George E. Wahlen Ogden Veterans Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. A care plan focus area initiated 9/9/24 documented resident 7 had altered respiratory status and required supplemental oxygen to maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident 119 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, Parkinson's disease with dyskinesia, acute kidney failure, dysphagia, muscle weakness, muscle wasting and atrophy, and traumatic subdural hemorrhage without loss of consciousness. Resident 119's medical record was reviewed 7/29/24 through 8/7/24. An admission Minimum Data Set (MDS) dated [DATE] revealed that resident 119 had short and long term memory problems.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Resident 78 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to occlusion or stenosis of small artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, dementia, stable burst fracture of second lumbar vertebra, and spinal stenosis. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 7/29/24 at 8:05 AM, an observation was made of the nursing staff posting which was located inside the facility entry area across from the reception desk. There were 2 days of postings observed: One of the postings was dated 7/14/24, the other was dated 7/15/24, with the 5 being difficult to read legibly. On 8/7/24 at 8:15 AM, an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: On 7/31/24 at approximately 8:25 AM, an interview was conducted with resident 24. Resident 24 was being administered his morning medication by Licensed Practical Nurse (LPN) 2. Resident 24 stated that he had just finished breakfast and it was his favorite, biscuits and gravy. LPN 2 was observed to administer all morning medications to the resident 24 which included Digoxin tablet 125 micrograms (mcg) by mouth one time a day for atrial fibrillation and Levothyroxine tablet 75 mcg by mouth one time a day for hypothyroidism. Resident 24's physician's orders were reviewed and revealed no supplemental information or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, anxiety disorder, chronic kidney disease, major depressive disorder and osseous stenosis ofneural canal ofcervical region. Resident 50's medical record was reviewed 7/29/24 through 8/7/24. Resident 50's physician's orders revealed the following orders: a. On 5/23/24 Methadone HCl (hydrochloride) Oral Tablet 10 MG (milligrams) (Methadone HCl). Give 30 mg by mouth two times a day related to vertebrogenic low back pain; other chronic pain; Watch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: 1. On 7/31/24 at 7:36 AM, an observation was made of the 200 hallway. Registered Nurse (RN) 6 was observed with a medication cart. RN 6 was observed to unlock her medication cart and walk away from the cart leaving it unattended. RN 6 was interviewed and stated she could not believe she left the cart unlocked and unattended. 2. On 7/31/24 at 9:19 AM, an observation was made of the 200 hallway medication cart. There was a Basaglar kwikpen with an open date of 6/29/24 that was available for use and was labeled for resident 60. Licensed Practical Nurse (LPN) 3 was interviewed and stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: On 7/29/24 at 9:14 AM, an interview was conducted with the DM who stated she was in the middle of getting her certification to serve as the DM. The DM stated she had been doing the job as a DM for 10 years, and had been employed at the facility for 2 years. The DM stated another full time kitchen employee ([NAME]) had completed the certification for DM, but was not working in that role. On 8/7/24 at 11:04 AM, a follow-up interview was conducted with the DM who stated it was her understanding that having 2 years of experience as the DM met the requirement to serve as the DM. The DM stated she was taking the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 7/29/24 at 9:14 AM, an initial kitchen tour was conducted. In the walk-in freezer a box of peanut butter cookie dough was open to air, a box with egg patties was open to air, a box containing corn on the cob was open to air, a box containing breaded chicken was open to air, and a box containing corn dogs was open to air. On 8/7/24 at 11:04 AM, a follow-up kitchen tour was conducted. In the walk-in refrigerator, a bag of parmesan cheese was open to air. In the walk-in freezer a box of peanut butter cookie dough was open to air, a box with sausage links was open to air, a box with frozen cut corn was open to air, a box with frozen peas was open to air, a box with chicken fried beef patties was open to air, and a box containing corn dogs was open to air. On 8/7/24 at 11:18 AM, an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.