George E. Wahlen Ogden Veterans Home

In the surveyor’s words

From the most serious findings on record at George E. Wahlen Ogden Veterans Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 28, 2025

  Based 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. Findings included: NOTICE On 2/26/25 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. […]

• Immediate jeopardy, isolatedF609Feb 28, 2025

  Based 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. Findings included: NOTICE On 2/26/25 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. […]

• Actual harm, isolatedF684Aug 7, 2024

  Based 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. […]

• No harm, potential for more than minimal, isolatedF695Feb 28, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF689Aug 7, 2024

  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. […]