A list of the most recent deficiencies for South Ogden Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-14 | 2023-11-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-14 | 2023-11-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-14 | 2023-11-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-14 | 2023-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-14 | 2023-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-14 | 2023-11-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-18 | 2023-11-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-09-18 | 2023-11-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-18 | 2023-11-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-18 | 2023-11-09 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-09-18 | 2023-11-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-18 | 2023-11-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-18 | 2023-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-18 | 2023-11-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-18 | 2023-11-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-18 | 2023-11-09 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-09-18 | 2023-11-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-18 | 2023-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-18 | 2023-11-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-18 | 2023-11-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-25 | 2023-07-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-25 | 2023-07-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-25 | 2023-07-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-25 | 2023-07-25 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-25 | 2023-07-25 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-04-25 | 2023-07-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-25 | 2023-07-25 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-25 | 2023-07-25 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-04-25 | 2023-07-25 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-25 | 2023-07-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-25 | 2023-07-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-25 | 2023-07-25 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-25 | 2023-07-25 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-04-25 | 2023-07-25 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-04-25 | 2023-07-25 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-04-25 | 2023-07-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-25 | 2023-07-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-25 | 2023-07-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-25 | 2023-07-25 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-04-25 | 2023-07-25 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-04-25 | 2023-07-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-25 | 2023-07-25 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-25 | 2023-07-25 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-04-25 | 2023-07-25 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-04-25 | 2023-07-25 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-04-25 | 2023-07-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-29 | 2023-05-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-29 | 2023-05-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-29 | 2023-04-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-29 | 2023-04-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-29 | 2023-04-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-29 | 2023-04-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-29 | 2023-04-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-29 | 2023-04-22 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-12-20 | 2023-02-03 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-20 | 2023-02-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-20 | 2023-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-20 | 2023-02-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-20 | 2023-02-03 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-12-20 | 2023-02-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-26 | 2022-10-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-26 | 2022-10-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-26 | 2022-10-07 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-08-26 | 2022-10-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-16 | 2022-04-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-16 | 2022-04-04 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-16 | 2022-02-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-16 | 2022-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-16 | 2022-02-01 | N |
| Post nurse staffing information every day. | Health | 2021-12-16 | 2022-02-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-12-16 | 2022-02-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-16 | 2022-02-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-16 | 2022-02-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-12-16 | 2022-02-01 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-16 | 2022-02-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-16 | 2022-02-01 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-16 | 2022-02-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-16 | 2022-02-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2022-02-01 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-12-16 | 2022-02-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-16 | 2022-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2022-02-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-16 | 2022-02-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-02-01 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-16 | 2022-01-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-16 | 2022-01-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-16 | 2022-01-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-16 | 2021-12-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-16 | 2021-12-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-16 | 2021-12-16 | N |
