Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Ogden, Llc during CMS and state inspections, most recent first.
Missed Ordered Dilantin Blood Level: A resident with dementia and a seizure disorder had a low Dilantin level, and the PCP ordered a repeat level to be drawn in one month. The EHR lacked documentation that the repeat lab was completed, no lab order was found to direct staff, and staff review of the resident lab calendar confirmed the ordered Dilantin blood draw was missed.
Failure to continue neuro checks after an unwitnessed fall. A resident with schizophrenia, seizure disorder, intellectual disability, and severe cognitive impairment had an unwitnessed fall, and staff documented that they could not complete full neurochecks because the resident was combative. Although later nursing notes were entered, the EHR lacked documentation of neuro checks at the required timed intervals, and the DON and RN acknowledged the checks were not continued as required.
Two residents with no cognitive impairment and complex medical and psychiatric histories were subjected to disrespectful and inappropriate language by staff, including the use of profanity and a stern tone during care interactions. Staff admitted to using expletives and harsh language in response to resident behaviors, which was overheard by other staff and acknowledged by the DON as a recurring issue. These actions did not align with facility policy requiring respectful communication and the promotion of resident dignity.
Dirty dishes from the prior meal remained in the dining room until after breakfast had started, and a resident’s room had a strong urine odor, soiled pads on the floor, dirty and stained doors, and chipped paint on baseboards and trim. The resident had cognitive intact status, used a walker and WC, required toileting hygiene assistance, and frequently declined help with peri care; staff said she would only allow one specific staff member to clean her room, and the Admin said there was no policy for maintaining a homelike environment.
A resident with intact cognition and diagnoses including HF, HTN, HLD, and edema had orders for Bumetanide, daily weights, PCP notification parameters, and ted hose for edema. However, the care plan lacked a focus area, goals, and interventions for edema and diuretic use, and the MDS coordinator acknowledged the omission.
Restorative program documentation, staff education, and nursing assessment were incomplete for two residents. One resident with severe cognitive impairment and dependence for several ADLs had care plan interventions for ROM and ambulation, but the POC repeatedly showed NA and the most recent restorative summary was months old. Another resident with intact cognition and multiple psychiatric diagnoses had care plan interventions for ambulation, dressing/grooming, and transfer practice, but the POC also repeatedly showed NA. Staff reported limited time, unclear training on restorative techniques, and that the restorative summary had not been updated recently.
Delayed Skin Treatment and Incomplete Skin Care for a Resident With Buttock Wound. A resident on hospice with limited mobility, incontinence, and an indwelling catheter developed an abrasion on the coccyx/buttock area, but ordered topical treatment did not start until 2 days later. The record also showed a missed weekly skin assessment, the resident was observed sitting in a wheelchair for over 2 hours, and staff changed his brief without applying barrier cream while a red, open area was present.
Failure to check G-tube placement for two residents. An RN hooked up tube feeding for a resident with severe intellectual disability, encephalopathy, and a gastric feeding tube without checking placement, stating it would be traumatic to the resident. Another resident with intact cognition and multiple psychiatric diagnoses also had no documentation of G-tube placement checks. The DON acknowledged placement was not being checked for these two residents and stated the facility did not have a feeding tube policy.
Failure to use EBP during resident care and transfers. A resident with a urinary catheter was transferred by a CNA who handled the catheter tubing with ungloved hands, attached it to her scrub pants, placed the bag on the floor, and left without washing hands before using sanitizer. Another resident with a gastrostomy tube received feeding care from an RN and CNA without EBP, despite the care plan documenting EBP in place.
The facility failed to keep the kitchen free of flies, as observed when the kitchen door was left open, allowing flies to enter. The Dietary Manager acknowledged the issue, noting that the door leading outside is frequently used. Flies were seen landing on food and utensils during meal service. Despite the facility's pest control policy, the kitchen had not been treated for flies.
Staff failed to maintain sanitary conditions during meal service, risking contamination. Staff C did not perform hand hygiene after cleaning a spill and used the same gloves to handle food. Staff B touched a butter container and bread with the same gloves. The facility's policy requires changing gloves and washing hands after contamination.
A facility failed to complete a comprehensive assessment for a resident within the required three-month interval. The last MDS assessment was completed in June, and the next was due in September but was not completed by late October. The MDS coordinator acknowledged the overdue assessment without providing a rationale.
The facility failed to update care plans for two residents on diuretic medication and one resident on hospice care. A resident with diabetes and renal failure and another with heart failure and diabetes were on diuretics, but their care plans lacked updates for medication and monitoring. Additionally, a resident with diabetes and a stroke was placed on hospice, but their care plan did not reflect this change. Interviews indicated an expectation for care plans to include these updates, but no specific policy was in place.
A resident on Coumadin did not receive timely follow-up lab work as ordered by the PCP, resulting in multiple delays in PT and INR testing. Despite having a system in place for tracking lab orders, the facility failed to conduct the tests on the specified dates, and there was no documentation of notifying the PCP about these delays.
A resident experienced a significant 10-pound weight loss over 10 days, which was not reported to the physician. The resident's weight dropped from 132.4 to 121.4 pounds, and an observation noted the resident did not eat lunch. The DON confirmed the physician was not notified.
Missed Ordered Dilantin Blood Level
Penalty
Summary
The facility failed to obtain a Dilantin blood level as ordered by the medical provider for one resident with dementia and a seizure disorder. The resident’s MDS assessment indicated severe cognitive impairment and inability to complete a Brief Interview for Mental Status. The April 2026 MAR showed an order for Dilantin 100 mg twice daily, and lab results from 11/12/25 showed the resident’s Dilantin level was low at 4.7 mcg/mL, below the therapeutic range of 10-20 mcg/mL. After the PCP reviewed the low level, a repeat Dilantin level was ordered to be drawn in one month, but the EHR did not contain documentation that the repeat blood draw was completed. No lab order was found in the EHR directing staff to complete the test, and no lab results were identified showing it was done. Staff interviews confirmed the order had been acknowledged and was supposed to be tracked on the resident lab calendar, but the December 2025 calendar did not show the repeat Dilantin lab, and the DON acknowledged the lab draw was missed and not drawn.
Failure to Continue Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to continue neurological assessments after an unwitnessed fall for a resident with schizophrenia, seizure disorder, intellectual disability, and severe cognitive impairment. The resident’s MDS noted the resident could not complete a Brief Interview for Mental Status and was unable to make daily decisions. The incident report documented the unwitnessed fall and noted staff were unable to complete neurochecks and could obtain only an eye assessment because the resident was combative. The EHR showed follow-up nursing notes after the fall, including assessments documented as within normal limits and notes that blood pressure could not always be obtained, but the record lacked documentation of completed or attempted neuro checks at the specific timed intervals required after the unwitnessed fall. The DON stated neuro checks are documented on paper and scanned into the EHR, but could not identify that they were initiated or completed for the resident after the fall. The RN who completed the initial assessment stated they attempted vitals and neurochecks but did not attempt any further neurochecks for the remainder of the shift and believed the resident was checked only one time after the fall.
Failure to Maintain Resident Dignity and Respect Due to Inappropriate Staff Language and Conduct
Penalty
Summary
The facility failed to treat two residents with dignity and respect, as evidenced by staff interactions and language used during care. One resident, with no cognitive impairment and a history of psychiatric diagnoses including depression, anxiety, and paranoid personality disorder, was involved in an incident where she became stuck in her wheelchair at a hallway threshold. After staff attempted to assist, the resident threw a urine-soaked pad at a CNA and used derogatory language. In response, the CNA told the resident to get her 'f***ing hands off me' after being pinched, and the resident scratched another staff member. The staff's use of profanity and the manner in which the situation was handled did not align with the facility's policy on promoting dignity and respect. Another resident, also cognitively intact and with multiple medical and psychiatric diagnoses, was subjected to inappropriate language from staff. An LPN overheard a CNA using profanity towards this resident through a baby monitor, stating 'f*** you too.' The LPN reported that this CNA frequently used inappropriate language in front of residents and had been previously addressed about this behavior. The CNA admitted to using stern language with this resident, stating she would not tolerate his 'BS,' though she denied using the full expletive. The Director of Nursing acknowledged awareness of the staff member's tendency to use inappropriate language and a stern tone, attributing it to staff stress and challenging resident behaviors. The facility's policy requires all staff to speak respectfully to residents and to promote and maintain resident dignity. The documented staff actions and language in these incidents were inconsistent with these expectations, resulting in a failure to honor residents' rights to dignity and respect.
Dirty Dining Area and Urine-Soiled Resident Room
Penalty
Summary
The facility failed to ensure a homelike environment for 1 of 13 residents reviewed. During an observation of the dining room and kitchen area on 9/3/25 at 6:30 AM, a multi-level cart containing dirty dishes from the previous day was found in the dining room area and was not moved back into the kitchen until 8:00 AM, after breakfast service had already begun and residents were eating. Resident #22, who had a BIMS score of 15 and diagnoses including heart failure, anxiety disorder, history of falling, paranoid personality disorder, insomnia, unspecified psychosis, and morbid obesity, used a walker and wheelchair and required toileting hygiene with set up and clean up assistance. Her care plan noted she required assistance with toileting and peri care, frequently declined assistance, and would throw soiled briefs on the floor. On 9/2/2025 at 11:41 AM, she was observed in a wheelchair in her room, which had a very heavy smell of urine, soiled absorbent pads on the floor next to the bed, dirty and stained bathroom and hallway doors, and chipped paint on many wood baseboards and trim areas. Staff interviews indicated the resident would only allow one particular staff person to clean her room, and the Administrator stated the facility did not have a policy related to maintaining a homelike environment.
Incomplete Care Plan for Edema and Diuretic Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident reviewed. Resident #41 had a BIMS score of 13, indicating intact cognition, and diagnoses that included medically complex conditions, heart failure, hypertension, hyperlipidemia, and edema. The resident also had a high-risk diuretic medication in the look-back period. The EHR showed orders for Bumetanide, including one order for 2 mg daily for edema and a prior order for 1 mg twice daily related to heart failure, along with a diagnosis of edema unspecified. The resident’s clinical orders also included daily weights, instructions to notify the PCP for weight gain of 3 pounds overnight or 5 pounds in one week, reporting of increased edema, dyspnea, weight, or decreased pulse oximeter, and ted hose to be applied in the morning and removed at bedtime for edema. Despite these orders and the edema diagnosis, the care plan initiated on 4/1/25 lacked a focus area, goals, and interventions for edema and the use of a diuretic. During interview, the MDS coordinator stated the diuretic medication and edema were expected to be included in the care plan and acknowledged they were not.
Restorative Program Documentation and Training Deficiencies
Penalty
Summary
The facility failed to complete required documentation, staff education, and nursing assessments for the Restorative Program for 2 of 2 residents reviewed. Resident #30 had severe cognitive impairment, was totally dependent for toileting hygiene and lower body dressing, and required partial assistance with sit-to-stand and transfers. The care plan included active ROM to the upper and lower extremities, Nu-step use, active ROM with a 1-pound dowel bar, and ambulation to meals, but the point-of-care record showed repeated entries of NA for ambulation and ROM activities over the look-back period. The most recent restorative summary in the nursing progress notes was dated months earlier and stated nursing would continue to monitor participation and adjust according to needs and requests. During observation, Resident #30 was seen sitting in a wheelchair at the dining room table, having difficulty sitting upright and leaning over the right arm of the chair. The resident slowly pushed the wheelchair toward the room and stated she could use some help. Staff A and Staff B stated they documented NA on the restorative POC when the resident was independent and staff did not need to help with exercises. Staff B also stated she was the primary restorative CNA but was frequently pulled to other CNA duties, had limited time to work with residents, and was not aware of specific training for CNA staff on how to safely provide the restorative services. Resident #2 had a BIMS score of 13 and diagnoses including anxiety disorder, depression, bipolar disorder, and schizophrenia. The resident was dependent for toileting, lower body dressing, and personal hygiene, and required maximum assistance with sit-to-stand and partial assistance with other transfers. The care plan included ambulation with assist of 1 and a walker, dressing/grooming participation, and transfer practice, but the POC record showed repeated NA documentation for ambulation, dressing/grooming, and transfer practice. The most recent restorative summary was also dated months earlier. Staff F stated restorative programs were developed by therapy and passed to the MDS Coordinator and restorative aide, that floor staff could do ambulation, and that the RNA was supposed to do ROM exercises; she also acknowledged that one day a week was not sufficient to maintain a resident's baseline and strength.
Delayed Skin Treatment and Incomplete Skin Care for a Resident With Buttock Wound
Penalty
Summary
The facility failed to adequately assess and intervene to prevent skin wounds for Resident #6, who was on hospice and had a history that included benign prostatic hyperplasia, repeated falls, dysphagia following cerebral infarction, protein calorie malnutrition, and urinary retention with an indwelling catheter. The resident’s MDS showed intact cognition with a BIMS score of 14, but he required total dependence for toileting hygiene and lower body dressing and substantial assistance with rolling, sitting, and toileting. His care plan identified a potential for changes in skin integrity related to decline in nutritional status, limited mobility, incontinence, and suprapubic catheter use. On 8/18/25, staff discovered an abrasion on the upper buttock/coccyx area, and the initial skin assessment documented a pink area without measurements. A faxed order on 8/18/25 directed staff to apply calmoseptine cream to the upper left buttock/coccyx three times daily and PRN, but the MAR/TAR showed treatment did not begin until 8/20/25. The record also showed a follow-up skin assessment on 8/25/25 documenting that the first layer of skin was off with a measured open area of 2.5 cm by 1.5 cm and pain with touching, while the chart lacked the weekly follow-up assessment due 9/01/25. On 9/03/25, the resident was observed sitting in his wheelchair for over 2 hours, repeatedly asking to go to bed, and later during personal care staff found a very red spot with a small open area on the left buttock; staff cleaned the area and applied a brief without applying barrier cream.
Failure to Check G-Tube Placement for Two Residents
Penalty
Summary
The facility failed to implement policies and procedures regarding the technical aspect of checking placement for gastrostomy tubes for 2 residents. Resident #33 had diagnoses including anxiety, psychotic disorder, severe intellectual disability, and encephalopathy, and the MDS documented that the resident received nutrition through a gastric feeding tube. During observation, an RN applied gloves, hooked up the tube feeding, and removed the gloves after completing hand hygiene, but did not check placement of the gastrostomy tube. The RN stated she was supposed to check placement but did not do so because she felt it would be traumatic to the resident. The resident record lacked information regarding checking placement of the g-tube. Resident #2’s MDS documented a BIMS score of 13, indicating intact cognition, and diagnoses of anxiety disorder, depression, bipolar disorder, and schizophrenia, with nutrition also provided through a gastric feeding tube. Review of the resident record lacked information regarding checking placement of the g-tube. The DON stated the expectation was to check placement for G-tubes and acknowledged that placement was being checked for another resident but not for Resident #2 and Resident #33. She also stated the facility did not have a policy regarding feeding tubes and that both residents had specialized gastrotomy tubes.
Failure to Use Enhanced Barrier Precautions During Care and Transfers
Penalty
Summary
The facility failed to implement adequate infection control practices for two residents with indwelling medical devices. Resident #6 had a BIMS score of 14, required extensive assistance with toileting and mobility, and had an indwelling urinary catheter; the care plan noted risks related to limited mobility, incontinence, nutritional decline, and suprapubic catheter use, but lacked specific instructions for Enhanced Barrier Precautions (EBP). During a transfer from a wheelchair to bed, a CNA handled the catheter tubing with ungloved hands, unhooked it from under the wheelchair, attached it to her scrub pants, assisted the resident into bed, placed the catheter bag in a tub on the floor, and left the room without washing her hands before using hand sanitizer in the hallway. The Infection Preventionist stated the staff member should have used EBP during the transfer and should not have hooked the catheter onto her person. Resident #33 had diagnoses including anxiety, psychotic disorder, severe intellectual disability, and encephalopathy, was rarely or never understood, and received nutrition through a gastrostomy tube. The care plan documented that EBP was in place, but when an RN and CNA hooked up the resident’s feeding, both staff members failed to apply EBP. The RN stated staff do not wear EBP because the resident will pull and grab at gowns and gloves, and the Corporate Nurse stated she would expect staff to apply EBP while providing care to a resident with a gastrostomy tube.
Failure to Maintain Kitchen Free of Flies
Penalty
Summary
The facility failed to maintain the kitchen and food preparation area free of insects, specifically flies. During an observation, it was noted that the door to the kitchen from the hallway, which had a sign indicating it should remain closed, was open, allowing flies to enter. The Dietary Manager acknowledged the presence of flies and mentioned that the door across from the kitchen door, which leads outside, is frequently used. Further observation revealed that the door to the outside was propped open while staff were unloading a truck, allowing flies to enter the kitchen. Flies were observed landing on plates, food, utensils, and dietary aides during meal service. The facility's pest control policy, dated 2021, stated that appropriate action would be taken to eliminate any reported pest situation, but the kitchen had not been treated for flies. The Dietary Manager expressed the expectation that flies should not be present in the kitchen or on food and service items.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
During a lunch service observation, staff at the facility failed to maintain sanitary conditions while serving food, which could increase the risk of contamination and foodborne illness. Staff C was observed spilling milk on the floor, cleaning it up with a paper towel while wearing gloves, and then failing to perform hand hygiene before continuing to fill glasses and place them on residents' trays. Additionally, Staff C used the same gloved hand to open a refrigerator door and handle a slice of cheese, which was then placed on a hamburger served to a resident. Staff B was also observed not following proper sanitary procedures. After washing her hands and applying gloves, she touched the outside of a butter container and then a slice of bread with the same gloved hand. The facility's policy on glove use, which aligns with the 2013 Food Code standards, requires that gloves be changed and hands washed after touching contaminated surfaces or when interruptions occur. The Dietary Manager confirmed the expectation that gloves should not touch other items before handling food.
Overdue Comprehensive Assessment for a Resident
Penalty
Summary
The facility failed to complete a comprehensive assessment for one resident within the required three-month interval. Specifically, the clinical record of a resident showed that the last Minimum Data Set (MDS) assessment was completed on June 14, 2024. The subsequent quarterly comprehensive assessment was due on September 14, 2024, but as of October 23, 2024, it had not been completed, making it over 25 days overdue. During an interview, the MDS coordinator acknowledged the overdue assessment and was unable to provide a rationale for the missed assessment.
Failure to Update Care Plans for Diuretic and Hospice Care
Penalty
Summary
The facility failed to revise and update the care plans for two residents on diuretic medication and one resident placed on hospice care. Resident #14, diagnosed with diabetes and renal failure, was receiving a diuretic medication, but their care plan, revised on 10/1/24, did not include updates for the diuretic medication and monitoring. Similarly, Resident #22, with heart failure and diabetes, was also on a diuretic, yet their care plan, revised on 8/9/24, lacked necessary updates for the medication and monitoring. Additionally, Resident #26, who had diabetes and a stroke, was placed on hospice services on 10/15/24, but their care plan, revised on 10/19/24, did not include updates for hospice care. Interviews with the MDS Coordinator and the Administrator revealed an expectation for care plans to include diuretic medication and hospice services, but the facility did not have a specific policy for updating care plans, relying instead on standard practice.
Failure to Timely Conduct Ordered Lab Work for Anticoagulant Monitoring
Penalty
Summary
The facility failed to obtain follow-up laboratory blood work for a resident using Coumadin, an anticoagulant, within the time frame ordered by the Primary Care Provider (PCP). The resident, who had intact cognition, was diagnosed with atrial fibrillation, heart failure, hypertension, and renal insufficiency. The initial lab work showed elevated Prothrombin Time (PT) and International Normalized Ratio (INR) levels, prompting the PCP to order follow-up tests. However, the facility did not complete these tests on the specified dates, and there was no documentation indicating that the PCP was notified of these delays. The Director of Nursing (DON) reported that routine labs are typically obtained on Wednesdays, but urgent PT and INR monitoring should follow the PCP's schedule. The facility's process involved hand-writing lab orders in a calendar accessible to all staff, with night shift staff responsible for preparing lab face sheets and noting upcoming draws on a nursing report sheet. Despite these procedures, the lab draws for the resident were delayed on multiple occasions, and the DON could not provide a rationale for the oversight. The lab calendar and PT/INR Tracking form both noted the correct draw dates, yet the tests were not conducted as ordered.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident. The resident, identified as Resident #86, experienced a 10-pound weight loss over a period of 10 days, which is considered significant as it exceeds a 7.5 percent loss. This weight loss was documented on the weights and vitals form, with the resident's weight recorded as 132.4 pounds on October 10 and 121.4 pounds on October 20. Despite this significant change, the physician was not informed, as confirmed by the Director of Nursing during an interview. Additionally, an observation on October 21 noted that the resident did not consume any of her lunch and left the dining room on her own.
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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 Ogden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastern Star Masonic Home | 6.3 mi | ★★★★★ | 4 | 0 |
| Westhaven Community | 6.7 mi | ★★★★★ | 0 | 0 |
| Perry Lutheran Homes Eden Acres Campus | 13.9 mi | ★★★★★ | 3 | 0 |
| Perry Lutheran Home | 14.2 mi | ★★★★★ | 6 | 0 |
| Aspire Of Perry | 14.3 mi | ★★★★★ | 15 | 0 |
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