Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonehenge Of Ogden during CMS and state inspections, most recent first.
Food handling and hand hygiene lapses occurred during lunch prep when the DM and other staff touched cart handles, refrigerator doors, packing boxes, saran wrap, meal tickets, and other surfaces with gloved hands, then returned to preparing food without changing gloves or washing hands. Staff also handled fruit, sandwiches, cold plates, and cottage cheese while continuing meal service, and a delivery driver entered the prep area and showed an invoice over the food prep space.
Two residents receiving antidepressants did not have documented GDR attempts in separate quarters, and no clinical contraindications were found in the record. One resident was on Auvelity for major depressive disorder, and another was on paroxetine for depression, GAD, and insomnia; the DON stated psychotropic reviews occurred, but the chart lacked evidence of GDR attempts or contraindication documentation.
A resident with bladder incontinence used a PureWick external urinary catheter at night, but the facility had no physician order for the device and no documentation for its care, treatment, or monitoring. The resident said staff were supposed to be taught how to use it and sometimes did not connect it to suction. An RN and the DON confirmed staff had not been trained on the device, and a CNA said she learned removal from another CNA and was not instructed on safe application.
The facility failed to ensure proper respiratory care for residents, as oxygen tubing and nasal cannulas were not dated, and physician orders for oxygen therapy were missing for some residents. Observations and interviews revealed that residents using nocturnal oxygen were unsure about the frequency of cannula changes, and staff did not consistently follow protocols for documenting and obtaining necessary orders.
The facility failed to adhere to food safety standards as the Maintenance Director entered the kitchen without a hair net, and the dining room refrigerator contained spoiled, undated, and unlabeled food. Observations included moldy produce and sticky spills. Interviews revealed confusion over cleaning responsibilities between the dietary and housekeeping departments.
Two residents with severely impaired cognition were involved in a relationship without a formal assessment of their capacity to consent. Despite exhibiting delusional behavior, the facility's staff allowed the relationship to continue based on informal interviews, without consulting a physician or conducting cognitive assessments. This oversight led to a failure to protect the residents from potential abuse or neglect.
A facility failed to implement policies to prevent abuse and exploitation, as evidenced by an incident involving two cognitively impaired residents found in bed together. Despite their impaired cognition, no formal assessment was conducted to determine their ability to consent to a relationship. Staff documented several interactions between the residents, including instances of undress, but failed to conduct a thorough investigation or notify the medical director. The lack of formal procedures and awareness among staff contributed to the deficiency.
Food Handling and Hand Hygiene Lapses During Meal Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During lunch meal service, the Dietary Manager washed hands and donned gloves, then handled a fruit container, moved and repositioned a rolling cart, touched the cart handle, and continued touching and cutting fruit with the same gloves. During sandwich preparation, staff repeatedly handled refrigerator doors, cold plates, original packing boxes, saran wrap, meal tickets, and other surfaces with gloved hands and returned to food preparation without changing gloves or performing hand hygiene after those contacts. A delivery driver also entered the kitchen and showed an invoice over the food prep area while food preparation was underway. The observations continued as staff obtained cottage cheese from the refrigerator, served a portion, and then resumed sandwich preparation without changing gloves. The Dietary Manager later stated that hand hygiene should be performed when changing tasks or starting the day, before touching food items, and after touching other surface areas that may contaminate food. The Dietary Manager also stated that staff should wash hands and don new gloves if they walked away from the food preparation area and returned, and that delivery staff should stand at the red line and not enter the food preparation area.
Failure to Document GDRs for Psychotropic Medications
Penalty
Summary
The facility did not ensure that two residents receiving psychotropic medications had gradual dose reductions (GDRs) attempted in separate quarters, and no clinical contraindications were documented in the medical record. One resident with diagnoses including major depressive disorder and insomnia received Auvelity, an antidepressant, with orders beginning in May 2025 and continuing through December 2025, then again in January 2026. The psychotropic drug review documented the medication was initiated in May 2025, noted 11 episodes of verbalization of sadness, and recommended no changes, but there was no documentation that a GDR was attempted or that a clinical contraindication existed before the survey inquiry. A second resident with diagnoses including depression, generalized anxiety disorder, and insomnia due to other mental disorders received paroxetine, an antidepressant, with orders from March 2025 through February 2026, including a dose change from 30 mg to 20 mg. The record showed the resident did not receive a GDR in two separate quarters with at least one month between attempts, unless clinically contraindicated. During interviews, the DON stated the psychotropic team reviewed residents monthly or quarterly and that medication dose reduction decisions were discussed with the team and provider, but the record did not contain documentation of attempted GDRs or clinical contraindications for either resident.
PureWick Device Used Without Orders or Staff Training
Penalty
Summary
The facility did not ensure appropriate care for a resident who was incontinent of bladder and using a PureWick external urinary catheter device. The resident was admitted with diagnoses including fracture around the internal prosthetic right hip joint, muscle weakness, abnormality of gait and mobility, congestive heart failure, lymphedema, and muscle wasting and atrophy. During interview, the resident stated she wore the PureWick at night and that staff were supposed to be taught how to use it, but sometimes the device was not plugged into suction after placement. Record review showed no physician orders for the PureWick device and no documentation on the Medication Administration Record or Treatment Administration Record for its care, treatment, or monitoring. Nursing documentation noted the resident was using the PureWick while in bed and later documented that she wore it at night, but there were no corresponding orders. A CNA stated staff removed the device in the morning, discarded the sponge, dumped and rinsed the canister, and reused it at night, and that she had only been shown how to remove it by another CNA with no facility education on care or treatment. The RN and DON both stated there were no orders or monitoring documentation for the device, and the DON confirmed staff had not been provided training on the PureWick.
Deficiency in Respiratory Care Documentation and Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents who required it, as evidenced by the lack of proper documentation and physician orders for oxygen therapy. Specifically, for four residents, the facility did not date the change of oxygen tubing and nasal cannulas, nor did it ensure there was a physician order for the use of oxygen for two residents. Resident 7, who was admitted with multiple diagnoses including dyspnea and major depressive disorder, reported using nocturnal oxygen but had never seen her cannulas changed. Observations confirmed that the nasal cannulas on both the concentrator and portable oxygen were not dated, and there was no order for oxygen therapy in her medical record. Similarly, Resident 8, with diagnoses including asthma and chronic kidney disease, also used nocturnal oxygen but was unsure about the frequency of cannula changes. Observations showed no dates on her oxygen cannula or tubing, and her medical record lacked an order for oxygen therapy. Residents 19 and 20, both with chronic respiratory conditions, also had undated oxygen cannulas and tubing. Interviews with staff, including an LPN and the DON, revealed that cannulas were supposed to be changed weekly and dated, but this was not consistently done. Additionally, the DON stated that a physician's order was required for oxygen use, but this protocol was not followed for the affected residents.
Food Safety Violations in Kitchen and Refrigerator
Penalty
Summary
The facility was found to be non-compliant with professional standards for food service safety. An observation on June 24, 2024, revealed that the Maintenance Director entered the kitchen area without wearing a hair net, which is a violation of food safety protocols. The Maintenance Director was seen checking lights and sprinkler heads on the kitchen ceiling and using a ladder, but at no point did he wear a hair net, which is required to prevent contamination in food preparation areas. Additionally, the refrigerator in the dining room was found to contain spoiled, undated, and unlabeled food items. Observations included an open bag of grapes, a styrofoam container of leftovers, an open bag of chips, and several open plastic containers of soda, all without dates or labels. A moldy onion was also found leaking liquid onto the refrigerator surface. Interviews with the housekeeper and dietary manager revealed confusion over the responsibility for cleaning the refrigerator, with both departments believing it was used by residents and employees and that cleaning duties were shared.
Failure to Assess Capacity for Consent in Resident Relationship
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 13 and Resident 151, were free from abuse, neglect, and misappropriation of property. Both residents were involved in a relationship that had not been evaluated for their capacity to consent. Resident 151, who had a BIMS score indicating severely impaired cognition, was noted to have delusions and paranoia, and his care plan included approaches to manage these symptoms. Despite these cognitive impairments, Resident 151 was found in situations suggesting a close relationship with Resident 13, who also had a BIMS score indicating severely impaired cognition and a history of delusions and hallucinations. The facility's social service worker (SSW) and Director of Nursing (DON) were aware of the relationship between the two residents but did not conduct a formal assessment to determine their capacity to consent. The SSW and DON interviewed the residents and concluded that they were satisfied with the residents' understanding of consent, despite both residents exhibiting confusion and delusional behavior. The SSW noted that Resident 151's daughter was in the process of gaining guardianship due to his poor decision-making, yet the facility allowed the relationship to continue without consulting a physician or conducting a cognitive assessment. Interviews with staff revealed a lack of awareness and formal policy regarding resident relationships. The DON admitted that no cognitive assessments were performed, and the decision to allow the relationship was based on informal interviews. The facility did not notify the medical director or conduct an interdisciplinary team meeting to discuss the residents' capacity to consent. This oversight resulted in a failure to protect the residents from potential abuse or neglect, as their cognitive impairments were not adequately considered in the decision-making process.
Failure to Implement Policies to Prevent Resident Exploitation
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as to investigate such allegations. This deficiency was highlighted by an incident involving two residents, identified as Resident 13 and Resident 151, who were found in bed together. Both residents had severely impaired cognition, with Brief Interview of Mental Status (BIMS) scores indicating severe cognitive impairment. Despite this, no formal assessment was conducted to determine their ability to consent to a relationship, and the facility did not have a policy regarding resident relationships. Resident 151, who had a history of vascular dementia and other medical conditions, was noted to have paranoid thoughts and delusions. His care plan included approaches to avoid power struggles and not to medicate him if his delusions were not distressing or harmful. On several occasions, staff documented interactions between Resident 151 and Resident 13, including instances where they were found in a state of undress. Despite these observations, the facility did not conduct a thorough investigation or notify the medical director to assess the residents' capacity to consent. Resident 13, who also had a history of cognitive impairment and other medical issues, was similarly involved in the relationship with Resident 151. Her care plan addressed her delusions and hallucinations, with interventions to ensure her safety. However, the facility's response to the relationship between the two residents was inadequate, as no formal cognitive assessments were conducted, and the physician was not notified. Interviews with staff revealed a lack of awareness and formal procedures to address such situations, contributing to the deficiency in preventing potential abuse or exploitation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Washington Terrace
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Ogden Health And Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| The Terrace Transitional | 1 mi | ★★★★★ | 0 | 0 |
| Crestwood Rehabilitation And Nursing | 1.5 mi | ★★★★★ | 23 | 0 |
| South Ogden Post-acute (cascades At South Ogden) | 1.7 mi | ★★★★★ | 0 | 0 |
| Harrison Pointe Healthcare And Rehabilitation | 1.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.