The incidents at Accura Healthcare of Ogden came to light during a November complaint investigation that revealed a pattern of inappropriate language directed at vulnerable residents.
Staff B, a licensed practical nurse, overheard the exchange on November 12 at 7:25 PM through Resident #3's roommate's baby monitor. She heard Staff A tell the resident "f you too" during their conversation.
Staff B told investigators that Staff A "swears like a sailor all the time and has been talked to about it." She said Staff A frequently uses profanity in front of residents despite previous warnings.
The investigation uncovered a second incident from three weeks earlier involving Staff A and a different resident. On October 23, Resident #1 had assaulted both Staff A and the facility's MDS Coordinator during what began as an attempt to help the resident navigate a flooring transition.
Staff A described the encounter in detail during her November 13 interview. Resident #1 had come down the hallway and gotten stuck on a lip in the flooring. When the MDS Coordinator tried to assist, Resident #1 called for Staff A's help.
After they managed to get the resident over the flooring obstacle, Resident #1 threw a urine-soaked bed pad at Staff A and called her a "dumb b."
The MDS Coordinator responded by telling the resident they couldn't talk that way and needed to go to her room to calm down. That's when Resident #1 reached around and pinched Staff A.
"I moved her hands and said get your fing hands off me," Staff A told investigators. The resident then scratched the MDS Coordinator in the face twice.
Staff called both the Director of Nursing and police to respond to the incident.
When asked what Resident #1 said after being cursed at, Staff A reported the resident "was just mumbling."
Staff A acknowledged using profanity "in the heat of the moment" during the physical altercation.
The investigation also examined Staff A's interactions with Resident #3, who has a complex medical history including heart failure, hip fracture, seizures, malnutrition, anxiety, depression, bipolar disorder, and schizophrenia. His care plan, initiated in May 2019, documented potential for behavioral issues and altered coping related to major depressive disorder, schizoaffective disorder, anxiety, history of traumatic brain injury, and a history of being sexually inappropriate.
Staff A told investigators she has known Resident #3 since she was young, describing him as "a buddy of her dad's." She claimed she doesn't curse at him directly but uses "a sternness with her voice" and tells him things like "I will not put up with your BS" without saying the full word.
When the Director of Nursing learned about Staff A's profanity during the October 23 incident, she called it unacceptable.
"I would not like to hear that coming from a staff member," the DON said during her November 14 interview.
But the DON also provided context for the challenging work environment. She explained that staff deal with significant abuse from residents and may be "getting worn out." She noted that Staff A was likely "at her breaking point" during the incident.
The DON cited an example of the pressures staff face: at the same time as the October incident, they had a hospice resident who used her call light 280 times in seven days.
"Stuff like that wears on them," the DON said.
She acknowledged that Staff A has "a short fuse" and said the facility has been working with her on anger management. Staff A has shown improvement over the past year, according to the DON.
The facility has instructed Staff A that when she feels overwhelmed, she should take five minutes to step away, go outside, or visit the DON's office rather than remain in resident areas.
The DON explained Staff A's stern approach with Resident #3 by saying his sister specifically requests that staff be firm with him. The sister believes Resident #3 is manipulative and that stern treatment prevents him from taking advantage of staff.
When informed about Staff A telling Resident #3 "f you too" through the baby monitor, the DON called it "right on the edge of not sure if it's appropriate."
She indicated that if Staff A had used the full word "bulls" instead of abbreviating it as "BS," that would have been clearly unacceptable.
The facility's policy on "Promoting/Maintaining Dignity," revised January 30, 2024, states it is the practice to "protect and promote resident rights and treat each resident with respect and dignity." The policy requires staff to "care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality."
The compliance guidelines specifically instruct all staff members to "speak respectfully to residents."
The inspection found the facility failed to ensure residents were treated with respect and dignity, citing minimal harm to a few residents. The violations centered on staff use of profanity directed at residents, both during face-to-face confrontations and through inadvertent monitoring equipment.
Resident #3 continues to live at the facility with his complex psychiatric and medical conditions, while Staff A remains employed despite the documented pattern of inappropriate language that supervisors acknowledge they've been addressing for over a year.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Ogden, LLC from 2025-11-14 including all violations, facility responses, and corrective action plans.
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