Cycle 1
Health 2024-08-07 · Fire 2024-08-07
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ogden, UT
George E. Wahlen Ogden Veterans Home
4-star overall rating with 2-star inspections with $12,363 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1102 North 1200 West, Ogden, UT
(801) 334-4300
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Avalon Health Care
Operator or chain grouping
Approved since
2010-02-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.51
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.01
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.40
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.15
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.70
CMS adjusted RN staffing hours
Adjusted total hours
5.67
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
185
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
79.11
Composite VBP score used to determine payment impact.
Payment multiplier
1.0256
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.05
Baseline 47.88% · Performance 30.77% · Measure score 8.05 · Achievement 8.05 · Improvement 6.93
Adjusted total nurse staffing
7.77
Baseline 4.86 hours · Performance 5.29 hours · Measure score 7.77 · Achievement 7.77 · Improvement 4.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 5.69% |
| Discharge to community | 43.61% |
50.57%
7 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 37.5% · Lower 95% interval 31.78% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.55% |
95.27%
1.7 pts worse
|
Numerator 29 · Denominator 31 |
| Falls with major injury | 3.23% |
0.77%
2.5 pts worse
|
Numerator 1 · Denominator 31 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 14 · Denominator 28 |
| Discharge mobility score | 39.29% |
50.94%
11.6 pts worse
|
Numerator 11 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.12% |
8.2%
0.1 pts worse
|
Numerator 25 · Denominator 308 |
| Staff flu vaccination coverage | 66.67% |
42%
24.7 pts better
|
Numerator 222 · Denominator 333 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 12 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.6%
0.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 3.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.5% |
16.1%
1.6 pts better
|
11.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 13.0% · Q3 17.0% · Q4 17.6% · 4Q avg 14.5% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
3.8%
1.6 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.1% · Q3 2.3% · Q4 1.1% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 54.2% |
24.1%
30.1 pts worse
|
19.6%
34.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.5% · Q2 55.4% · Q3 53.4% · Q4 54.3% · 4Q avg 54.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
15.4%
8.7 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 9.8% · Q3 5.3% · Q4 2.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.6% |
18.3%
2.3 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 24.5% · Q3 16.9% · Q4 18.0% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
13.6%
7.8 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 20.5% · Q3 17.9% · Q4 19.8% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.8%
0.4 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 1.9% · Q4 3.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
22.4%
3.8 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 26.6% · Q3 26.1% · Q4 24.9% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.1%
1.5 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.5% · Q3 0.8% · Q4 3.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.3%
6.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
0.9%
3.5 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
91.0%
7.1 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-01 · Fire 2022-12-01
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-03-25 · Fire 2021-03-25
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-08-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-08-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-27
D · Potential for more than minimal harm
2022-12-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-12-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-12-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-12-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-14
D · Potential for more than minimal harm
2021-03-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-03-29
D · Potential for more than minimal harm
2021-03-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-03-29
D · Potential for more than minimal harm
2021-03-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-03-29
Inspection history
Recent health citations
J · Immediate jeopardy
2025-02-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-28
J · Immediate jeopardy
2025-02-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-07
G · Actual harm
2024-08-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-04
Penalties and ownership
What sits behind the stars
$12,363
2025-02-28
Fine
Fine · fine $12,363
Fine
Ownership
Avalon Va Management LLC
5% Or Greater Direct Ownership Interest · Organization
Aston, Andrea
Operational/Managerial Control · Individual
Avalon Health Care Management, Inc.
Operational/Managerial Control · Organization
Avalon Health Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Health Care, Inc.
Operational/Managerial Control · Organization
Avalon Holding, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Veterans Services, L.l.c.
5% Or Greater Indirect Ownership Interest · Organization
Bird, Jill
Operational/Managerial Control · Individual
Borisevich, Maria
Operational/Managerial Control · Individual
Borisevich, Maria
Corporate Officer · Individual
Dangerfield, David
Corporate Director · Individual
Hash, Alan
Operational/Managerial Control · Individual
Hash, Alan
Corporate Officer · Individual
Hyrum A Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
K-Team LLC
5% Or Greater Indirect Ownership Interest · Organization
Kirton, Byron
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Byron
Corporate Director · Individual
Kirton, Hyrum
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Hyrum
Operational/Managerial Control · Individual
Kirton, Hyrum
Corporate Director · Individual
Kirton, Hyrum
Corporate Officer · Individual
Kirton, Spencer
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Spencer
Corporate Director · Individual
Mohr, Robert
Operational/Managerial Control · Individual
Smith, Nicole
Operational/Managerial Control · Individual
Smith, Nicole
Corporate Officer · Individual
Spencer K Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
State Of Utah
Operational/Managerial Control · Organization
The Byron A Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
Woltil, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Lomond Peak Nursing and Rehabilitation, LLC
Ogden, UT
2-star overall rating with 2-star inspections with 11 recent health deficiencies
#2
Harrison Pointe Healthcare and Rehabilitation
Ogden, UT
3-star overall rating with 3-star inspections with 8 recent health deficiencies
#3
Crestwood Rehabilitation and Nursing
Ogden, UT
2-star overall rating with 1-star inspections with $20,013 in total fines with 16 recent health deficiencies
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