Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Logan Health - Conrad during CMS and state inspections, most recent first.
A resident’s MDS active diagnoses section incorrectly continued to list pneumonia even though the resident had been admitted with pneumonia months earlier, had no later hospital admission, and had fully recovered after treatment. Staff acknowledged the diagnosis should have been removed once the illness resolved.
A resident with dementia was receiving olanzapine 2.5 mg daily, but the order listed dementia without behavioral disturbance as the diagnosis. Staff stated the medication had been started for prior exit-seeking and anger toward staff, yet the diagnosis in the EHR did not match the reason for use and the discrepancy was missed. The resident was observed at dinner without disruptive behavior, and the facility’s pharmacy MRR policy required review of medication indication.
Food Storage and Dating Deficiencies: The facility failed to discard expired food and failed to properly date, label, and store food in the kitchen dry storage, meat freezer, and vegetable cooler. Expired oatmeal and cream of wheat were found, along with open, undated meat items and lettuce. An LPN stated open items needed to be dated and food discarded by use-by or expiration date, but the items remained present on a later observation.
Failure to maintain COVID-19 vaccination documentation for a staff member was identified during record review and interviews. The staff member stated he had been asked about vaccination when he started at the facility and signed a declination form, while other staff identified a different staff member as responsible for tracking COVID-19 status. The facility policy required ongoing screening and maintenance of vaccination surveillance data for employees and residents.
Several residents reported receiving cold meals, and observations confirmed that food was plated and left in uninsulated carts with doors open for extended periods before being served. Staff acknowledged a lack of knowledge about proper serving temperatures and noted that food trays often sat for 20 to 30 minutes before delivery. Temperature checks at the time of service showed hot foods were consistently below the required 135°F, with some items as low as 104°F, due to prolonged holding times and inadequate equipment.
Surveyors observed multiple instances of expired, undated, and improperly stored food items throughout the facility, including moldy strawberries, expired baking soda, undated produce with signs of spoilage, and unidentifiable frozen meat. Staff interviews revealed inconsistent monitoring and disposal of expired items, and a public area cooler was found in use without temperature logs or a thermometer, despite policy requirements for proper food storage and labeling.
Expired and improperly labeled medications and supplies, including insulin without identifiers or expiration date, as well as expired ointments, dressings, and a suture removal kit, were found in the medication room. Pharmacy and facility staff were responsible for monthly checks, but expired items remained undetected despite these procedures.
The facility did not consistently implement infection control protocols, including failing to post enhanced barrier precaution signage for two residents with a pressure sore and a Foley catheter, not ensuring a coughing staff member wore a mask as required, and not enforcing hand hygiene after handling contaminated laundry, despite clear facility policies and staff awareness.
Two residents experienced distress and frustration when water was served in soft plastic disposable cups instead of hard plastic cups, while other beverages were provided in sturdier containers. Staff interviews revealed that hard plastic cups were available in the kitchen, but nursing staff opted for disposable cups, despite the facility's policy to provide appropriate adaptive equipment to support resident independence.
A resident with a documented diagnosis of bipolar disorder, supported by a current prescription for Aripiprazole, did not have this mental health condition listed on their PASARR. Staff confirmed the diagnosis was present in the medical history and linked to medication orders, but it was not included in the current diagnoses used for the PASARR, and the reason for this omission was unknown.
A resident with multiple chronic conditions was admitted without a baseline care plan being completed within 48 hours, as required by facility policy. The responsible staff member was absent at the time of admission, and no other staff initiated or completed the care plan, resulting in a delay in outlining necessary care instructions for the new admission.
A resident did not receive showers as frequently as indicated in their care plan, which specified a preference for showers twice weekly. Documentation showed the resident received only 12 showers over a 96-day period, with extended gaps between some showers and only one recorded refusal. Staff interviews confirmed inconsistent shower frequency and uncertainty in documentation practices.
A pharmacist did not identify or address the extended use of a PRN psychotropic medication for a resident, as required by facility policy. The resident had an ongoing PRN order for lorazepam without a stop date, and monthly medication regimen reviews over several months failed to note this irregularity, despite policies limiting PRN psychotropic use to 14 days unless properly documented by a physician.
The facility did not have a qualified Dietary Manager, as the Director of Food Services had expired certifications and had not yet completed the necessary testing to renew them. This deficiency had the potential to impact all residents, as the facility's job requirements specified current ServSafe and State Certification in Safe Food Handling and Sanitation.
Surveyors found that two residents' POLST forms were not fully completed, with one lacking a provider's signature and another missing a proper resident or representative signature and date. Staff confirmed that all required fields should be filled out, but could not explain the omissions.
The facility failed to provide adequate supervision on a secure dementia unit, resulting in a resident ingesting odor eliminator and unsecured chemicals. Additionally, two residents experienced falls due to inadequate supervision and improper use of mobility aids. The incidents highlight the need for improved safety protocols and staff training.
The facility failed to ensure an RN was on staff for at least eight consecutive hours a day, seven days a week. A review of the CMS Payroll-based Journal and nursing schedules revealed the absence of RN coverage on multiple days, including a specific instance on 10/29/23. A staff member confirmed the lack of RN coverage without providing a reason.
The facility failed to ensure proper food storage, hygiene, and sanitation practices. Food was stored directly on the floor in the cooler and freezer. A staff member improperly wore a beard cover and did not perform hand hygiene while serving food. Another staff member did not clean a thermometer before and between taking food temperatures.
The facility failed to ensure staff and residents had access to grievance forms, investigate grievances, and maintain evidence of grievance outcomes. Multiple residents reported unresolved complaints and were unaware of the grievance process. Staff interviews revealed inconsistencies in providing and completing grievance forms, and the grievance log was incomplete.
The facility failed to provide palatable food at an appetizing temperature for four residents. Complaints included consistently cold food, repetitive meals, and serving spicy food despite restrictions. Observations confirmed food temperatures below the required 140 degrees Fahrenheit.
The facility failed to provide dignity and respect for two residents by not knocking and announcing themselves before entering rooms. Both residents and their family members expressed frustration over the lack of privacy. Staff members acknowledged the protocol but did not adhere to it, as observed in multiple instances.
The facility failed to assess a resident for self-administration of medications. The resident was observed administering Systane eye drops without a physician's order or proper assessment, despite having moderate cognitive impairment. The facility's policy required such assessments, but none were found for the resident.
The facility failed to support and assist two residents, who were spouses, in their request to share bed space. Despite multiple requests and a maintenance log entry, the facility did not fulfill their request for a double bed or to have their single beds pushed together. Staff interviews revealed a lack of follow-up and completion of the task.
The facility failed to investigate and report an injury of unknown origin for a resident who complained of shoulder pain and had a bruise on the upper arm. The required investigation and root cause analysis were not submitted to the State Survey Agency within the mandated timeline.
The facility failed to revise a resident's care plan after multiple falls, leading to continued injuries. Staff interviews and document reviews revealed that care plans were not updated with new interventions, and the resident's care plan did not include any new measures after several falls.
The facility failed to ensure a resident had access to their hearing aids, despite care plan instructions and requests from the resident's daughter. Staff provided conflicting information about the location and handling of the hearing aids, leading to the resident frequently being without them and experiencing communication difficulties.
The facility failed to address the use of personal refrigerators in resident rooms, leading to potential food safety issues. A resident's refrigerator contained expired and unlabeled food items, and staff interviews revealed inconsistent practices and lack of a clear policy for personal refrigerators.
The facility failed to submit accurate direct care staffing information to CMS, with discrepancies found between the Payroll-based Journal and the facility's nursing schedules. A staff member acknowledged the errors and corrected the data moving forward.
The facility failed to post nurse staffing information daily at the beginning of each shift. Observations revealed incomplete postings for multiple shifts, and a staff member confirmed that nurses complete the postings after their shifts but could not explain the missing information.
Inaccurate MDS Active Diagnosis Entry
Penalty
Summary
The facility failed to accurately complete the active diagnoses section of the MDS for 1 of 17 sampled residents. Resident #1 was observed with a dry, hacking cough and no obvious shortness of breath, and the resident denied any recent hospital admission or treatment for a respiratory illness. Review of the EHR showed pneumonia was listed as a diagnosis when the resident was admitted to the facility in May 2025, and the record did not show any hospital admission since that time. However, the Quarterly MDS assessment with an ARD of 2/22/26 still listed pneumonia as an active diagnosis. Staff stated the resident had pneumonia when initially admitted in May 2025 and acknowledged the diagnosis should have been deleted after the resident completed treatment and fully recovered.
Antipsychotic Medication Lacked Correct Indication Documentation
Penalty
Summary
The facility failed to ensure an appropriate indication was documented for the use of olanzapine, an antipsychotic medication, for one resident with dementia. The resident’s physician order, dated 11/21/25, showed olanzapine 2.5 mg daily for a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. During a dinner observation on 5/4/26, the resident was sitting with two male residents, finished dinner, stated she was still hungry, and was given a sandwich by staff; no disruptive behavior was observed at that time. During interviews, staff stated the resident had previously exhibited exit-seeking behaviors and anger toward staff when prevented from leaving, and that olanzapine had been started while the resident was at an assisted living facility and continued after admission because of those behaviors. Staff also stated the diagnosis should have reflected dementia with behaviors, but the diagnosis list in the EHR had shown dementia without behavioral disturbance, and the discrepancy was missed. The facility’s policy for pharmacy medication regimen review stated the pharmacist’s review may include evaluating medications for appropriate dose, indication, and duration.
Food Storage and Dating Deficiencies
Penalty
Summary
The facility failed to discard expired food and failed to properly date, label, and store food in the main kitchen freezer and cooler. During an observation of the kitchen and interview with staff member G on 5/4/26 at 4:11 p.m., the dry storage area contained two cups of instant oatmeal that expired on 3/11/26, five boxes of instant cream of wheat that expired on 4/1/26, and a 28-ounce box of creamy wheat that was open to air and not dated. The meat freezer contained three plastic bags of food items, including a breaded meat product, breaded meat patties, and beef patties, and all three bags were open to air and not dated when received or opened. The vegetable cooler contained an open bag of leaf lettuce that was not dated when received or opened. Staff member G stated she had been in her current position for one month and stated she was aware that all open items needed to be dated and that food needed to be discarded by its use-by date or expiration date. During a later observation on 5/7/26 at 9:31 a.m., the three bags in the meat freezer and the bag of leaf lettuce were still present, open to air and not dated when opened.
Failure to Maintain COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain documentation of the COVID-19 vaccination status, received or refused, for staff member F among the staff sampled for COVID-19 vaccination tracking. Review of staff member F’s vaccination status showed the staff member signed a declination on 5/6/26. During an interview on 5/6/26 at 10:42 a.m., staff member F stated he had been asked about getting the COVID-19 vaccination when he initially started at the facility in August 2025 and said he signed the declination form earlier on 5/6/26. During an interview on 5/7/26 at 8:59 a.m., staff members C and D stated staff member B was currently responsible for staff COVID-19 status documentation. The facility policy titled, COVID-19 Vaccination Program, dated February 2025, stated screening would be ongoing and allow employees and residents who initially declined to receive the vaccine at a later date, and that the Infection Control Coordinator or designee would maintain surveillance data on COVID-19 vaccine coverage among employees and residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature for six of seventeen sampled residents. Multiple residents reported that their meals were often served cold, both in the dining area and in their rooms. Observations confirmed that food was plated, covered, and placed in uninsulated metal carts with the doors left open during the tray assembly process. The carts did not maintain heat effectively, and the doors remained open for extended periods, sometimes up to 15 minutes or longer, before being closed and transported for meal service. Staff interviews revealed a lack of knowledge regarding proper food serving temperatures and acknowledged that food trays could sit for 20 to 30 minutes before being served, especially for residents eating in their rooms. Temperature checks of food items at the time of service showed that hot foods, such as fish sandwiches, chicken sandwiches, fries, pulled pork, and mashed potatoes, were consistently below the facility's policy requirement of 135°F. Recorded temperatures ranged from approximately 104°F to 128°F at the time of service. The facility's own temperature logs indicated that food was cooked to appropriate temperatures but then sat for extended periods—between one hour and one and a half hours—before being served to residents, resulting in significant temperature drops. Staff interviews further confirmed that the facility no longer used a steam table to keep food hot due to staffing issues, and the current process did not ensure that food remained at safe temperatures. Staff also reported that the metal carts used for food delivery were not insulated, contributing to the loss of heat. The facility's policy required hot foods to be held and served at or above 135°F, but this standard was not met during the survey period, as evidenced by both staff statements and direct temperature measurements.
Failure to Properly Store, Label, and Monitor Food Items
Penalty
Summary
The facility failed to store, label, and monitor food in accordance with professional standards, as evidenced by multiple observations of expired, undated, and improperly stored food items in various storage areas. Surveyors found a package of strawberries covered in thick white mold in a refrigerator on the secure unit, and staff interviews revealed that a resident may have placed the strawberries there without staff noticing. In the dry storage area, six boxes of baking soda were found to be expired, and in the walk-in cooler, an open bag of undated Brussel sprouts and a bag of shallots with a use-by date had a white, slimy appearance and brownish liquid at the bottom. Staff acknowledged that all kitchen staff were responsible for checking and disposing of expired items, but these items had not been removed. A small food cooler in a public dining area lacked a thermometer and temperature logs, yet contained various undated food items, including yogurts, cheese snacks, and fruit bowls. Staff stated the cooler was not supposed to be in use but could not explain why it continued to be used. In the kitchen freezer, a plastic bag with unidentifiable frozen meat was found without a label or date, and staff could not confirm its contents. Additional observations included expired yogurt in a medication storage room refrigerator, and in the main dining room freezer, a half-eaten, undated ice cream cake with no patient identifiers, undated ice cream sandwiches, and undated frozen substances in disposable cups. Facility policy required labeling, dating, and monitoring of food items, but these procedures were not consistently followed.
Expired and Unlabeled Medications Found in Medication Room
Penalty
Summary
Expired and improperly labeled items were found in the medication room during an observation, including an open bottle of Humulin R insulin without resident identifiers or an open or expiration date, as well as expired Ayr Saline Nasal gel, A&D ointment, diaper rash ointment, a suture removal kit, and duoderm adhesive dressings. Staff interviews revealed that pharmacy staff are responsible for monthly checks of medication expiration dates, and facility staff are also expected to double-check for expired medications and supplies. Despite these procedures, expired items remained in the medication room, and a staff member responsible for monthly checks was unsure how the expired medications were missed. Facility policy requires pharmacy staff to verify all medication expiration dates and remove expired medications.
Failure to Implement and Enforce Infection Control Measures
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures for residents requiring enhanced barrier precautions. In two cases, residents with conditions necessitating enhanced barrier precautions—one with a Stage III pressure sore and another with a Foley catheter—did not have the required signage posted outside their rooms. There was also no evidence of a PPE supply cart or staff donning extra PPE for the resident with the pressure sore. Staff interviews confirmed awareness that these conditions required enhanced barrier precautions, but the signage and procedures were not consistently followed or implemented. Additionally, a staff member with a persistent cough, reportedly following a recent influenza outbreak, was observed not wearing a mask while coughing in a communal dining area. Multiple staff interviews indicated that this staff member was repeatedly reminded to wear a mask, in accordance with posted facility signage and policy, but did not consistently comply. The facility's posted instructions clearly stated that anyone with illness symptoms should wear a mask, but this was not enforced. Furthermore, a staff member working in the laundry area failed to perform hand hygiene after removing contaminated gown and gloves before entering the clean side of the laundry facility. This was observed by another staff member, who acknowledged the lapse and intended to address it. Facility policies required hand hygiene after handling contaminated laundry, but this protocol was not followed in practice.
Failure to Provide Appropriate Hydration Equipment Causes Resident Distress
Penalty
Summary
The facility failed to provide hydration in non-disposable cups, resulting in two residents experiencing distress and frustration. Observations showed that while lunch beverages such as juice, milk, and hot drinks were served in hard plastic cups, water was consistently provided in clear, soft plastic disposable cups. One resident expressed that using the disposable water cups made her feel as though she was in jail and caused her frustration due to shakiness and difficulty handling the cup. Another resident was observed struggling to grasp the soft plastic cup and was unable to drink from it, leading to visible distress and vocal expressions of frustration. Interviews with staff revealed conflicting accounts regarding the availability of appropriate cups. Dietary staff stated that there were sufficient hard plastic cups available in the kitchen and that nursing staff chose to use disposable cups for convenience. There was mention of a shortage of small hard plastic cups, but alternative sizes were available and could have been provided upon request. The facility's own standard of care policy indicated that residents should be provided with appropriate adaptive equipment to maintain or improve their ability to feed themselves, which was not followed in this instance.
PASARR Documentation Omission for Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's diagnosed mental health condition was accurately reflected on their PASARR documentation. Specifically, a review of the resident's physician orders showed that the resident was prescribed Aripiprazole 2 mg daily for bipolar disorder, with the diagnosis documented in the resident's past medical history and H&P. However, the PASARR completed for the resident did not list bipolar disorder as a diagnosis. Staff interviews confirmed that the diagnosis was present in the medical history and associated with a current medication order, but it was not included in the list of current diagnoses used to generate the PASARR, and staff were unable to explain the omission.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for a newly admitted resident. Observation revealed that the resident was experiencing swollen legs with sock indentations and reported discomfort, as well as a need for assistance with dressing, personal hygiene, and meal setup. The resident's medical history included congestive heart failure, diabetes mellitus Type 2, bipolar disorder, hypertension, obesity, and atrial fibrillation. Despite these complex needs, the baseline care plan was not completed within the required timeframe. Record review showed that the baseline care plan was initiated several days after admission and not completed until a week later. During an interview, the staff member responsible for care plans stated that the delay occurred because she was not present at the time of admission and no other staff initiated or completed the plan in her absence. Facility policy requires that a baseline care plan be developed within 48 hours of admission to ensure effective and person-centered care, but this was not followed in this instance.
Failure to Provide Showers According to Resident Preference
Penalty
Summary
A deficiency was identified when a resident did not receive showers according to their stated preference, as documented in their care plan, which indicated a preference for showers twice per week. Review of the resident's shower records over a 96-day period showed the resident received only 12 showers, with significant gaps of 27 and 26 days between some showers. Interviews with staff confirmed that the resident sometimes went a week and a half between showers, and there was uncertainty regarding documentation accuracy. Only one documented refusal was noted during the review period, indicating that missed showers were not due to resident refusal.
Pharmacist Failed to Identify Prolonged PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a licensed pharmacist identified and addressed the prolonged use of an as-needed (PRN) psychotropic medication for a resident. Review of the resident's physician orders showed a PRN order for Lorazepam oral concentrate, to be given every 8 hours as needed for anxiety, with no stop date indicated. The order was active from November 2024 through April 2025. Monthly medication regimen reviews conducted by the pharmacist for December 2024 through March 2025 did not identify any significant irregularities for this resident, despite the ongoing PRN order for a psychotropic medication. During an interview, the pharmacist responsible for the medication regimen reviews stated that she reviews progress notes, vital signs, labs, physician's orders, and assessments, and is aware that psychotropic medications should be minimized and PRN orders are generally limited to 14 days unless otherwise documented by the physician. However, she was unsure how she missed the prolonged PRN lorazepam order for multiple months. Facility policy requires that PRN psychotropic medications be limited to 14 days unless the physician documents a rationale and duration for continued use, which was not present in this case.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified Dietary Manager, as required for the food and nutrition service. During interviews, the Director of Food Services acknowledged that all of his certifications had expired and had been expired for some time. He reported that although he had registered for a certification course, he had not yet taken the test to renew his credentials. Another staff member confirmed that efforts were underway to get the Director certified. Review of the facility's job requirements for the Food Service Director indicated that ServSafe and State Certification in Safe Food Handling and Sanitation were required, with Certified Dietary Manager status preferred. This lack of current certification in the Director of Food Services had the potential to affect all residents in the facility.
Incomplete POLST Forms and Missing Provider Signatures
Penalty
Summary
The facility failed to ensure that Provider Orders for Life Sustaining Treatment (POLST) forms were fully and properly completed for two residents. For one resident, the POLST form indicated a preference for no CPR with selective treatment and was signed by the resident, but lacked the required signature from a physician or advanced practice practitioner. For another resident, the POLST form indicated a preference for comfort-focused treatment with no CPR, but the patient signature section only contained an 'x' and a check mark, with no printed name or date from the resident or their representative. During staff interviews, it was confirmed that POLST forms should be fully completed, including signatures, printed names, and dates from both the resident or their representative and the provider. The staff member interviewed was unable to explain why the forms were incomplete, though facility policy requires that POLST forms be reviewed and signed by a provider upon admission, with copies placed in the patient's chart and properly documented.
Inadequate Supervision and Chemical Safety in Secure Dementia Unit
Penalty
Summary
The facility failed to provide adequate supervision on a secure dementia unit, resulting in a resident ingesting odor eliminator. Staff member R expressed discomfort working alone on the secure care unit, citing safety concerns. Observations revealed that residents were left unsupervised in the dining room for 10 minutes. Staff member N confirmed that the shower room, where the incident occurred, was not locked, and various chemicals were found unsecured in the room. Resident #34, who is severely cognitively impaired, was known to drink anything left unattended, yet the only intervention was a sign in her room reminding her to call staff for a drink. Staff members acknowledged the need for locks on doors and one-on-one care for Resident #34, but these measures were not implemented due to staffing limitations. The SDS binder was also found to be incomplete, lacking information on several chemicals present in the unit. The facility also failed to provide adequate supervision for fall prevention for two residents. Resident #15 was observed ambulating without her walker and using furniture for support, despite her care plan indicating she required supervision and should not have a bedside table to prevent falls. Staff members had conflicting views on her fall risk, and her nursing progress notes documented multiple falls. Additionally, Resident #6 experienced a fall resulting in a head laceration requiring stitches due to the absence of foot pedals on his wheelchair. Staff members were inconsistent in their knowledge of Resident #6's ability to self-propel and the necessity of foot pedals, leading to inadequate fall prevention measures. The facility's failure to secure chemicals and provide adequate supervision resulted in significant safety hazards for residents with cognitive impairments. The lack of proper labeling and storage of chemicals, incomplete SDS information, and insufficient staffing contributed to these deficiencies. The incidents involving Resident #34, Resident #15, and Resident #6 highlight the need for improved safety protocols and staff training to prevent future occurrences.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on staff for at least eight consecutive hours a day, seven days a week. This deficiency was identified through a review of the CMS Payroll-based Journal, which showed the facility lacked RN coverage for eight consecutive hours on 39 days between 10/8/23 and 12/31/23. Additionally, the facility's nursing schedules confirmed the absence of RN coverage for eight consecutive hours on 10/29/23. During an interview on 4/23/24, a staff member reviewed the schedule and confirmed that no RN was scheduled on 10/29/23, without providing a reason for the absence.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food storage, hygiene, and sanitation practices in the kitchen. Observations revealed that food was stored directly on the floor in both the cooler and freezer, contrary to standard practice requiring food to be six inches off the floor. Additionally, a staff member improperly wore a beard cover, repeatedly touched his face and beard without performing hand hygiene while serving food. Another staff member failed to clean a thermometer before and between taking the temperatures of different foods on the buffet. These deficiencies were identified through observations, interviews, and record reviews, indicating lapses in adherence to professional standards for food storage and handling.
Failure to Ensure Access to Grievance Process and Proper Documentation
Penalty
Summary
The facility failed to ensure that staff and residents had access to the grievance process forms, were able to complete grievance forms for concerns voiced by residents, investigate grievances, and maintain evidence demonstrating the results of all grievances. This deficiency was observed in three of the 22 sampled residents. Resident #16 reported multiple complaints regarding staffing, food quality, a wound on her ankle, and not receiving ice water or food as ordered. Despite notifying staff and writing letters to the administrator, her concerns were not addressed, and she was unaware of a grievance process or form. Staff interviews revealed that grievance forms were not consistently provided or completed, and some staff members were unaware of where to find the forms. Additionally, the facility's grievance log did not include all reported concerns, and there was no evidence of investigation or follow-up for many grievances. Resident #35 also reported unresolved complaints about a cold room, not receiving a double bed as discussed, and dissatisfaction with the food. She and her husband were unaware of a grievance form or process and relied on floor staff to address their concerns. Staff member V, who was responsible for processing grievances, was unaware of any grievances beyond the two listed in the log and had not received any forms. The facility was in the process of placing grievance boxes with forms after surveyors questioned their location. Another resident and a family member also reported not knowing about the grievance process. The grievance box was found to be inaccessible to residents in wheelchairs, and staff members were generally unaware of the location of grievance forms.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature for four residents. Resident #16 reported that the food was consistently cold and often not what she ordered, despite voicing her concerns to management. Resident #35 also complained about the food being cold and repetitive. Staff member V confirmed that management receives test trays and completes questionnaires on food quality, but temperature issues persist. Surveyors observed that the food served was not at an appetizing temperature, and resident #16 was served spicy food despite a documented restriction against it. Resident #16 was visibly upset and had to call her husband to bring in food from outside. Resident #10 stated that food was always served late and not hot. Resident #21 also expressed concerns about hot food being served cold. During an observation, resident #33's breakfast was found to be below the required temperature, with eggs at 100 degrees Fahrenheit and potatoes at 90 degrees Fahrenheit. The plate had a cover but no food warmer underneath. According to the CDC, food items served should be at least 140 degrees Fahrenheit or higher.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to provide dignity and respect for residents by not adhering to the protocol of knocking and announcing themselves before entering resident rooms. This deficiency was observed in the cases of two residents. In the first instance, a staff member entered the room of a resident who was lying in bed and visiting with family members without knocking. The resident expressed frustration over the lack of privacy, and the family member confirmed that staff frequently entered without knocking. Despite acknowledging the protocol, the staff member repeated the action shortly after the initial observation. In the second instance, another resident was lying in bed when a staff member entered the room without knocking. A family member noted that while some staff knocked, most did not, and expressed frustration over the lack of privacy. This behavior was observed again when another staff member entered the same resident's room without knocking or asking for permission. Both staff members acknowledged that they were supposed to knock before entering but failed to do so. The facility's policy on resident rights and responsibilities, which includes the right to privacy, was not followed in these instances.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications. During an observation, a staff member was seen providing all of a resident's medications, but the resident had a bottle of Systane eye drops on her bedside table. The resident stated she administered the eye drops herself but could not verbalize the correct administration instructions or potential side effects. The staff member confirmed that no residents were allowed to self-administer medications. Further observation showed the resident administering the eye drops incorrectly and dropping the bottle on the floor before placing it back on the table. A review of the resident's records showed no physician's order for the eye drops or for self-administration of medications. The resident had a BIMS score indicating moderate cognitive impairment. The facility's policy required an assessment for self-administration of medications upon admission and quarterly, but no such assessment was found for the resident. The staff member also stated that the resident did not self-administer any medications, contradicting the observations.
Failure to Support Resident Bed Sharing Request
Penalty
Summary
The facility failed to support and assist two residents, who were spouses, in their request to share bed space. The couple had requested either a double bed or to have their single beds pushed together on 2/12/24. Despite multiple requests from the residents, the facility did not fulfill their request. During an observation and interview, the residents expressed their distress over the situation, with one resident becoming emotional and stating there was no reason they should not be allowed to share a bed. The surveyor observed that the single beds were placed in separate sections of the room, preventing the couple from sharing a bed as they wished. The facility's maintenance log showed a request for a wider/longer bed made on 2/12/24, but there was no completion date or comments indicating the task was completed. Interviews with staff revealed that the facility did not have longer or wider beds and the only option was to push the beds together and lock the wheels. However, this task was not completed, and there was no follow-up on the request. Staff members were unaware of why the beds had not been addressed, and no further complaints were received from the residents after the initial request at the care conference.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report findings following an incident of injury of unknown origin for one resident. The incident occurred when the resident complained of pain in the right shoulder, and an assessment revealed redness and a bruise on the left upper arm. The bruise measured approximately 10x6 cm. The resident could not recall what happened and stated she had not fallen. The facility did not submit the complete investigation and root cause analysis to the State Survey Agency within the required five working days. Additionally, a staff member responsible for reporting was unable to locate any findings or documentation of the incident being submitted to the State Survey Agency.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise a resident care plan to show effective interventions following multiple falls with injury for one resident. During an observation, the resident was seen pacing in the hallway without shoes, wearing regular socks, and had a large bruise on her left eye and forehead. Staff interviews revealed that the resident frequently fell, and the care plans were not updated with new interventions, leading staff to disregard them. Incident reports showed the resident had fallen multiple times, but the care plan had not been revised to include new interventions after these falls. A review of the facility's documents indicated that care plans should be reviewed and revised by each service responsible, and the fall prevention plan of care should be modified after a fall event. However, the resident's care plan, last revised after the most recent fall, did not include any new interventions following the previous falls. This lack of updating and revising the care plan contributed to the resident's continued falls and injuries.
Failure to Ensure Resident Access to Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident had access to their hearing aids for necessary communication. Observations and interviews revealed that the hearing aids were not consistently placed in the resident's ears in the morning, despite requests from the resident's daughter and instructions in the care plan. Staff members provided conflicting information about the location and handling of the hearing aids, with some stating they were kept in the resident's room and others indicating they were stored in the medication room for charging. This inconsistency led to the resident frequently being without their hearing aids, impacting their ability to hear conversations and watch television. Interviews with staff and the resident's family highlighted that the hearing aids were essential for the resident's daily activities, yet they were often not put in until specifically requested by the daughter. The care plan clearly stated that the hearing aids should be placed in the resident's ears in the morning, but this directive was not consistently followed. The failure to adhere to the care plan and ensure the resident had access to their hearing aids resulted in communication difficulties and a diminished quality of life for the resident.
Failure to Address Personal Refrigerator Use and Food Safety
Penalty
Summary
The facility failed to adequately address the use of personal refrigerators in resident rooms, leading to potential food safety issues. During an observation, a resident's refrigerator was found to contain expired food items, including open containers of yogurt and milk, and a dessert dish with unidentified contents. The refrigerator also had a sticky substance on the bottom. The resident was unsure how long the food had been in the refrigerator. Staff interviews revealed that refrigerator temperature checks were documented in the electronic medical record, but no specific policy for personal refrigerators was provided upon request. Staff members indicated they followed a policy from another facility, which required items to be labeled and dated, but this was not adhered to in this case. The deficiency was further highlighted by the lack of a clear policy on personal refrigerators and the inconsistent practice of checking and documenting refrigerator temperatures. Despite staff claims that the refrigerator was checked daily, the presence of expired and unlabeled food items indicated a failure in the implementation of proper infection prevention and control measures. The facility's inability to provide a specific policy for personal refrigerators during the survey further underscored the deficiency in addressing food safety and preventing foodborne illnesses among residents.
Inaccurate Staffing Information Submission to CMS
Penalty
Summary
The facility failed to electronically submit accurate and complete direct care staffing information to CMS. The CMS Payroll-based Journal for the facility indicated concerns for licensed nurse staff on 66 days and a lack of RN coverage for eight consecutive hours each day on 39 days within the specified period. However, a review of the facility's nursing schedules showed that licensed staff were present 24 hours a day, and RN coverage was maintained for eight consecutive hours each day except for one day. These findings were inconsistent with the PBJ submissions. During an interview, a staff member acknowledged the errors in the PBJ data and mentioned that corrections were made moving forward by adding missing job codes to the system.
Failure to Post Nurse Staffing Information Daily
Penalty
Summary
The facility failed to post the nurse staffing information on a daily basis at the beginning of each shift. During an observation on 4/22/24 at 6:30 p.m., it was found that the nurse staffing posting for the morning shift on 4/22/24 had not been filled out. Additionally, the posting for 4/18/24 was incomplete for the evening and night shifts. During an interview on 4/23/24 at 6:44 p.m., a staff member stated that nurses complete the posting after their shift but was unaware of why the postings on 4/18/24 and 4/22/24 were not completed.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Conrad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Health Care Center - Shelby | 23.7 mi | ★★★★★ | 0 | 0 |
| Northern Pines Rehabilitation And Nursing | 35.7 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.