George E. Wahlen Ogden Veterans Home

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility did not ensure each resident was free from abuse. Specifically, a resident's husband tried to shove a spoon with medication into another resident's mouth. In another incident the same resident's husband shoved her and removed her clothing to change her clothes. There were no interventions to prevent the resident from further abuse. The findings for resident 1 were determined to have resulted in immediate jeopardy. Resident identifiers: 1 and 2.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility did not ensure all alleged violations involving abuse were reported immediately to the State Survey Agency. Specifically, it was not reported to the State Survey Agency when a resident's husband tried to shove a spoon with medication into her mouth. The findings for resident 1 were determined to have resulted in immediate jeopardy. Resident identifiers: 1 and 2.

Inspectors wroteBased on observation, interview or record review it was determined, for 2 of 9 sampled residents, 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, residents on oxygen were using empty oxygen tanks. Resident identifier: 7 and 8. Findings Included: 1. Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic systolic congestive heart failure. On 2/25/25 at 1:32 PM, an observation was made of resident 7's portable oxygen tank while in use. The oxygen tank indicator was observed in the red refill area. Resident 7's medical records were reviewed on 2/25/25. [...]

Inspectors wroteBased on observation, interview and record review, for 2 of 38 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choice. Specifically, a resident was administered medications by the nurse after he was unable to put them in his own mouth and was experiencing confusion, having difficulty staying awake, had gurgling sounds when breathing, and difficulty keeping oxygen saturation above 90 percent. No monitoring was documented for his change in condition. The resident was discharged to the hospital with an overdose. In addition, a resident was experiencing low oxygen levels in the evening and was not monitored throughout the night to ensure it was above 90 percent after the resident was provided increased oxygen. Resident identifiers: [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 38 sampled residents, the facility did not ensure each resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident rolled out of a high bed and hit his head on a feeding tube pump. In addition, a family member noticed the change in condition and transported the resident to the hospital. Resident identifier: 119.

Inspectors wroteBased on interview and record review it was determined, for 2 of 38 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident was unable to provide verbal pain scores. The resident sustained a fall and an x-ray was not obtained for 15 days with revealed the resident sustained an L2 fracture. In addition, another resident had pain medication that was documented as ineffective and there was no follow-up. Resident identifiers: 77 and 78.

Inspectors wroteBased on observation and interview, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: The facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses, Certified Nurses Aides, and the resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that the medication error rates was not 5 percent or greater. Observations of 35 opportunities revealed 2 medication errors which resulted in a 5.71 percent medication error rate. Specifically, a resident was administered thyroid medication not on an empty stomach and an apical pulse was not obtained prior to administering Digoxin. Resident identifier: 24.

Inspectors wroteBased on interview and record review it was determined, for 2 of 38 sampled resident, that the facility did not ensure each resident was free of any significant medication errors. Specifically a resident was administered pain medication and anti-anxiety medications not according to physician's orders. In addition, another resident had a blood thinner held longer than 7 days. Resident identifiers: 50 and 119.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, a medication cart was left unlocked and unattended. In addition, medication was available for use past the expiration date. Resident identifiers: 60.

Inspectors wroteBased on interview, the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were open to air.