OGDEN — Eight Northern Utah nursing homes have been fined for health and safety violations in the last three years, and in two cases residents were found to be in immediate danger.

Also, according to state and federal data, at least three local nursing homes had dozens of deficiencies found by health inspectors during unannounced visits.

Inspection reports posted on the government’s Medicare website show problems in local centers ranging from unpalatable, unsanitary food and filthy conditions to potentially life-threatening medication errors and failure to prevent patients with dementia from wandering away.

The Utah Bureau of Health Facilities Licensing and Certification strives to inspect each of Utah’s 98 nursing homes every 12 to 16 months. Greg Bateman, long-term care survey section manager, said when major deficiencies are found, follow-up inspections are conducted within one to three months.

“If conditions do not change, if individuals have or are likely to suffer serious injury, impairment or death, we start looking at recommending … civil monetary penalties,” Bateman said.

If a nursing home loses certification and the government cuts off Medicaid and Medicare reimbursements, “most would need to implement a discharge plan for residents,” Bateman said. “I doubt many nursing homes could survive on private pay only.”

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DEMENTIA PATIENT WALKS AWAY THREE TIMES

Lomond Peak Nursing and Rehabilitation in northern Ogden has had at least four inspections since August 2015.

State inspectors logged dozens of deficiencies in the past three years, including one in the K category, which signifies “immediate jeopardy to resident health or safety — deficiency is part of a pattern.” 

Inspectors detailed the case of a woman who wandered away from the home three times, in escalating degrees of danger.

The first time, the woman was found a block or two away. On the second incident, an off-duty employee spotted the woman a mile away at a busy intersection. The third time, the woman’s daughter returned her to Lomond Peak — she had walked a mile and a half along a six-lane road to her daughter’s home.

The report said the woman had severe cognitive impairment and tried to wander daily. A nurse told an inspector “conditions in the facility were busy and chaotic” on the day of the third incident.

Inspectors faulted the home for a pattern of failing to prevent wandering by dementia patients and for not documenting and reporting the incidents.

In another finding, inspectors docked Lomond Peak for preventable weight loss among patients, failure to follow doctors’ dietary orders and lack of follow-up on abnormal lab results.

One patient lost 12.9 percent of his weight in 28 days, from 134.2 pounds to 114.6 pounds, inspectors found. The man, who suffered from liver disease, had only toast for breakfast and a roll for lunch because he had not received the food he ordered from the alternative menu and because the kitchen did not provide extra meat as ordered by a doctor, the report said.

“I am going to starve to death before (the liver disease) kills me,” the man told an inspector.

Inspectors also criticized Lomond Peak for insufficient nursing staff; medication administration errors; residue on dishes, soiled kitchen areas and unsanitary food services practices; and “a dried brown substance on a resident shower chair … and bugs in all the light fixtures.”

Lomond Peak — rated “much below average” on the Medicare.gov nursing home comparison website — underwent an ownership change a few years ago.

“The previous owners went insolvent, and at the last moment another group, under a different name, reopened Lomond Peak,” Bateman said.

Under the name Deseret Health and Rehab, the nursing home was assessed a $1,625 fine in 2013 by the U.S. Centers for Medicare and Medicaid Services.

A Lomond Peak administrator did not return a phone call.

INCONSISTENT ATTENTION TO RISKS OF WANDERING

Another Ogden nursing home, Mountain View Health Services, was found by inspectors to have lost track of three patients and disagreed internally about how to handle them. This resulted in an “immediate jeopardy” finding. The center’s rating by Medicare is “below average.”

A resident prone to temper tantrums when she did not get her daily newspaper walked almost half a mile, crossing a busy road during morning rush hour, inspectors reported. Another time, she was found at a doughnut shop.

A second patient, suffering multiple personalities and self-destructive behavior, was found underneath a neighbor’s carport.

Inspectors also documented disagreements between nursing staff and Mountain View’s administrator about whether a man who had garbled speech, confusion and agitation should be allowed outside unattended.

The administrator allowed the man to walk to a convenience store to buy cigarettes, despite concerns voiced by a weekend nurse about the man’s capabilities and safety. The man once was retrieved after wandering nearby along Harrison Boulevard at 10:30 p.m., one nurse told inspectors.

Mountain View racked up 56 deficiencies in health and safety, inspectors reported. The home was fined $2,015 after a 2013 inspection and $15,210 in the wake of the 2015 review, Medicare records show.

An administrator did not return a phone call.

UNAPPETIZING FOOD, AND SPLINTERS ON BEDRAILS

Washington Terrace Center in Washington Terrace was assessed $4,680 in fines after 27 deficiencies were reported in a July 2015 inspection. The home received a “much below average” rating by Medicare.

Call lights went unanswered, showers were not completed as scheduled and residents did not get adequate help eating in the dining room, all symptoms of under-staffing, inspectors reported. Beds throughout the home had splintered handrails, they said.

An inspector listed sanitation problems in food service, including an observation that a staff member wiped his nose with his hand while serving people meals. Asked about it, the staff member discounted the issue and told the inspector “he knew more about germs than most people.”

Resident council minutes revealed many complaints about food quality. A test tray was judged unpalatable by inspectors, who reported:

• The soup was spilled down the side of the bowl. The soup was extremely bland with a salty and oily taste. The soup had extremely small pieces of ground-up beef.

• The Reuben sandwich was cold, bland and dry. The Reuben had a small piece of sliced meat with a piece of Swiss cheese between two large pieces of bread. There was no sauerkraut. A dining manager said she bought sauerkraut that morning and the cook forgot to put it on the Reuben.

• The tuna sandwich was warm and bland. The temperature of the sandwich was 74 degrees.

  Potatoes were cold to the taste with a rubber texture. The potatoes did not have any flavor of potatoes.

• The cucumber salad was warm. The temperature was 70.5.

• The watermelon was cut into different sizes and was warm.

A MOTHER’S GRIEF

Even nursing homes with top ratings sometimes run afoul of inspectors — and the loved ones of patients.

“It’s terrible the way they treat you over there,” said Fern Hawks, a 95-year-old Ogden resident whose daughter was in a local nursing home.

BRIANA SCROGGINS/Standard-Examiner

She said Mt. Ogden Health and Rehabilitation Center of Washington Terrace did not have enough staff to feed her daughter, help her with her wheelchair and prevent her from falling out of bed repeatedly.

Hawks said her daughter, Joyce Bovero, 74, died in the home on Oct. 22, 2015. Bovero had suffered strokes and was unable to talk, walk or feed herself, Hawks said.

Hawks said Bovero was starving.

“You don’t eat if you can’t feed yourself,” she said. “She had to have all of her food ground up, puree and liquids, and it was the same old thing every day.”

Hawks said she visited her daughter as often as she could, “but they wouldn’t even let me have a chair in the room to set on.”

The nursing home’s marketing and administrative offices did not return phone calls.

Mt. Ogden is rated “much above average” by Medicare and had no deficiencies in its most recent inspection in December 2015. In its 2013 and 2014 reviews, inspectors logged nine deficiencies total.

Bateman, who has been with the state for 22 years, said most serious deficiencies are cleared up relatively quickly, because otherwise a home’s state and federal certifications and Medicare and Medicaid reimbursements are in peril.

WATCHING OUT FOR THE VULNERABLE

From a consumer’s standpoint, Utah nursing home failings often become known when the state’s long-term care ombudsman gets involved.

“We are the eyes and ears of most agencies,” said ombudsman Daniel Musto. “We’re often the ones who identify problems.”

Musto’s office, which contracts with local aging offices to do ombudsman work around the state, took 1,679 complaints about long-term care facilities in fiscal 2015. He said 1,081 cases were opened and 903 facility consultations were conducted.

Ombudsmen follow a complaining patient’s wishes, he said.

“We want them to know the importance of the program and that (ombudsmen) are here to help individuals and protect them from abuse, neglect and exploitation. We are the voice for individuals who are unable to stress their wants and needs and fears.”

INFORMATION AND HELP FOR NURSING HOME CONSUMERS

The Medicare.gov website features a Nursing Home Compare database. Find deficiency reports and Medicare ratings on all local nursing homes.

ProPublica’s Nursing Home Inspect tool burrows deep inside federal data to provided insight on various measures of nursing home quality.

Contact a local representative of the state’s long-term care ombudsman with concerns or questions. 

Report a violation of a long-term care patient’s personal rights.

Report physical or emotional abuse, neglect, exploitation or patient self neglect.

You can reach reporter Mark Shenefelt at mshenefelt@standard.net or 801 625-4224. Follow him on Twitter at @mshenefelt and like him on Facebook at www.facebook.com/SEmarkshenefelt.