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Lomond Peak Nursing and Rehabilitation on Wednesday, June 5, 2019, in Ogden.

OGDEN — Resident 33 could not leave his room in an Ogden nursing home for at least two months.

“I’ve been suicidal,” the man told a state inspector. “I have no kind of life.”

The man, identified by number on an inspection report, was injured in a fall in September 2018, then gained weight and developed an abdominal abscess and could no longer fit into his manual wheelchair.

In response to a state citation for causing “actual harm” to the patient, the nursing home said it had bought a wheelchair to accommodate his size. But that had been in March, before he outgrew it.

“The manual wheelchair purchased by the facility is an appropriate chair for (Resident 33),” the written response in November said. “It may not be comfortable for extended periods of time but would be perfectly appropriate for 2-3 hours at a time. Aside from a custom wheelchair for which there is no funding, this is the best option available.”

Resident 33’s situation is an example of violations that have led regulators to single out Lomond Peak Nursing & Rehabilitation as a “special focus facility,” the only such nursing home in Utah.

State licensing officials, working with the U.S. Centers for Medicare & Medicaid Services, inspect homes at least annually. Homes get into trouble by logging poor results three years in a row.

Rating categories include abuse of patients, quality of health care, food quality and safety, infection control, and incident documentation and reporting.


Four other homes, including Mountain View Health Services in South Ogden, are listed as SSF “candidates.”

One of those four could drop into the SFF spot if and when Lomond Peak “graduates” from the extra scrutiny by passing inspections through an 18-month period, said Joel Hoffman, head of the state’s nursing homes licensing bureau.

“When you’re a Special Focus Facility, you know you’re under the gun,” Hoffman said Wednesday. “If you lose your certification you are pretty much put out of business.”

The Lomond Peak administrator’s office did not immediately return a phone message.

But Hoffman said the nursing home has hired a consulting company to help it improve operations and meet requirements to maintain Medicare funding.

A nursing home losing certification “is a rare event, because they know that their whole future depends on it,” Hoffman said. “They are going to invest that much more to keep it.”

When a home falls into the bottom five of Utah’s 103 nursing homes, according to the inspection ratings, their owners become worried.

“You don’t expect them to be in the bottom five for long,” he said.

Utah’s bottom five came to light Monday after U.S. Sens. Bob Casey and Pat Toomey of Pennsylvania released a previously secret list they obtained from Medicare regulators.

The list includes about 400 nursing homes around the country categorized as SFF sites or SFF candidates. About 15,000 nursing home are in business nationwide.

SFF homes are flagged as such on Medicare’s Nursing Home Compare site. But Casey objected that those listed as SFF candidates were not known to the public.

On Nursing Home Compare, all homes are rated on a scale of one to five stars. For instance, Mountain View is rated “much below average” overall.

Consumers can read inspection reports about all homes on the federal site.


In its most recent inspection, on Nov. 15, 2018, Lomond Peak received 30 health violation citations, triple the state average.

The report cited the home for instances of not supporting patients’ desires for self determination.

Resident 32 told the inspector she had asked for a daily shower but had been denied.

The woman “was observed to have greasy and unkempt hair,” the inspection report said.

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Lomond Peak Nursing and Rehabilitation on Wednesday, June 5, 2019, in Ogden.

Another resident was wearing his heavy coat in bed and told the inspector the heater in his room blew cold air all night.

The inspector elsewhere found debris, dirt, food and toilet paper on the floors, rooms without baseboards, dried urine on fitted sheets, and an armoire without drawers.

Lomond View also failed to protect residents from abuse by fellow patients, the report said.

Resident 14 was involved in three physical assaults from late August to early November, according to the report. He had a fistfight over cigarettes, kicked a resident in the groin who bumped him with his wheelchair, slugged a staff member and punched a resident who tried to open a drink for him.

The man finally was kicked out on Sept. 15.

Several instances of physical abuse were not reported to state authorities as required, and the home did not have evidence that all alleged violations of abuse were thoroughly investigated, the report said.

A licensed practical nurse’s shift notes filed after one of the fights said “crowding and noise” in the home were predisposing factors so some of the residents’ conflicts.

Further, investigators docked the home for not having sufficient staff to care for all residents around the clock, said it did not adequately monitor a suicidal patient and said it did not have and maintain an infection prevention and control program.

“Review of the facility infection control tracking and trending log revealed a high incidence of facility acquired E-coli urinary tract infections,” the report said.

Thirty-three urinary infections occurred over a nine-month period in the 74-bed home, according to the report.


At Mountain View, a complaint inspection flagged two alleged incidents of staff members abusing dementia patients.

One staff member reported a colleague slapped a patient’s hands while changing her brief and then slapped her on the lips when she complained.

The same certified nursing assistant was reported to have slapped a different patient and “called him a dirty Mexican,” and turned the man toward the wall and told him to “kiss the wall,” the report said.

Mountain View Health Services

Mountain View Health Services on Thursday, June 6, 2019, in South Ogden.

The home’s administrator told the inspector the CNA had been suspended, although the internal investigation determined no abuse had occurred. The inspector later found no record of a suspension.

The administrator told the inspector two “disgruntled” employees had recently resigned without notice, one threatening to “get even” with the nursing home, according to the report.

Mountain View did not immediately return a phone message.

You can reach reporter Mark Shenefelt at mshenefelt@standard.net or 801 625-4224. Follow him on Twitter at @mshenefelt.

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