Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 George E. Wahlen Ogden Veterans Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was subjected to abuse by her husband, who was also a resident. The husband attempted to force medication into another resident's mouth and forcibly removed his wife's clothing. The facility failed to implement interventions to prevent further abuse, and staff did not adequately document or report the incidents, contributing to the deficiency.
A facility failed to report an alleged abuse incident where a resident's husband attempted to force medication into her mouth, resulting in immediate jeopardy. The incident was not documented or communicated to the Administrator, who oversees abuse allegations. The residents involved had significant medical and cognitive conditions, and the facility acknowledged a breakdown in internal reporting processes.
Two residents requiring supplemental oxygen were found using nearly empty portable oxygen tanks, despite their medical conditions necessitating consistent oxygen supply. Facility staff, including the ADON, CNA, LPN, and DON, acknowledged procedures for checking and replacing tanks, but these were not consistently followed, resulting in the deficiency.
Two residents in a LTC facility did not receive care according to professional standards and their care plans. One resident was given medications despite being unable to self-administer and showing signs of overdose, leading to hospitalization. Another resident experienced low oxygen levels without proper monitoring. Staff interviews revealed inadequate documentation and understanding of protocols for changes in condition.
A resident with severe dementia and Parkinson's disease fell from a high bed, hitting his head on a feeding tube pump, due to inadequate supervision and failure to follow the care plan. The call light was not promptly answered, and the bed was not in the lowest position as required. The resident sustained injuries and was later diagnosed with a brain bleed at the hospital. Staff failed to notify the physician of the fall and the resident's declining condition in a timely manner.
The facility failed to provide adequate pain management for two residents. One resident with severe cognitive impairment experienced a fall and a delayed x-ray revealed a lumbar fracture. Despite complaints and non-verbal pain indicators, pain management interventions were not effectively implemented. Another resident under hospice care reported severe pain that was not effectively managed by prescribed medications, with documented instances of ineffective pain relief. Staff interviews revealed inconsistencies in pain assessment and management practices.
The facility did not post daily nurse staffing information as required. Observations showed outdated postings, with one date being illegible. The CNAC stated the night supervisor was responsible for updates, which varied daily based on staff schedules.
A facility exceeded the acceptable medication error rate with two errors out of 35 opportunities, resulting in a 5.71% error rate. A resident received Levothyroxine after breakfast instead of on an empty stomach, and Digoxin was administered without obtaining an apical pulse. Staff interviews revealed non-compliance with medication protocols, and the resident's care plan lacked documentation of medication preferences.
Two residents in a facility experienced significant medication errors. One resident received incorrect dosages of Methadone and Xanax, leading to increased pain and discomfort. Another resident had a blood thinner held for over a month due to a communication lapse, despite a 7-day hold order following a fall. Staff interviews revealed issues with medication administration protocols and communication.
A medication cart was left unlocked and unattended by an RN, and a Basaglar kwikpen labeled for a resident was found past its expiration date. The LPN acknowledged the oversight, and the Unit Manager confirmed that expired medications should be checked by nurses, with random audits by leadership.
The facility did not employ a full-time Registered Dietitian (RD) or a certified Dietary Manager (DM) to serve as the director of nutrition services. The DM was in the process of obtaining certification but had not completed it due to a medical concern. Another employee had completed the certification but was not working in that role. The RD conducted monthly audits and provided recommendations, but the facility lacked the required full-time qualified staff.
The facility failed to store food items in the walk-in freezer and refrigerator according to professional standards, with several items left open to air. The Dietary Manager acknowledged the issue, stating that items should be sealed and dated to prevent freezer burn or contamination. Daily checks were conducted by morning managers, and the Registered Dietitian performed monthly audits.
Failure to Protect Resident from Abuse by Spouse
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an immediate jeopardy situation. A resident's husband was involved in two incidents where he exhibited aggressive behavior towards his wife and another resident. In one incident, he attempted to force medication into another resident's mouth, and in another, he shoved his wife and forcibly removed her clothing to change her. These actions were not prevented by the facility, and no interventions were in place to protect the resident from further abuse. The resident involved in the incidents had severe cognitive impairment due to Alzheimer's disease and dementia, making her vulnerable to abuse. Despite her condition, the facility did not implement adequate measures to ensure her safety. The resident's husband, who was cognitively intact, had been her primary caregiver and was experiencing caregiver burnout, which contributed to his aggressive behavior. The facility staff were aware of the husband's frustration and the resident's resistance to care but failed to intervene appropriately. Interviews with staff revealed that the incidents were not properly documented or reported to management in a timely manner. The facility's administrator and director of nursing were not informed of a previous incident involving the husband, which could have influenced their response to the recent events. The lack of documentation and communication among staff members contributed to the facility's failure to protect the resident from abuse and address the husband's caregiver burnout effectively.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident's husband to the State Survey Agency, resulting in a deficiency. The incident occurred when the husband attempted to force medication into the resident's mouth using a spoon. This event was not reported immediately as required, and the facility did not document the incident in the resident's medical record. The failure to report and document the incident led to the identification of immediate jeopardy. The deficiency involved two residents, one of whom was diagnosed with Alzheimer's disease, dementia, muscle weakness, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. The other resident, who attempted to force the medication, was diagnosed with PTSD and recurrent severe major depressive disorder, with a BIMS score indicating cognitive intactness. The incident was not communicated to the facility's Administrator, who oversees abuse allegations, until much later, highlighting a breakdown in the facility's internal reporting processes. The Administrator was unaware of the incident until informed by the Social Service Director, indicating a lapse in communication and reporting within the facility. The Administrator stated that if she had been informed earlier, she would have sought guidance from the corporate office. The facility acknowledged that staff had not consistently notified management about incidents, which contributed to the deficiency and the subsequent immediate jeopardy finding.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required supplemental oxygen. Resident 7, who had a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic systolic congestive heart failure, was observed using a portable oxygen tank with the indicator in the red refill area, indicating it was nearly empty. This observation was made despite a care plan that documented the resident's need for supplemental oxygen to maintain oxygen saturation. Additionally, the facility's grievance records revealed multiple complaints about low or empty oxygen tanks being used by residents. Similarly, Resident 8, diagnosed with acute respiratory failure with hypoxia and chronic respiratory failure with hypercapnia, was found using a portable oxygen tank with the indicator on zero in the red area. The resident expressed a need for oxygen due to shortness of breath. Interviews with facility staff, including the ADON, CNA, LPN, and DON, revealed that while there were procedures in place for checking and replacing oxygen tanks, these were not consistently followed. Staff acknowledged the need to change tanks when indicators were in the red, but observations showed this was not done in a timely manner, leading to the deficiency.
Failure to Monitor and Document Resident Conditions
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice, their comprehensive person-centered care plans, and their choices. One resident, who was cognitively intact and had multiple diagnoses including respiratory failure and congestive heart failure, was administered medications by a nurse despite being unable to put them in his mouth and showing signs of confusion, difficulty staying awake, and low oxygen saturation. The resident was later discharged to the hospital with an overdose, and there was no documented monitoring of his change in condition. Another resident, who was also cognitively intact and had diagnoses including paroxysmal atrial fibrillation and chronic obstructive pulmonary disease, experienced low oxygen levels in the evening. Despite being provided increased oxygen, there was no documented monitoring throughout the night to ensure the oxygen saturation remained above 90 percent. The resident's medical record lacked documentation of follow-up actions or monitoring after the initial intervention. Interviews with staff revealed a lack of understanding and adherence to protocols for monitoring changes in residents' conditions. The staff failed to document vital signs and changes in condition, and there was confusion about the appropriate actions to take when residents exhibited signs of overdose or respiratory distress. The facility did not have a policy regarding resident overdose, contributing to the deficiencies observed.
Failure to Prevent Fall and Ensure Timely Medical Response
Penalty
Summary
The facility failed to ensure a safe environment for Resident 119, who was at risk for falls due to multiple medical conditions, including severe dementia and Parkinson's disease. The resident was dependent on staff for mobility and had a care plan in place to mitigate fall risks, which included keeping the bed in the lowest position and conducting hourly safety checks. However, the resident rolled out of a high bed and sustained injuries after hitting his head on a feeding tube pump. This incident occurred despite the presence of a call light system, which was not promptly responded to by staff. The incident report and subsequent interviews revealed that the bed was not in the lowest position as required by the care plan, and the call light was activated for over four minutes before staff responded. The resident's fall resulted in a laceration to the scalp and eyebrow, as well as a skin tear on the knee. The resident's family member noticed a change in the resident's condition and transported him to the hospital, where a brain bleed was diagnosed. The facility's documentation indicated that the nurse on duty failed to notify the physician of the fall and the resident's declining condition in a timely manner. Interviews with facility staff, including a registered nurse and a unit manager, highlighted lapses in communication and monitoring following the fall. The RN supervisor was not informed of the fall or the resident's decreasing blood pressure, which should have prompted immediate medical intervention. The facility's fall prevention program, which includes regular assessments and interventions, was not effectively implemented in this case, leading to the resident's injury and subsequent hospitalization.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident 78, who had severe cognitive impairment and a history of falls, sustained a fall in the facility's bathroom. Despite complaints of pain from the resident and observations of non-verbal pain indicators, an x-ray was not obtained until 15 days later, revealing a fracture in the lumbar spine. The care plan for Resident 78 included interventions for pain management, but these were not effectively implemented, as evidenced by the delayed response to the resident's pain and the use of an inappropriate pain assessment scale. Resident 77, who was under hospice care with a terminal prognosis, reported severe pain that was not effectively managed by the prescribed pain medications. Despite receiving scheduled and as-needed doses of Morphine, the resident continued to experience high levels of pain, with documented instances where the medication was ineffective. The facility's failure to promptly administer additional doses or alternative pain management strategies contributed to the resident's ongoing discomfort. Interviews with staff revealed inconsistencies in pain assessment and management practices. Staff members acknowledged the challenges in assessing pain for residents with cognitive impairments and noted the use of a numerical pain scale that was not suitable for Resident 78. Additionally, there were delays in obtaining necessary diagnostic tests and adjustments to pain management plans, which further exacerbated the residents' pain and discomfort.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information. Observations on two separate occasions revealed that the postings were not updated daily as required. On one occasion, the postings were dated from two weeks prior, and on another occasion, they were from three days prior. The postings were located in the facility entry area, but the dates were not current, and one date was difficult to read. An interview with the Certified Nursing Aide Coordinator indicated that the night supervisor was responsible for updating the postings, and the information varied daily based on the staff schedule. This indicates a lapse in maintaining up-to-date and legible nurse staffing information accessible to residents and visitors.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors out of 35 opportunities, resulting in a 5.71 percent error rate. The errors involved a resident who was administered thyroid medication, Levothyroxine, not on an empty stomach as required, and Digoxin without obtaining an apical pulse beforehand. The resident had just finished breakfast when the medications were administered, contrary to the physician's order for Levothyroxine to be given at 6:00 AM on an empty stomach. The Licensed Practical Nurse (LPN) administering the medication did not obtain an apical pulse for Digoxin, despite acknowledging that it is a standard nursing practice to do so. Interviews with nursing staff revealed a lack of adherence to medication administration protocols. The LPN stated that the heart rate was checked using a machine, but no apical pulse was obtained, and the supervising Registered Nurse (RN) confirmed that Levothyroxine should be administered 30 minutes to 1 hour before food or other medications. The Unit Manager also confirmed that the resident's care plan did not document preferences for medication administration, which contributed to the errors. The Nursing 2022 Drug Handbook specifies that an apical-radial pulse should be taken for 1 minute before administering Digoxin, highlighting the deviation from standard practice in this case.
Medication Errors and Delayed Treatment in Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident 50 was administered pain medication and anti-anxiety medications not according to physician's orders. Specifically, there were multiple instances where Resident 50 received incorrect dosages of Methadone, a pain medication. On one occasion, the resident was given 10 mg of Methadone instead of the prescribed 30 mg, and on another, the resident received Xanax instead of Methadone. These errors were identified through narcotic records and incident reports, and the resident experienced increased pain and discomfort as a result. In another case, Resident 119 had a blood thinner, Plavix, held for longer than the prescribed 7 days following a fall with a head injury. The order to hold the medication was communicated by the resident's son, based on advice from a cardiologist, but the facility failed to follow up appropriately to restart the medication. As a result, Resident 119 did not receive the blood thinner from April 24 until May 30, which could have posed significant health risks given the resident's medical history, including atherosclerotic heart disease. Interviews with facility staff revealed lapses in communication and medication administration protocols. LPNs and RNs involved in the care of Resident 50 admitted to errors in medication dispensing and administration, often due to oversight or unfamiliarity with the resident's medication regimen. Similarly, the delay in restarting Resident 119's blood thinner was attributed to a lack of proactive communication with the physician and reliance on family members for medical decisions. These deficiencies highlight significant gaps in the facility's medication management processes.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles. During an observation, a medication cart was found unlocked and unattended in the 200 hallway by RN 6, who admitted to leaving it in that state. This lapse in protocol could potentially lead to unauthorized access to medications, posing a risk to resident safety. Additionally, a Basaglar kwikpen labeled for resident 60 was found on the medication cart with an open date of 6/29/24, indicating it was past its 28-day usability period. LPN 3 acknowledged that the medication should have been discarded. The Unit Manager confirmed that the process for checking expired medications was the responsibility of the nurses, with random audits conducted by the leadership team. However, the expired medication was not identified and removed in a timely manner, highlighting a gap in the facility's medication management practices.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility was found to have a deficiency in employing a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. The Dietary Manager (DM) was in the process of obtaining her certification but had not yet completed it due to a medical concern, despite having two years of experience in the role. Another full-time kitchen employee had completed the certification for DM but was not working in that capacity. The Registered Dietitian (RD) conducted monthly kitchen audits and provided recommendations based on her findings, but the facility did not have a full-time RD or a certified DM in place as required.
Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility was found to have deficiencies in the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that several food items in the walk-in freezer, including peanut butter cookie dough, egg patties, corn on the cob, breaded chicken, and corn dogs, were left open to air. A follow-up kitchen tour revealed similar issues, with additional items such as parmesan cheese in the refrigerator and sausage links, frozen cut corn, frozen peas, chicken fried beef patties, and corn dogs in the freezer also being open to air. An interview with the Dietary Manager (DM) revealed that the facility's protocol involved returning partially used food items to the freezer, either wrapped and dated or thrown away if there was very little left. The DM stated that items in the refrigerator and freezer were checked daily by morning managers, and cooks were expected to ensure proper storage. The Registered Dietitian (RD) visited the facility weekly and conducted monthly kitchen audits, sharing any concerns with the DM, administrator, Infection Control coordinator, and corporate dietitian. The DM acknowledged that items left open to air could result in freezer burn or contamination, emphasizing the need for all items to be sealed and dated.
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What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ogden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lomond Peak Nursing And Rehabilitation, Llc | 2.1 mi | ★★★★★ | 11 | 0 |
| Harrison Pointe Healthcare And Rehabilitation | 6.1 mi | ★★★★★ | 5 | 0 |
| Crestwood Rehabilitation And Nursing | 6.4 mi | ★★★★★ | 4 | 0 |
| Stonehenge Of Ogden | 6.9 mi | ★★★★★ | 0 | 0 |
| Mt Ogden Health And Rehabilitation Center | 7.9 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.