at 3:03 AM, the note documented, Last Recorded Vitals of: T 98.4 - 6/4/2021 00:42 Route: Forehead (non-contact) , P 91 - 6/4/2021 00:42 Pulse Type: Regular , R 18.0- 6/4/2021 00:44, BP 78/34 - 6/4/2021 00:41 Position: Sitting r/arm , , O2 95.0 % - 6/4/2021 00:44 Method: Room Air , Liters of Oxygen:2, W 103.2 lb - 6/3/2021 15:09 Scale: Wheelchair Capillary Refill < 3 seconds: Normal.
k. On 6/4/2021 at 3:09 AM, the note documented, Upon Sn (skilled nurse) arriving to shift, CNA (certified nurse assistant) reported pt having low BP, SN went and performed manual BP and noted Bp was 100/20 diastolic was difficult to hear/note. Pt was lethargic and only alert and oriented to person. Sn called and notified Oncall NP who gave order for NS (normal saline) at 200 ml/hr via IV (intravenous), SN placed 22g (gauge) IV to right inner wrist and started fluid replacement. SN changed tubing and feed and assured pt was receiving tube feed as well. Oncall NP stated to call around 2200 (10:00 PM) with update of vitals after NS had been running for a few hours. SN rechecked BP at 2200 and found it to be 78/34, Pt continuing to be lethargic and was now diaphoretic and clammy. Sn notified oncall NP who stated to send pt out via emergent transport, SN called 911 and sent pt to [local hospital], SN notified pts husband [name omitted] and called DON (Director of Nursing) [name omitted] for update. SN received call from [local hospital] around 0200 (2:00 AM) and MD (medical doctor) stated would continue pt on fluids at hospital and would be sending pt back within the next 5 hours or so after fluids completed. Sn will continue to watch for update and notify next shift.
b. On 6/4/2021 at 3:46 AM, the note documented, Pt came back from ED (emergency department) with no report from hospital besides MD calling at 0200 stating she would be back in 5 hours after fluids complete. Hospital stated pt was dehydrated. vitals completed upon pt arrival to facility BP-102/56, P-81, O2-99%3L, temp-98.4F, R-16. SN received orders from oncall NP to continue 5% dextrose with .45 sodium IV at 100ml/hr. Sn placed pt back on tube feed and WCTM. Sn texted oncall DON with update on pt and pt need for social work refferal (sic) due to decline/no improvement in pt condition since admit. WCTM
Review of resident 24's vital signs revealed the following:
a. On 5/31/21 at 11:32, the BP 140/73, P 89, R 16.
b. On 6/1/21 at 1:31 AM, the BP 140/73, P 89, R 16. Results were obtained from the progress notes.
c. On 6/1/21 at 11:04 AM, the BP 112/50, P 96, R 18.
d. On 6/1/21 at 10:26 PM, the BP 101/56, P 95, R 1(sic).
e. On 6/2/21 at 10:15 AM, the BP 100/45, P 104, R 16.
f. On 6/2/21 at 9:11 PM, the BP 93/47, P 92, R 16.
g. On 6/3/21 at 9:20 AM, the BP 116/68, P 92, R 20. On 6/3/21 at 2:13 PM the Lisinopril and Amlodipine were discontinued. Review of the June 2021 Medication Administration Record revealed that resident 24 received the dose of both medications on 6/3/21 prior to discontinuation of the medications.
h. On 6/4/21 at 12:41 AM, the BP was 78/34, P 91, R 18.
i. On 6/4/21 at 3:09 AM, progress note documented BP 100/20 when arrived on shift. The progress note was entered at 3:09 AM by the night shift nurse. Night shift starts at 6 PM until 6 AM. The next documented BP 78/34 and was at 10:00 PM.
j. On 6/4/21 at 3:46 AM, the BP 102/56, P 81, R 16. Results were obtained from the progress notes.
Review of the Nutritional Risk Assessments on 6/2/21 by the facility Registered Dietitian (RD) documented the resident ht. was 64, admission wt. was 105 lbs, Ideal Weight Range (IWR) was 108-132, and Body Mass Index (BMI) was 18. Enteral Nutrition Order documented the formula as Vital AF at a rate of 40 cc/hr with a H2O flush at a rate of 17 cc/hr. The formula documented calories at 1152 and protein at 72. The free water was documented as 778+408 with a total volume of 1323. It should be noted that the actual total volume calculated was 778 + 408 =1186 total water and not 1323. The assessment documented that the resident was confused and disoriented but able to make needs known. Medications with nutritional implications were documented as Pantoprazole. The assessment documented that the calorie needs for the current body wt. were adjusted for weight gain, and the percentage of caloric needs were between 1432-1670 with a 30-35 factors. Hydration needs were documented for current body weight and adjusted for normal, ml were >1500 and the needs were documented as met and as min (minimum) req.(requirement). The RD did not document how she calculated the resident's hydration needs. Protein needs for current body weight were adjusted for normal and repletion at 48-57 grams with a 1.0-1.2 factor. The assessment documented a diagnosis of malnutrition with a BMI <18.5 and TF. The diet order stated to increase TF to 55 cc/hr and change flush to 18 cc/hr. The summary of review documented, 74 yo resident at nutritional risk r/t weakness, FTT (Failure to Thrive) w/ (with) malnutrition, encephalopathy, AKF (acute kidney failure), CKD (chronic kidney disease) , TIA/CVA (transient ischemic attack/cerebrovascular accident), HTN (hypertension), PEG tube, esophageal obstruction, GERD (gastro-esophageal reflux disease). 97% IWR/BMI 18.0. Needs based on CBW (current body weight) for wt gain - 105# 1432-1670 kcal (30-35/kg) >1500 ml (min req) 48-57 gm Pro (1.0-1.2/kg for repletion) NPO att (and) tolerating TF of Vital AF @ 40 cc/hr x 24 hrs w/ flush 17 cc/hr x 24 hrs providing 1152 kcal, 72 gm Protein and 778+408=1323 cc fluid/day as ordered. Suggest increasing TF to 55 cc/hr and flush to 18 cc/hr to provide 1584 kcal/day, 99 gm protein and 1069+432=1526 cc/day to help meet nutritional needs and aid in weight gain. Resident is self directed with food choices. Dietary available to cater to needs and preferences. Monitor per POC (plan of care). Will follow as needed.
Review of resident 24's lab results revealed the following:
a. On 6/2/21 the BMP documented the sodium as 135 normal, potassium as 5.1 normal, Chloride 101 normal, BUN 71 high, creatinine 1.54 high. The Lab report was noted and signed by NP 1 on 6/3/21.
b. On 6/7/21 the CMP documented abnormal values for the following; glucose 135 high, BUN (Blood Urea Nitrogen) 47 high, BUN/Creatinine ratio 64 high, Sodium 131 low, Potassium 5.4 high, Albumin 3.4 low. The Lab report was noted and signed by NP 1 on 6/8/21. A written note next to NP 1 signature stated Dietary - re check BMP on 6/9/21. It should be noted that the dietary note was written in a different script than the NP 1 and did not contain a signature or initial.
c. On 6/9/21 the BMP documented abnormal values for the following; glucose 112 high, BUN 48 high, BUN/Creatinine Ratio 61 high, Sodium 130 low, Chloride 95 low. The Lab report was noted and signed by NP 1 on 6/11/21.
d. On 6/14/21 the CMP documented abnormal values for the following; glucose 103 high, BUN 36 high, BUN/Creatinine Ratio 63 high, Sodium 132 low, Chloride 95 low. The Lab report was noted and signed by NP 1 on 6/15/21.
Review of the Dietary Recommendation sheets for 6/2/21 revealed that resident 24 was identified and documented by the RD with nutritional concerns of increased needs. The recommendations were to change the TF rate to 55 cc/hr and flush to 18 cc/hr. The nursing follow-up was not signed or dated. The weekly weights dated 6/4/21 for resident 24 listed a weight of 105 that was dated on 6/2/21, IWR 108-132, %IWR 97, and BMI 18. [Note: The RD did not address resident 24's hydration needs while resident 24's formula rate was being adjusted.]
Review of resident 24's Hospital History and Physical (H & P) on 5/26/21 documented that the resident was found to have esophageal dysmotility and stricture and failed a swallow study which resulted in a PEG tube placement on 5/25/21. The resident presented to the emergency department on 5/26/21 with complaints of tingling (left side) and weakness. The patient reported nothing to eat or drink since 5/23/21. PEG tube balloon placement was determined to be in the stomach. Lab results were documented as Sodium 141, Chloride 105, Potassium 4.5, BUN 25 high, Creatinine 1.75 mg/dl (deciliter) high, and glucose 103 high. The history of present illness documented that resident 24 received IV fluids in the ED, type and amount unknown. The exam documented a thin female, dry mucous membranes with skin that was well perfused. Vital signs on 5/26/21 at 3:00 PM were BP 100/40, P 90, and R 15. The impression was documented as toxic metabolic encephalopathy likely due to dehydration, malnutrition, toxic side effects of chronic meds in the setting of AKI (acute kidney injury). The plan for severe protein calorie malnutrition was to have a nutrition consult, TF, and monitor for refeeding syndrome. The plan for the AKI due to the dehydration was to monitor Creatinine and TF. On 5/27/21 at 8:01 AM, the VS were documented as BP 119/42, P 87, and R 16. The exam documented a frail cachectic female. No documentation of dry mucous membranes were noted on the 5/27/21 exam. IV thiamine was ordered for malnutrition, and TF were documented as having begun. Lab results were documented as Sodium 138, Chloride 109, Potassium 3.8, BUN 33 high, Creatinine 1.32 high, and glucose 118 high. On 5/27/21 at 12:06 PM the BP was 130/46, P was 92, and R was 16. On 5/27/21 at 2:26 PM, the provider note recommended thiamine 500 mg IV daily for 3 days. Resident 24's medication list on 5/26/21 at 1:11 PM documented Thiamine Hydrochloride in Sodium Chloride 105 ml at 200 ml/hr IV daily, and Sodium Chloride 500 mls @ 999 ml/hr IV Q (every) 31M (minutes) SCH (scheduled).
On 5/31/21 at 11:49 AM, resident 24's Hospital Discharge orders documented a TF order for Vital AF at a rate of 40 cc/hr. with a free water flush at 65 cc every 4 hours. The hospital discharge paperwork listed a past and present condition of dehydration, protein calorie malnutrition, acute dehydration, and acute renal failure. The principal diagnosis at discharge was documented as severe protein calorie malnutrition. Lab results on date of discharge 5/31/21 were Sodium 136, Chloride 106, Potassium 5.3 high, BUN 30 high, and Creatinine 0.94.
On 6/3/21 at 11:00 PM, resident 24's Hospital H & P documented that the resident was noted to have hypotension at the facility and received 1 liter of fluid. Vital signs were documented as BP 92/34, P 87, and R 31. Lab results were documented as Sodium 139, Chloride 107, Potassium 5.0, BUN 81 high, Creatinine 1.12 H. The orders documented that resident 24 received Dextrose/Sodium Chloride 1,000 mls @ 200 ml/hr IV every 5 hrs., and the IV fluids were documented as stopped on 6/4/21 at 6:59 AM. The narrative documented that the BUN creatinine ratio significantly elevated suggesting dehydration Patient needs IV hydration. She received a L (liter) fluid normal saline plus a L of D5 (Dextrose 5%) half normal saline. The nursing facility where she resides is a (sic) will to (sic) continue IV hydration as well. For this reason I do not think the patient needs readmission to the hospital and they can continue hydration at the nursing home. Patient's blood pressures were improved upon discharge.
On 6/16/21 at 1:08 PM, an interview was conducted with RN 2. RN 2 stated that NP 1 assessed the resident and ordered to increase the Tylenol to 1000 milligram three times a day, and to add Lansoprazole 5 ml two times a day. RN 2 stated that the TF was running at 48 ml/hr with water at 20 ml/hr. RN 2 stated that the TF was a continuous feed, but it was taken off for therapy and sometimes taken off to give her tummy a break. At 1:13 PM RN 2 was observed to obtain a new bottle of TF formula and entered resident 24's room. The TF formula was observed as Vital AF 1.2 formula and came in a 8 fluid ounce or 237 ml bottle. RN 2 stated that the TF was running at a rate of 48 ml/hr, but when viewed was observed to be running at a rate of 49 ml/hr. They turned it up and didn't tell me, it wasn't me. It was probably night shift. RN 2 was observed to view the date and time stamp on the bag and stated that the bag was hung on 6/14/21 and should be changed every 24 hours. RN 2 stated she would obtain a new bag and tubing. RN 2 stated that the risk of having the same bag and tubing used past 24 hours was that it could get bacteria in it.
On 6/16/21 at 2:49 PM, a telephone interview was conducted with the RD. The RD stated that the resident was on a TF with a BMI of 18 and 97% of IWR. The RD stated that she utilized charts with recommendations based on IDW and if the resident was underweight she would multiply by a certain number to give more calories. The RD stated that the resident was on 1.2 calorie formula, and the goal rate was 55 cc/hr. The RD stated that the wt. loss that had occurred was because the resident was not tolerating what she needed to gain wt. The RD stated that the total volume that was calculated was based on 778 from the formula and 408 was base of the 17 cc/hr water flush. The RD confirmed that the calculated total water was miscalculated and was 1186 and not 1323 as documented in the assessment. The RD stated that was the orders that was received from the hospital for resident 24's TF. The RD stated that she determined that resident 24 required more to meet her nutritional needs and recommended to increase the TF rate to 55 cc/hr with a water flush of 18 cc/hr and that this was stated in the summary of the assessment that was completed on 6/2/21. The RD further stated that she recommended a total water of 1526 cc per day based on the 1069 from the formula + 432 from the free water to equal 1526 cc/day. It should be noted that 1069 + 432 = 1501 and not the 1526 cc/day that was documented. The RD stated that the chart utilized for water needs stated not less than 1500 ml/ day, and based on the assessment she wasn't getting her water needs from the orders coming from the hospital. The RD stated that resident 24 needed 1432 to 1670, or 30-35 cal per kilogram for wt gain. The RD stated that when she had recommendations for residents' nutritional or hydration needs she provided a form to the DON and diet manager. The RD stated that the nurses usually check with the doctor and place the orders in the chart, but that nursing was responsible for updating orders in the medical records. The RD stated that she made recommendations, but did not change any orders in the medical records. The RD stated that they could increase resident 24's free water but did not want to dilute the sodium as resident 24's sodium levels were really low and didn't want to dilute them out further. The RD stated that she discussed this with the nursing staff. Don't want to do a water overload. So, yes at some point that is a nursing order or a doctor order and not a RD order. The RD stated that she discussed this with LPN 1, but did not discuss this with the DON or the physician or NP. The RD stated, they don't think she can eat. If she can't meet her needs with the TF then maybe hospice would be the option. I've been waiting to see how she tolerates it and hear back as to what they want to do. The RD stated that she was not aware that resident 24 went to the hospital for dehydration, and did not have a note that this had happened. The RD stated that her recommendations would be the same. If it's fluids that's a medical call. Dehydration would be a medical issue and not a dietary issue. The RD stated she had not seen resident 24 since 6/2/21. The RD stated she had talked to the DM this morning and resident 24 was still NPO, and there was nothing they can do until the rate could be increased. The RD stated that she was in the building one time per week and communicated with nurses and providers by text or phone. The RD stated that if the resident remained at the facility long enough then she would recheck them in a month or two. If the resident had wt. changes the DM would notify her. The RD stated that she could not change a diet order without a physician order. The RD stated that she made recommendations and the nurse or facility contacted the MD to make those changes to the diet. The RD stated that she did not have a lot of contact with the MD and that communication went through the nursing staff.
On 6/16/21 at 4:05 PM, an interview was conducted with the DON. The DON stated that the RD filled out recommendation forms when she visited. The DON stated that she would update the resident orders based on the recommendation sheets, talk to the patient, and if it coincided with the weekly weight/nutrition meting or nutrition at risk meeting then it would be added to the skin and wt. assessment. Otherwise, it would be located in the RD assessment only. The DON stated that those recommendations did not get uploaded into each resident's records as multiple residents were located on a form, but that they were kept with the Nutrition at Risk (NAR) notes. The DON stated that she communicated those recommendations to the physician, and it was documented in the order in the electronic medical records. If the recommendations were not given to the DON then the Assistant Director of Nursing (ADON) would get those recommendations. The DON stated that dietary received a copy so they could update the meal tickets, but either the DON or ADON put the orders into the electronic medical records. The DON stated that the floor nurse would document a progress note on any communication with the RD recommendations, would notify the MD, and notify the DON.
On 6/17/21 at 9:05 AM, an interview was conducted with LPN 1. LPN 1 stated that the RD was in the building one time a week and could be contacted by telephone. LPN 1 stated that anytime they had a TF resident the RD took over that resident's care. She is really involved with their rates. LPN 1 stated that the recommendations were communicated on T.O. (telephone order) forms or if she was out in a room she would send a message through the secure system in the electronic medical records. Most the time we just give her a phone call, its just quicker that way. LPN 1 stated that he communicated with the RD 1-2 weeks ago about resident 24. LPN 1 stated that resident 24 was having some GI distress and they discussed maybe using a different formula. They decided to stick with the current formula because there was only one other option, and to start some gas medications. LPN 1 stated that resident 24's pain had been pretty good. She had general pain and was now on scheduled gas-x that seemed to be helping with the discomfort. LPN 1 stated that resident 24 had a KUB (kidney, ureters, and bladder x-ray) that revealed no impaction but a high fecal load. LPN 1 stated that they gave her some laxatives and she cleared that out. Review of the diagnostics results revealed the KUB was obtained on 6/7/21. LPN 1 stated that they tried to reduce resident 24's TF rate due to the complaints of discomfort. LPN 1 stated that resident 24 was at a rate of 48 ml/hr last week this week she was at 49 ml/hr, so it's not going down and she seem to be tolerating it fairly well. LPN 1 stated that he talked to the RD initially about the TF rates with the GI problems and with different formula options. LPN 1 stated that there was no discussion about the free water or increasing the water flush rate. LPN 1 stated that the TF was a continuous feed 24/7 and was turned off for transfers, toileting, and therapy.
On 6/17/21 at 9:22 AM, an observation was made of resident 24 in her room. Resident 24's TF was running at a rate of 55 ml/hr with a water flush at a rate of 20 ml/hr. The tube feed bag was observed dated 6/16/21 at 11:30 PM, and the bag was observed full with formula to 1000 ml line. The water bag was not labeled and was filled to the 800 ml line.
On 6/17/21 at 12:16 PM, an interview was conducted with NP 1. NP 1 stated that communication with the RD was by a written order or just let the nurse know that nutrition needed to see the resident. NP 1 stated that he relied on the RD's recommendations with TF. I just take it and agree with it most of the time. Go based off what they calculate the residents needs are. I collaborate with the MD on the resident. I will let the nurse know with a VO (verbal order) to place them on a night time feed. NP 1 stated he had called the RD a couple of times over the years but nothing recently. Not very good at knowing all the nutritional needs of the residents that was why I rely on her. Don't know off the top of the head what the recommendations were but would go based on them. Usually they come out of the hospital on a rate and a goal. I don't generally write new orders for a TF when they get here. NP 1 stated that if the nutritional needs were not being met for a TF he would expect the RD to let them know. NP 1 stated that he
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not immediately...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not immediately notify the physician when there was an accident that involved the resident and had the potential for physician intervention, a significant change in the resident's status, or a need to alter treatment. Specifically, the physician was not notified when the resident sustained multiple falls. Resident identifier 7.
Findings include:
Resident 7 was admitted to the facility on [DATE] with diagnoses which consisted of intervertebral disc degeneration lumbar region, repeated falls, polyneuropathy, type 2 diabetes mellitus, benign prostatic hyperplasia, major depressive disorder, hypertension, spinal stenosis lumbar region without neurogenic claudication, and weakness.
On 6/14/21 at 10:34 AM, an interview was conducted with resident 7. Resident 7 reported bilateral weakness in the lower extremities, and stated that he falls all the time.
Review of resident 7's incident reports revealed 9 fall since admission. The following incident reports revealed no physician notification of the incident:
a. On 5/7/21 at 7:00 PM, the report documented that the resident was found on the floor next to the bed. The report did not document that notification was made to the physician of the fall. Nursing progress notes were reviewed, no notes were documented prior to 5/13/21.
b. On 5/20/21 at 7:30 PM, the report documented that the resident was found on the floor next to the side of the bed with their buttocks on the floor and legs crossed side ways extending under bed. The report did not document that notification was made to the physician of the fall. Nursing progress notes were reviewed and no documentation could be found for physician notification of the 7:30 PM fall.
c. On 6/7/21 at 8:00 PM, the report documented that the resident was found on the floor in front of the wheelchair with legs crossed underneath him. The report did not document that notification was made to the physician of the fall. Nursing progress notes were reviewed and no documentation could be found for physician notification.
On 6/17/21 at 8:51 AM, Licensed Practical Nurse (LPN) 1. LPN 1 stated that they notify the provider with each resident fall along with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the family. LPN 1 stated that documentation of notification was under risk management in the electronic medical records and would also be documented in a nursing progress note. The LPN stated that the Nurse Practitioner (NP) 1 was in the facility 5 days a week and the physician was there 1 day a week. LPN 1 stated that they either call the provider or the the on call provider when notification needed to be made.
On 6/17/21 at 10:36 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that physician notification was noted in risk management. If we notified it could be there. The CRN stated that the nurses should notify the physician after each fall.
On 6/17/21 at 1:00 PM, a follow-up interview was conducted with the CRN. The CRN stated that NP 2 provided copy of a note with documentation showing that notification was made of the fall on 5/7/21. It should be noted that the note did not document the time of notification. The CRN stated that there was no documentation of physician notification for the falls that occurred on 5/20/21 and 6/7/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out of 23 sampled residents, that the facility did not ensure that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out of 23 sampled residents, that the facility did not ensure that the baseline care plans were developed and implemented within 48 hours of a resident's admission and included instructions needed to provide effective and person-centered care. Specifically, two resident's baseline care plans were not developed within 48 hours of admission. Resident identifiers were 75 and 81.
Findings include:
1. Resident 81 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery, artificial right knee joint, insomnia, chondromalacia, hypertension, osteoarthritis of right and left knee, major depressive disorder single episode, hyperlipidemia, long term use of anticoagulants, and gastro-esophageal reflux disease.
On 6/15/21 resident 81's medical records were reviewed.
Review of resident 81's care plan revealed a focus area for emotional, intellectual, physical, and social needs related to physical limitations with interventions that were initiated on 6/8/21, and a focus area for potential for altered mood/behavioral and social isolation related to facility quarantine with interventions that were initiated on 6/14/21. All other care plan focus areas with interventions were initiated on 6/15/21. It should be noted that the resident was discharged from the facility on 6/16/21.
On 6/16/21 at 9:58 AM, an interview was conducted with the Director of Nursing (DON) and Corporate Resource Nurse (CRN). The DON stated that the admission paperwork was completed by herself, the Assistant Director of Nursing, or a floor nurse and they complete the care plan as well. Once the care plan was completed it was given to the nurse and a copy was provided to the resident. The DON stated that a signed sheet was retained in the resident's medical record indicating that they received a copy of the care plan. The DON stated that the baseline care plan would be included in the comprehensive care plan and would show the date that the focus area was initiated. The DON stated that the baseline care plans contained and covered (if applicable) the admitting diagnosis, services to be provided, dietary instructions, medications, discharge plans, activities of daily living (ADLs), any black box warnings for medications, communication and dental issues or concerns, nutrition, bleeding and anticoagulant use, dialysis, and subcategories for pain, fall, cognition, skin, tube feeds, and psychoactive medications. The DON stated that the completion goal for the baseline care plan was the date of admit, but was not aware of the regulatory guidelines. The DON stated that resident 81 only had one care area or focus area for emotional, intellectual, spiritual needs that was initiated on 6/8/21. All other care plans were initiated on 6/15/21. The DON agreed that the nursing staff did not have the benefit of the care plan as it was not available until yesterday, but that they could have read through all of the resident documentation to see the history.
2. Resident 75 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery, presence of right artificial shoulder joint, chronic atrial fibrillation, long term use of anticoagulants, and hypertension.
On 6/15/21 resident 75's medical records were reviewed.
Review of resident 75's care plan revealed that all focus areas with interventions were initiated on 6/14/21.
On 6/17/21 at 1:52 PM, a follow-up interview was conducted with the DON. The DON stated that resident 75 was admitted on [DATE] and the baseline care plan was completed on 6/14/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose, excessive duration, without adequate monitoring, without adequate indication for its use, in the presence of adverse consequences or any combination of these reasons. Specifically, a resident's medication was administered when it should have been held per the physician's ordered parameters. Resident identifier 20.
Findings include:
Resident 20 was admitted to the facility on [DATE] with diagnoses which included fracture of right acetabulum, type 2 diabetes mellitus, chronic obstructive pulmonary disease, dependence on supplemental oxygen, macular degeneration, spondylosis without myelopathy or radiculopathy cervical region, hypothyroidism, aortocoronary bypass graft, hypotension, gout, hyperlipidemia, insomnia, paroxysmal atrial fibrillation, multiple fractures of the ribs, history of falling, weakness, end stage renal disease, dependence on renal dialysis, and Parkinson's disease.
On 6/15/21 resident 20's medical records were reviewed.
Review of resident 20's physician orders revealed an order for Midodrine 10 milligrams three times a day, hold for systolic blood pressure greater than 90. The order was initiated on 5/21/21.
Resident 20's May 2021 Medication Administration Record (MAR) was reviewed. The Midodrine was administered when it should have been held per the physician ordered parameters on the following dates:
a. On 5/22/21 at bedtime (HS) the blood pressure was (BP) 92/54 and the Midodrine was documented as administered.
b. On 5/23/21 at 7:00 AM, the BP was 134/72 and the Midodrine was documented as administered.
c. On 5/23/21 at 2:00 PM, the BP was 134/72 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse.
d. On 5/24/21 at 7:00 AM, the BP was 109/56 and the Midodrine was documented as administered.
e. On 5/31/21 at 7:00 AM, the BP was 131/60 and the Midodrine was documented as administered.
f. On 5/31/21 at 2:00 PM, the BP was 131/60 and the Midodrine was documented as administered.
Resident 20's June 2021 MAR was reviewed. The Midodrine was administered when it should have been held per the physician ordered parameters on the following dates:
a. On 6/1/21 at 7:00 AM, the BP was 118/54 and the Midodrine was documented as administered.
b. On 6/1/21 at 2:00 PM, the BP was 118/54 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse.
c. On 6/1/21 at HS the BP was 105/55 and the Midodrine was documented as administered.
d. On 6/2/21 at 7:00 AM, the BP was 114/53 and the Midodrine was documented as administered.
e. On 6/2/21 at 2:00 PM, the BP was 114/53 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse.
f. On 6/6/21 at 7:00 AM, the BP was 122/60 and the Midodrine was documented as administered.
g. On 6/6/21 at 2:00 PM, BP was 122/60 and the Midodrine was documented as administered.
h. On 6/6/21 at HS the BP was 121/60 and the Midodrine was documented as administered.
i. On 6/7/21 at 7:00 AM, the BP was 112/65 and the Midodrine was documented as administered.
j. On 6/7/21 at 2:00 PM, the BP was 122/60 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse.
k. On 6/8/21 at 7:00 AM, the BP was 114/58 and the Midodrine was documented as administered.
l. On 6/8/21 at 2:00 PM, the BP was 114/58 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse.
m. On 6/8/21 at HS the BP was 111/53 and the Midodrine was documented as administered.
n. On 6/9/21 at HS the BP was 137/55 and the Midodrine was documented as administered.
o. On 6/11/21 at 2:00 PM, the BP was 114/82 and the Midodrine was documented as administered.
p. On 6/12/21 at HS the BP was 93/56 and the Midodrine was documented as administered.
q. On 6/13/21 at 7:00 AM, the BP was 116/61 and the Midodrine was documented as administered.
r. On 6/13/21 at 2:00 PM, the BP was 116/61 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse.
s. On 6/14/21 at 7:00 AM, the BP was 126/63 and the Midodrine was documented as administered.
t. On 6/14/21 at 2:00 PM, the BP was 126/63 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as 7:00 AM reading and documented by the same licensed nurse.
u. On 6/15/21 at 7:00 AM, the BP was 134/72 and the Midodrine was documented as administered.
v. On 6/15/21 at 2:00 PM, the BP was 134/72 and the Midodrine was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse.
On 6/16/21 at 7:53 AM, and interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the Certified Nurse Assistants (CNAs) obtained the BP readings for the nurse one time per shift and when BP medications were administered. The LPN stated that if the CNA was not available she would obtain a BP reading prior to administering a BP medication. LPN 2 stated that she would document the blood pressure readings in the MAR and verify any medications with parameters.
On 6/16/21 at 10:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility does not have standing orders to hold BP medications for parameters. The DON stated that providers would put parameters on each individual order or if the nurse identified a trend with BP readings they would inform the provider. The DON stated that there should be a BP reading obtained either by a CNA or a licensed nurse (LN) and the LN should verify the reading prior to administering the BP medication. The DON stated that the LN should have obtained a new BP reading for each medication administration and they should have held the medication per the physician parameters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 80 was admitted to the facility on [DATE] with diagnoses which consisted of methicillin resistant staphylococcus aur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 80 was admitted to the facility on [DATE] with diagnoses which consisted of methicillin resistant staphylococcus aureus (MRSA) infection, insomnia, allergic rhinitis, gastro-esophageal reflux disease, rheumatoid arthritis, polymyositis, intervertebral disc degeneration lumbar region, spinal stenosis, artificial knee joint, bacteremia, anemia, hyperlipidemia, asthma, cellulitis of the right lower limb, and osteomyelitis.
On 6/15/21 resident 80's medical records were reviewed.
Review of resident 80's orders revealed an order for Isolation Precautions: Contact precautions at all times r/t (related to): MRSA in R (right) shin wound. The order was initiated on 6/14/21.
Review of resident 80's hospital History and Physical on 6/4/21 documented that resident 80 had microbiology results that showed positive for MRSA in the Shin Superficial Wound Culture on 6/1/21 and MRSA in the Blood Culture on 5/31/21.
Review of resident 80's progress notes revealed the following:
a. On 6/8/21 at 3:52 PM, the note documented, patient is on vancomycin for MRSA in RLE (right lower extremity).
b. On 6/8/21 at 4:41 PM, the note documented, Isolation is required for active infection with all services provided within room.
c. On 6/9/21 at 4:07 AM, the note documented, Contact precautions utilized.
d. On 6/11/21 at 12:51 AM, the note documented, Isolation is required for active infection with all services provided within room.
e. On 6/11/21 at 10:17 AM, the note documented, Isolation is required for active infection with all services provided within room.
f. On 6/15/21 at 1:08 AM, the note documented, Isolation is required for active infection with all services provided within room.
Review of resident 80's care plan revealed a focus area for Infection MRSA in RLE that was initiated on 6/14/21. The interventions documented included, but were not limited to, Educate both the resident and the direct care staff that the infection is contagious., and Maintain universal precautions when providing resident care.
Review of the facility Policy and Procedures for Isolation - Categories of Transmission-Based Precautions documented under Contact Precautions .may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy further stated that staff and visitors should wear gloves when entering the room, and a gown should be donned upon entering the room and doffed before exiting the room. The guidance was last revised in October 2018.
On 6/14/21 at approximately 11:15 AM, an observation was made of room [ROOM NUMBER]. No cautionary signs were posted on the door alerting staff to any TBP, and no PPE cart was located outside of the resident room.
On 6/14/21 at 2:55 PM, an observation was made of room [ROOM NUMBER]. A cautionary sign was observed posted on room [ROOM NUMBER] door that stated contact precautions, wear a gown, gloves when providing direct care, clean hands with alcohol based hand rub (ABHR). An interview was conducted with CNA 3. CNA 3 stated that resident 80 was on contact precautions for MRSA in her wound.
On 6/16/21 at 7:50 AM, an interview was conducted with CNA 6. CNA 6 stated that she worked for an agency and this was the first day working at the facility. CNA 6 stated that for any isolation precautions there was usually a sign posted on the door. CNA 6 stated that since this was the first day at the facility she was unsure of how they did things here.
06/16/21 07:55 AM, an interview was conducted with CNA 7. CNA 7 stated that she was a agency aide and was not aware that room [ROOM NUMBER] was on TBP. CNA 7 stated that she was informed of TBP by signs that were posted on a resident door or she would ask a nurse. CNA 7 stated that if there was not a sign posted on a resident door alerting her to the TBP then she was unaware of how she would be informed of this information. CNA 7 was observed to shrug her shoulders when asked how she would know if a room had TBP without a sign posted.
On 6/16/21 at 10:32 AM, an interview was conducted with the DON and CRN. The DON stated that resident 80 was admitted on [DATE] and contact precaution signs were placed on 6/15/21. The DON stated that the delay in implementing the TBP signs was a miscommunication between staff. The DON stated that the licensed nursing staff were responsible for placing signs and the PPE carts outside of the residents rooms when they were on TBP. The DON stated that resident 80 has had the shin wound since admission, but was made aware of the MRSA in the wound on 6/8/21. The DON stated that initially upon admission they were trying to determine if the MRSA infection was located in the residents blood or wound. The DON stated that the MRSA infection was communicated to staff verbally by her on 6/8/21 and for them to update their perspective communication sheets. The DON further stated that they communicated in morning meeting that there was an infection and that they were trying to clarify the location. The DON stated that she instructed staff in the morning meeting that there was an infection that it was in either the wound or blood, and if providing treatment or care to put on the necessary PPE (gloves, gowns and universal mask, and eye protection).
On 6/17/21 at 10:47 AM, an interview was conducted with laundry aide (LA) 1. LA 1 stated that the laundry from the isolation was usually bagged for transport and to identify that it needed to be handled and processed differently. LA 1 stated that if he went into a room to get laundry he would wear all the required PPE. LA 1 stated that he would know about the TBP and required PPE based on the signs on the door.
Based on observation, interview, and record review it was determined, for 1 of 23 sample residents, that the facility did not maintain an infection prevention and control program designed to provide a sanitary environment and to prevent the development and transmission of communicable diseases and infections, including SARS-CoV-2 (COVID-19). Specifically, staff did not utilize appropriate PPE when entering isolation rooms for 2 residents on contact and droplet precautions. Additionally, a resident on contact isolation precautions did not have the cautionary signs posted alerting staff and visitors of Transmission Based Precautions (TBP) and Personal Protective Equipment (PPE) was not located outside the resident's door. Resident identifiers: 80, 81, and 83.
Findings include:
1. Resident 81 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery, artificial right knee joint, insomnia, chondromalacia, hypertension, osteoarthritis of right and left knee, major depressive disorder single episode, hyperlipidemia, long term use of anticoagulants, and gastro-esophageal reflux disease.
On 6/14/21 at approximately 11:00 AM an observation was made of room [ROOM NUMBER]. Resident 81 was residing in room [ROOM NUMBER] on a new admission quarantine with contact/droplet isolation precautions. room [ROOM NUMBER] had signage posted on the door that stated new admit/quarantine 14 days leave your surgical mask in place, gown - washable, eye protection/face shield or goggles, gloves, door to remain closed - unless otherwise noted. room [ROOM NUMBER] had a start date of 6/4/21 with an end date of 6/24/21. A Personal Protective Equipment (PPE) cart was located outside of the door and contained washable gowns, gloves, and biohazard bags.
On 6/15/21 resident 81's medical records were reviewed.
Review of resident 81's physician orders revealed no order for quarantine with contact/droplet isolation precautions.
Review of resident 81's June 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of COVID-19 monitoring every shift for signs and symptoms (s/sx.) consistent with COVID-19.
Review of resident 81's progress notes revealed that monitoring for s/sx consistent with COVID-19 was not documented as conducted every shift. Additionally, the following progress notes documented an active infection. It should be noted that resident 81 did not have an active infection requiring isolation during the entire stay while at the facility.
a. On 6/6/21 at 3:40 PM, the note documented, Isolation is required for active infection with all services provided within room.
b. On 6/7/21 at 1:23 PM, the note documented, Isolation is required for active infection with all services provided within room.
c. On 6/8/21 at 10:56 PM, the note documented, Isolation is required for active infection with all services provided within room.
d. On 6/12/21 at 10:27 PM, the note documented, Isolation is required for active infection with all services provided within room.
e. On 6/15/21 at 1:11 AM, the note documented, Isolation is required for active infection with all services provided within room.
No lab results were found for a COVID-19 test that was ordered or obtained by the facility.
No documentation could be found of a COVID-19 immunization.
2. Resident 83 was admitted to the facility on [DATE] with diagnoses which consisted of fusion of spine lumbar region, stable burst fracture of the first lumbar vertebra, displaced fracture of the seventh cervical vertebra, major laceration of the liver, multiple fractures of the ribs, laceration of right lower leg, fracture of left pubis, familial hypophosphatemia, dislocation of Cervical (C)1/C2 vertebrae, pneumothorax, alcohol abuse, and acute posthemorrhagic anemia.
On 6/14/21 at approximately 11:00 AM an observation was made of room [ROOM NUMBER]. Resident 83 was residing in room [ROOM NUMBER] on a new admission quarantine with contact/droplet isolation precautions. room [ROOM NUMBER] had signage posted on the door that stated new admit/quarantine 14 days leave your surgical mask in place, gown - washable, eye protection/face shield or goggles, gloves, door to remain closed- unless otherwise noted. room [ROOM NUMBER] had a start date of 6/9/21 with an end date of 6/23/21. A Personal Protective Equipment Cart (PPE) was located outside of the door and contained washable gowns, gloves, and biohazard bags.
On 6/15/21 resident 83's medical records were reviewed.
Review of resident 83's physician orders revealed no order for quarantine with contact/droplet isolation precautions.
Review of resident 83's June 2021 MAR and TAR revealed no documentation of COVID-19 monitoring every shift for s/sx. consistent with COVID-19.
Review of resident 83's progress notes revealed that monitoring for s/sx consistent with COVID-19 was not documented as conducted every shift.
No lab results were found for a COVID-19 test that was ordered or obtained by the facility.
No documentation could be found of a COVID-19 immunization.
Review of the facility policy and procedures for COVID-19 documented under Infection Precautions that TBP were implemented when a resident develops signs and symptoms of a transmissible or communicable infection ('suspected case') or has tested positive for a communicable infection by a laboratory ('confirmed case'). Transmission-based precautions are additional measures taken to protect healthcare workers, other residents and visitors. Depending on how the infection is spread, one or more of the following precautions may be implemented:
Contact Precautions - Contact precautions are used when the infection can be spread by touching an infected person (direct contact), or by indirect contact with items that the infected person has touched.
- COVID-19 can be spread by touching an infected person or object and then touching one's own mouth, nose or eyes.
- Droplets infected with CoV-2 can land on surfaces and survive for unknown periods of time.
- Environmental cleaning, hand hygiene and the proper use of PPE are all important for contact precautions.
Droplet Precautions - Droplet precautions are implemented to control the spread of infections by droplets through short distances in the air. Droplets are large particles (greater than 5 microns) that can be inhaled when an infected person coughs, sneezes, or talks. Respiratory procedures like suctioning can also generate droplets.
- The COVID-19 coronavirus is primarily spread through droplets.
- Facemasks should be placed on anyone suspected or confirmed to have COVID-19.
- In addition, facemasks should be worn when coming within six feet of suspected or confirmed COVID-19 infected individuals in order to protect from respiratory droplets.
- Masks, gowns, gloves and goggles should be worn during procedures that expose healthcare personnel to splashes or sprays of secretions.
It should be noted that the facility policy and procedures did not address the process for implementing source control measures with new admissions. The guidance provided in the facility policy and procedures for COVID-19 was last updated on April 6, 2020.
On 6/14/21 at 11:09 AM, an observation was made of dietary aide (DA) 1 exiting room [ROOM NUMBER] quarantine/new admit room. No hand hygiene was observed upon exit of the room. DA 1 was observed to enter room [ROOM NUMBER] and exit immediately. An immediate interview was conducted with DA 1. DA 1 stated she was taking food orders from the residents for the following day meals. DA 1 stated that if a room was on precautions she would donn gloves. DA 1 stated that for room [ROOM NUMBER] the required PPE was just goggles and a mask. DA 1 stated that for room [ROOM NUMBER] she walked in, talked to the resident, and walked out. DA 1 stated that for new admissions on quarantine she just put on goggles, and the glasses she wore had sides so they were technically a goggle. Immediately following our interview DA 1 was observed to enter room [ROOM NUMBER]. DA 1 did not donn any additional PPE or perform hand hygiene prior to entering room [ROOM NUMBER]. DA 1 was observed to perform hand hygiene upon exit of room [ROOM NUMBER]. DA 1 was observed to wear a surgical mask and glasses only in room [ROOM NUMBER] and room [ROOM NUMBER].
On 6/14/21 at 2:08 PM, an observation was made of Certified Nurse Assistant (CNA) 5. CNA 5 was observed to enter room [ROOM NUMBER], picked up the lunch meal tray from the bedside table, and removed it. CNA 5 did not donn any additional PPE and was observed to wear a surgical mask only. The meal tray was not bagged for transport.
On 6/14/21 at 2:12 PM, an interview was conducted with CNA 5. CNA 5 stated that room [ROOM NUMBER]'s meal tray should be bagged in a biohazard bag for transport to the kitchen and the bags were located in the PPE cart outside the resident room. CNA 5 stated, I forgot to bag it. CNA 5 stated just to enter the room we don't have to gown. CNA 5 stated that if the sign on the resident door stated additional PPE was required then he would donn it. CNA 5 stated I didn't look [at the sign] because the door was open.
On 6/16/21 at 7:53 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the nurse on shift would do the admission paper work and determine the resident's COVID-19 vaccination status. LPN 2 stated that if the resident did not have the vaccine they would be quarantined on contact/droplet precautions for 14 days. LPN 2 stated that they would place a sign on the door alerting the type of TBP and a PPE cart would be placed outside the resident door. LPN 2 stated that the floor sheet would show the COVID vaccine status for each resident. LPN 2 stated that the nurse brains would say quarantine 14 days due to new admit, no COVID vaccine. LPN 2 stated that if a resident was on quarantine for new admission with contact/droplet precautions the PPE worn would be a N95 mask, goggles, gloves and a gown. LPN 2 stated that they conduct COVID-19 monitoring every shift for every resident and they assess for cough, shortness of breath, nausea and vomiting, fever, and changes in oxygen saturation. LPN 2 stated that this was documented in the progress notes.
On 6/16/21 at 10:03 AM, a follow-up interview was conducted with DA 1. DA 1 stated that meal trays from the quarantine or vaccine precaution rooms were placed in a biohazard bag and kept separate from the meal cart. DA 1 stated that those trays were processed separately form the rest of the dishes.
On 6/16/21 at 10:32 AM, an interview was conducted with the Director of Nursing (DON) and Corporate Resource Nurse (CRN). The DON stated that new admissions were quarantined for 14 days on contact/droplet precautions. The DON stated that signs on the resident door stated PPE was required for any close contact for greater than 15 minutes and while providing cares. If we are just dropping off trays then we don't need full PPE. Meal trays that go out of quarantine rooms should be placed in a biohazard bag so kitchen staff can identify that they are from those rooms. The DON stated that it was addressed that the meal tray was taken to the kitchen without being bagged and they were aware of it.
On 6/17/21 at 11:18 AM, an observation was made of CNA 7. CNA 7 was observed entering room [ROOM NUMBER] wearing only a surgical mask, no other PPE was observed donned. CNA 7 exited room [ROOM NUMBER] and performed hand hygiene. An immediate interview was conducted with CNA 7. CNA 7 stated that she did not wear a gown or gloves in room [ROOM NUMBER], because she just went in to say hi.
On 6/17/21 at 11:50 AM, a follow-up interview was conducted with CNA 7. CNA 7 stated she should wear a mask, gown, goggles, and gloves when entering room [ROOM NUMBER]. But was told by the other nurse lady, not sure who, that I didn't have to wear all that if I wasn't giving patient cares.
Review of the Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes stated under New Admissions and Residents who Leave the Facility that In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance for recommended PPE use when caring for resident in quarantine referred back to, and was described in, the section Manage Residents who have had Close Contact with Someone with SARS-CoV-2 Infection. The PPE guidance further stated, HCP (healthcare personnel) should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically...
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Based on observation and interview it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically, dry food was outdated in the dry food storage room and still being given to residents. Resident identifiers: All.
Findings include:
1. On 6/14/21 at 8:30 AM, an initial tour of the facility kitchen was conducted. The following was observed:
a.
A package of frozen vegetables was open and exposed to air, no expiration date was on the package.
b.
A Blendtec mixer bottle was uncovered in the freezer with frozen fruit in the bottom of the blender, it was not labeled or dated.
c.
A box of single use soy sauce packets with an expiration date of 2/24/21 was located in the dry storage.
d.
Six individual serve boxes of Cheerios with an expiration date of 4/28/21 was in the kitchen and 38 individual serve boxes of Cheerios with an expiration date of 4/28/21 was located in the dry storage room.
e.
A metal container full of sugar free assorted jams with an expiration date of 8/29/20 was in the kitchen and a box of single use sugar free assorted jams with an expiration date of 8/29/20 was in the dry storage room.
f.
A half empty bottle of peanut butter with an expiration date of 5/29/19 was on a shelf in the kitchen and 4 bottles of peanut butter with an expiration date of 5/29/19 was in the dry storage room.
g.
Two coconut pecan frosting containers with an expiration date of 5/1/2020 was in the dry storage room.
h.
An opened, undated bottle of Med pass 2.0 Butter Pecan nutritional shake was found in the small fridge with no open or use by date.
On 6/14/21 at 8:45 AM, an interview was conducted with the dietary cook (DC). The DC stated the fruit in the mixer was for a resident and could be discarded. The DC stated the peanut butter and jam were given to the residents almost daily.
On 6/14/21 at 8:45 AM, an observation was made of the DC removing the mixer containing frozen fruit from the freezer and setting it on the counter.
On 6/14/21 at 11:43 AM, an interview was conducted with the Dietary Manager (DM). The DM stated there was no need to put an expiration date on freezer items because the freezing stops everything from growing. The DM stated that the staff just know that items expired after they were removed from the freezer. We only keep something for at most a week after it's open. The DM stated there was not an itemized list of when things were pulled and when they expired, so no there isn't a way employees would know the exact expiration date. The DM stated she does not know why expiration dates were an issue, we go through things so fast here.
On 6/14/21 at 12:05 PM, an observation was made of the expired peanut butter and expired sugar free jams being used in the kitchen.
On 6/14/21 at 12:55 PM, a follow-up interview was conducted with the DM. The DM stated that they placed the date on an item when an item was recieved. The DM stated that they go through food items so fast, that there was not a need to put the expiration date on the item also.
On 6/14/21 at 1:50 PM, an interview was conducted with Dietary Aide (DA) 1. The DA 1 stated if something was opened in the small fridge it was the nurse's stuff, and they watch it. The DA 1 stated that dietary would place food items in there but do not watch when it was opened. DA 1 stated the sugar free jams in the kitchen were used for the residents and was unsure who was responsible for checking the expiration dates.
On 6/14/21 at 2:00 PM, an interview was conducted with registered nurse (RN) 1. The RN 1 stated when a drink or food was opened in the small fridge that they needed to use for med pass, they were supposed to date it if it was a multi-use bottle. If it was applesauce or something like that we just throw it away.
On 6/14/21 at 2:40 PM, an observation was made of the peanut butter removed from the kitchen. The expired sugar free assorted jams were observed still available for use in the kitchen.
On 6/15/21 at 11:50 AM, an interview was conducted with the DC. The DC stated things were only left in the kitchen for 4 days at the most before they were used. The DC stated that she did not know about the expiration dates of food items. We just know they are ok if they are in the kitchen.
On 6/16/21 at 7:35 AM, an observation was made of the expired sugar free syrup, soy sauce, cheerios, and frosting still available for use in the downstairs pantry. The Peanut butter was observed removed.
On 6/16/21 at 7:40 AM, an observation was made of the expired sugar free individual packets being used in kitchen.
On 6/17/21 at 9:30 AM, an observation was made of the expired sugar free individual packets available for use in the downstairs pantry with the expiration date of 8/29/2020.
On 6/17/21 at 10:55 AM, a follow-up interview was conducted with the DC. The DC stated the food was rotated and they used what comes first. The DC stated that the snacks and foods from the pantry were used so fast, and the snacks were consumed usually within 5 days. The DC stated they did not check the expiration dates when they bring an item up from the pantry.
On 6/17/21 at 11:56 AM, a follow-up interview was conducted with the DM. The DM stated there was no process for determining when something expired first. It was a first in first out method with the food in the pantry. We go through food really fast here, like weekly and my staff is really good. The DM stated staff just get food from the pantry, they did not check the expiration dates.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (85/100). Above average facility, better than most options in Utah.
- • No fines on record. Clean compliance history, better than most Utah facilities.
- • 39% turnover. Below Utah's 48% average. Good staff retention means consistent care.
Concerns
- • 8 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Stonehenge Of South Jordan's CMS Rating?
CMS assigns Stonehenge of South Jordan an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Utah, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Stonehenge Of South Jordan Staffed?
CMS rates Stonehenge of South Jordan's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 39%, compared to the Utah average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Stonehenge Of South Jordan?
State health inspectors documented 8 deficiencies at Stonehenge of South Jordan during 2021 to 2024. These included: 1 that caused actual resident harm and 7 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Stonehenge Of South Jordan?
Stonehenge of South Jordan is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by STONEHENGE OF UTAH, a chain that manages multiple nursing homes. With 32 certified beds and approximately 24 residents (about 75% occupancy), it is a smaller facility located in South Jordan, Utah.
How Does Stonehenge Of South Jordan Compare to Other Utah Nursing Homes?
Compared to the 100 nursing homes in Utah, Stonehenge of South Jordan's overall rating (5 stars) is above the state average of 3.4, staff turnover (39%) is near the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.
What Should Families Ask When Visiting Stonehenge Of South Jordan?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Stonehenge Of South Jordan Safe?
Based on CMS inspection data, Stonehenge of South Jordan has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Utah. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Stonehenge Of South Jordan Stick Around?
Stonehenge of South Jordan has a staff turnover rate of 39%, which is about average for Utah nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Stonehenge Of South Jordan Ever Fined?
Stonehenge of South Jordan has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Stonehenge Of South Jordan on Any Federal Watch List?
Stonehenge of South Jordan is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.