Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Health Care Of Logan during CMS and state inspections, most recent first.
PASSARs did not accurately reflect current diagnoses for four residents. Medical records showed missing psychiatric and behavioral diagnoses, including depression, anxiety, PTSD, schizoaffective disorder, psychosis, and intellectual disabilities, while the DON confirmed the discrepancies and stated the nurse completing the PASSARs needed more education.
Improper Food Temperature Control During Meal Service: During meal service, coleslaw was held at 45.9 degrees F and later 47 degrees F instead of being kept at 41 degrees F or below, and it was served without being returned to the cooler. BBQ pork sandwiches were also held on the steam table with top layers ranging from 116.9 degrees F to 122.7 degrees F; staff reheated one pan in the oven and moved sandwich layers on the steam table until they reached 142.3 degrees F before serving. The CDM/Dietary Mgr acknowledged the cold food and reheating practices were not appropriate.
Failure to Obtain Consent for Psychotropic Medication: A resident had an order for Klonopin 0.5 mg PO daily for anxiety, but the facility administered the psychotropic medication without obtaining consent from the resident's legal representative. Surveyors found that consent was not obtained until after the medication had already been started, and the DON confirmed the issue.
A resident's POST form named the husband as surrogate, but after the husband became incapacitated and the daughter became the health care surrogate, the form was not reviewed or updated. The DON confirmed the facility did not obtain a new POST form when the surrogate changed.
A computer screen was observed unlocked and open to view with no staff member nearby, despite facility policy requiring workforce members to lock their screen whenever stepping away, even briefly. NA #153 later returned to the computer and closed it, and the DON confirmed the screen should be locked whenever staff have stepped away.
Failure to revise care plans for two residents. One resident’s care plan did not reflect eyes-on-resident monitoring for behaviors despite a history of multiple events with other residents, and another resident’s care plan did not include a documented GAD diagnosis that had been in the medical record since 06/14/23. The DON confirmed both omissions.
Failure to Provide Timely ADL Care: A dependent resident was observed yelling out while in a room with a strong urine odor. The resident was found soiled and wet, with dried brown rings on the fitted sheet. An LPN stated she did not know when the resident had last been changed, and the DON later confirmed the resident should have been changed sooner.
Expired supplies were found in one medication/storage room during an observation with an LPN. Items included Amsino [NAME] supplies, a suction catheter kit, urinary catheter Statlocks, and a urine test kit, all past the manufacturer-stamped expiration dates. The LPN agreed the items should have been discarded, and the DON confirmed the finding.
An LPN served a resident with dysphagia a drink that was not yet pudding thick, allowing him to take several sips before the inconsistency was recognized. The resident had orders for pureed food and pudding-thick liquids, with a history of cerebral infarction and swallowing impairment documented by SLP and MBSS findings.
A resident’s care plan contained incorrect dates for an inpatient psychiatric stay under the psychotropic medications focus area. During record review, surveyors found the dates were entered incorrectly, and the DON confirmed the error when notified.
Urinary storage bag on floor. A resident’s urinary storage bag was observed touching the floor, and an LPN stated it was due to the low bed and said she would take care of it. Later, the DON confirmed urinary storage bags should not be touching the floor.
The facility failed to document that the 5-day follow-up investigation for a Facility Reported Incident was sent to OHFLAC. A resident removed a toilet seat, broke a mirror, and displayed verbal behaviors toward staff; staff secured the area, removed sharp objects, and the physician ordered IM Haldol and Benadryl. Although the follow-up investigation was completed, there was no fax or email receipt confirming submission, and the DON and Administrator confirmed the missing documentation.
A resident with a history of psychiatric illness and repeated aggression physically assaulted another resident, causing significant injuries including facial lacerations, a hematoma, and suspected brain bleed. Despite existing care plan interventions and staff training, the aggressive behavior was not prevented, leading to actual harm.
Staff continued to use a blue laundry detergent known to cause skin irritation and rashes among multiple residents when the hypoallergenic detergent was unavailable. Despite previous complaints and awareness of adverse effects, the blue detergent remained stored and in use, leading to confirmed outbreaks of skin issues.
A facility failed to protect residents from abuse, leading to immediate jeopardy situations. An LPN verbally abused a resident, causing fear among others, while two residents with dementia were involved in nonconsensual sexual contact. The facility did not properly assess consent or take immediate corrective action, placing all residents at risk.
The facility failed to secure hazardous materials by leaving the Central Supply room door open and the cabinet unlocked, exposing residents to dangerous items. Staff interviews revealed a lack of adherence to safety protocols. Additionally, the facility did not implement adequate fall prevention measures for a resident, as fall mats were obstructed and a bed alarm was not properly connected.
The facility failed to maintain resident dignity and proper meal service. A resident was improperly transported backwards in a Geri chair, a practice confirmed by a nurse aide and deemed inappropriate by an RN. Additionally, meal service delays were observed, with residents waiting up to 15 minutes for meals, and inconsistencies in serving residents simultaneously in shared rooms. Staff interviews acknowledged these issues and the need for correction.
The facility did not protect the privacy of residents' medical records when a medication computer screen was left unlocked and visible, displaying residents' pictures and names. An LPN acknowledged the oversight, and an RN confirmed the screen should have been locked.
A resident was administered Ziprasidone before showers to prevent combative behavior, despite recommendations to specify the diagnosis or discontinue the medication. The DON stated it was necessary to prevent harm, as the resident had a history of hitting and scratching staff.
The facility failed to properly investigate an alleged sexual abuse incident involving two residents. Staff witnessed the residents in a sexual position, but the investigation lacked interviews with the involved parties and witnesses. The social worker did not obtain statements until after surveyor intervention and assumed consent without assessing the resident's capacity. The facility concluded no abuse occurred without sufficient evidence.
The facility failed to implement care plans for three residents, leading to deficiencies in hydration, activity engagement, and fall prevention. A resident at risk for dehydration did not receive adequate fluids, another was not invited to preferred activities, and a third had ineffective fall prevention measures due to obstructed fall mats and an unconnected bed alarm.
The facility failed to follow physician's orders for medication administration for multiple residents, leading to missed doses, incorrect documentation, and late administration. An LPN did not document medication administration during system downtime, and another LPN prematurely checked off medication before administering it. Additionally, a resident did not receive the prescribed water flush before feeding, and several medications were administered late to another resident.
A resident was prescribed an antipsychotic medication, Ziprasidone, to be administered before showers due to combative behavior. Despite recommendations to specify the diagnosis or discontinue the medication, it was continued without exploring non-pharmacological interventions. The DON stated the medication was necessary to prevent harm during showers.
The facility failed to serve meals at safe and appetizing temperatures, as observed during an evening meal service. Staff delays and improper handling led to meals being served cold, with temperatures recorded below acceptable levels. Multiple residents reported dissatisfaction with the temperature of their meals, indicating a recurring issue with meal service.
The facility failed to maintain infection control standards during medication administration, linen disposal, and dinner service. A resident's dinner tray was placed back on the cart with clean trays after being contaminated, and an LPN did not use a barrier for a medicine cup. Soiled linen was found under sinks in two rooms, confirmed by staff as inappropriate.
The facility failed to report a bruise on a cognitively impaired resident and an allegation of verbal abuse by another resident. A nurse noticed a bruise on a resident who claimed to have bumped her eye, but the incident was not reported to authorities. Another resident accused a male staff member of making threats, but the social worker was unaware, and the allegation was not reported. The COO and Quality Assurance Director confirmed the need for reporting.
A facility failed to provide an accurate bed hold policy to a resident and their responsible party upon discharge to the hospital. The resident used three Medicaid bed hold days during an initial hospital stay. Upon a subsequent discharge, the facility incorrectly notified the responsible party that 12 bed hold days were available, while only nine days remained. The business office manager confirmed the error, noting the discrepancy between the verbal communication and the written notice.
A facility failed to maintain a resident's personal hygiene by not shaving chin hair, which was approximately 3 cm long. The resident expressed discomfort with the chin hair and noted her nails were only recently cut. A nurse aide mentioned the resident sometimes refused care but was unsure when the chin hair was last shaved. Records showed no refusals of care in the past 30 days and lacked a care plan for refusals. The DON confirmed the chin hair should have been shaved.
The facility failed to provide a legible activity program calendar, as observed by surveyors who noted it was written in bright colors that were difficult to read. A resident confirmed the issue, stating the colors were too bright to decipher, even with glasses. The Activity Director acknowledged the problem.
A resident at risk for dehydration did not receive adequate hydration due to the absence of a water pitcher in their room. Despite the care plan's focus on preventing dehydration, observations confirmed the lack of water access, and the DON acknowledged the issue without providing a solution.
The facility did not complete yearly performance evaluations for all nurse aides, with two evaluations found incomplete. One evaluation lacked a completion date, while another was missing selections in the characteristics portion and was also undated. The Nurse Aide Supervisor acknowledged these oversights as mistakes.
The facility failed to maintain accurate medical records for three residents. An LPN prematurely documented medication administration before it was given, and discrepancies were found in a resident's POST forms, including conflicting information and incomplete documentation. The DON acknowledged the errors, and a nurse was unaware of documentation requirements.
PASSARs Did Not Reflect Residents’ Current Diagnoses
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASSAR) documents accurately reflected residents’ current diagnoses. During record review and staff interview, four of six residents reviewed for PASSAR had diagnoses in their medical records that were not included on the most recent PASSAR forms. The residents identified were #9, #13, #23, and #51, and the missing diagnoses included Adjustment Disorder with depressed mood, schizoaffective disorder bipolar type, Post Traumatic Stress Disorder, Major depressive disorder, generalized anxiety disorder, Schizoaffective Disorder, bipolar unspecified psychosis, and intellectual disabilities. For Resident #9, the medical record showed Adjustment Disorder with depressed mood and schizoaffective disorder bipolar type, but these were absent from the PASSAR dated 09/09/25. For Resident #13, the record showed PTSD, Major depressive disorder, and generalized anxiety disorder, but these were not included on the PASSAR dated 12/19/25. For Resident #23, the record showed Schizoaffective Disorder, bipolar unspecified psychosis, and intellectual disabilities, but these were not included on the PASSAR dated 12/22/25. For Resident #51, the PASSAR dated 03/26/24 did not include generalized anxiety disorder, which had been present in the medical record since 06/14/23. The DON confirmed the discrepancies for each resident and stated that the nurse who rounds with the doctor was completing the PASSARs and needed more education.
Improper Food Temperature Control During Meal Service
Penalty
Summary
Food was not held and served at safe temperatures during the noontime meal service in the kitchen. An observation beginning at 11:17 AM found coleslaw taken from the cooler and placed near the steam table on a cart for service with an initial temperature of 45.9 degrees F. When the temperature was checked again at 12:01 PM, it was 47 degrees F. The coleslaw was not returned to the cooler to be brought down to 41 degrees F or below, and staff began serving the meal after the last temperature was obtained. The Certified Dietary Manager acknowledged that cold food should be held at 41 degrees F or below and agreed the coleslaw was served anyway. BBQ pork sandwiches were also observed being held for service on the steam table. Two pans contained four layers of sandwiches each, and the top two layers on each tray had temperatures ranging from 116.9 degrees F to 122.7 degrees F. Staff placed one pan back into the oven to reheat, then removed the top two layers from the remaining pan and placed them in a pan on the steam table. The bottom two layers were greater than 135 degrees F, and the top two layers later reached 142.3 degrees F before being served to residents. The Dietary Manager confirmed the BBQ sandwiches should not have been reheated on the steam table and agreed they should have been reheated to 165 degrees F.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
Resident #2 had a physician's order for Klonopin 0.5 mg by mouth every day for anxiety, started on 08/27/25, but the facility did not obtain consent for this psychotropic medication until 02/09/26. During record review on 02/09/26, surveyors identified that the medication had been administered without consent from the resident's legal representative. On 02/10/26, the DON confirmed that the medication was given without the required consent.
Updated POST Form Not Completed After Surrogate Change
Penalty
Summary
Failure to ensure an updated Physician's Order for Scope of Treatment (POST) form was completed for Resident #50 was identified during record review and staff interview. The resident's POST form dated 03/28/23 named the husband as surrogate, but the resident's daughter was made surrogate on 05/21/24 after the husband became incapacitated, and the POST form was not reviewed and updated at that time. The DON confirmed during interview that the facility did not obtain a new POST form when the daughter became the health care surrogate.
Unlocked Computer Screen Exposed Confidential Records
Penalty
Summary
The facility failed to ensure medical records were kept private and confidential. During a tour of the facility on 02/03/26 at 3:00 PM, a computer screen was observed left unlocked and open to view, with no staff member near the computer. The facility policy provided by the DON stated that all workforce members must lock their computer screen whenever stepping away, even briefly. At 3:05 PM, NA #153 returned to the computer and closed the screen, and stated, "I never leave my computer up." At 4:00 PM, the DON was notified and confirmed the computer screen should be locked whenever staff have stepped away.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise care plans for two residents in the abuse care area. For Resident #92, the care plan had not been revised to reflect the use of eyes-on-resident monitoring for behaviors, even though the resident had a history of multiple events with other residents and the DON confirmed this monitoring was in effect. For Resident #51, the care plan had not been revised to include the diagnosis of Generalized Anxiety Disorder (GAD), which had been present in the medical record since 06/14/23, and the DON confirmed the diagnosis was not listed on the care plan.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide ADL care for a dependent resident. During observation on 02/02/2026 at 2:07 PM, the resident was heard yelling out, and upon entering the room a strong urine odor was noted. The resident was observed to be soiled and wet, and dried brown rings were seen on the fitted sheet. At 2:12 PM, an LPN stated that she did not know when the resident had last been changed and said, "we will get her cleaned up." At 3:15 PM, the DON was notified and confirmed the resident should have been changed sooner. At approximately 3:30 PM, the DON notified the surveyor that the resident was clean, dry, and odor-free.
Expired Supplies Found in Medication/Storage Room
Penalty
Summary
The facility failed to ensure that supplies in one of two medication/supply storage rooms were stored in accordance with accepted professional practices. During an observation of the [NAME] Wing medication/storage room with an LPN, surveyors found multiple expired supplies, including six Amsino [NAME] items, one suction catheter kit, four urinary catheter Statlocks, and one urine test kit. The expiration dates posted on the items showed that each had expired beyond the manufacturer's instructions. The LPN agreed that the stamped expiration dates were in the past and that the items should have been discarded, and the DON later confirmed this finding.
Improperly Thickened Liquids Served to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure Resident #12 received liquids at the pudding-thick consistency ordered for him. During the noon meal observation, an LPN was seen adding thickener to the resident’s orange Kool Aid in a 12-ounce cup that was nearly full. After stirring for at least two minutes, the liquid still did not hold its shape on a spoon and easily slid off in a dripping motion, indicating it was not pudding thick. Despite this, the resident was assisted to a sitting position and was able to drink from the cup before the inconsistency was identified. The resident’s record showed he had a physician order for a regular diet with pureed texture and pudding-thick liquids, and his care plan directed that diet. His history included cerebral infarction affecting the right dominant side and dysphagia following cerebral infarction. A prior speech-language pathology discharge note and a modified barium swallow study documented swallowing impairment and aspiration with thin and nectar consistencies. The DON confirmed the resident drank some of the liquid before it was thickened to the correct consistency, and the LPN had been educated about thickened liquids.
Inaccurate Care Plan Dates for Psychiatric Stay
Penalty
Summary
The facility failed to maintain an accurate and complete record for Resident #92 in the care plan under the focus area of psychotropic medications. During record review, the care plan listed incorrect dates for the resident’s inpatient psychiatric stay, showing 12/17/25 until 01/10/25 instead of the correct dates of 12/17/24 until 01/10/25. This was identified for one of five residents reviewed under the abuse care area, and the Director of Nursing confirmed the dates were incorrect when notified.
Urinary Storage Bag on Floor
Penalty
Summary
The facility failed to maintain an effective infection control program for urinary storage bags. During an observation of Resident #10, the resident’s urinary storage bag was found on the floor at 2:05 PM on 02/02/2026. When notified four minutes later, an LPN stated that it was because the bed was low and said, "I'll take care of it." Later that afternoon, the DON was notified and confirmed that urinary storage bags should not be touching the floor.
Failure to Document Timely Submission of 5-Day Follow-Up Investigation
Penalty
Summary
The facility failed to report the results of all investigations to the appropriate state officials within five working days of a Facility Reported Incident involving Resident #23. The incident occurred when the resident removed the toilet seat from the toilet and crashed it into a mirror, breaking the mirror; staff responded after hearing the loud noise and provided safety for the resident. The resident displayed verbal behaviors toward staff, and the in-house physician was contacted with new orders for Haldol 15 mg IM x1 and Benadryl 125 mg IM x1. Staff cleaned up the glass and removed multiple sharp objects from the room, along with other objects that could be used to injure the resident or others. Although the 5-Day Follow-up investigation was completed, there was no documentation of fax or email receipts confirming that the follow-up was sent to OHFLAC, and the DON and Administrator confirmed there was no documentation showing it had been sent.
Resident-to-Resident Physical Abuse Resulting in Actual Harm
Penalty
Summary
A deficiency occurred when a resident with a documented history of psychiatric illness and repeated verbal and physical aggression physically assaulted another resident, resulting in actual physical injury. The aggressive resident's care plan included interventions such as redirection, coping skills encouragement, monitoring for triggers, and offering sensory tools, but these measures did not prevent the incident. On the day of the event, the aggressive resident struck another resident in the face twice with a closed fist after an altercation in the hallway, causing the victim to sustain superficial lacerations, a large hematoma, orbital fractures, and a suspected brain bleed. Prior to this incident, the aggressive resident had a pattern of similar behaviors, including striking staff, being involved in altercations with other residents, and requiring psychiatric interventions and medication adjustments. Despite these interventions and repeated staff in-services on abuse prevention and resident redirection, the resident continued to display aggressive behaviors, including pushing another resident and punching a roommate. The care plan was updated, and 1:1 supervision was initiated after previous incidents, but these actions were not sufficient to prevent the assault that resulted in significant harm. The facility's failure to ensure the safety of all residents and to prevent resident-to-resident abuse led to actual harm. The incident was reported to law enforcement, and the aggressive resident was ultimately removed from the facility. The deficiency was identified as past non-compliance, as the facility had already taken corrective actions prior to the survey.
Failure to Prevent Resident Skin Irritation from Laundry Detergent
Penalty
Summary
The facility failed to ensure that residents were protected from skin irritation and rashes associated with the use of a specific laundry detergent known to cause such reactions. During the survey, it was found that the blue detergent, which had previously caused outbreaks of rashes and itchiness among approximately half of the residents (from neck to feet, but not on hands or face), was still being stored and used in the facility. Record review and staff interviews confirmed that the hypoallergenic detergent was intended for use, but when it was unavailable, staff substituted the blue detergent, despite being aware of its adverse effects on residents. Observation in the laundry area revealed both the blue and a clear detergent present, with the blue detergent still accessible and connected for use. The laundry aide confirmed that the blue detergent was used as a backup and acknowledged that its use led to skin issues among residents. The administrator was unaware that the blue detergent remained in use, despite previous complaints and known skin-related concerns. This sequence of actions and inactions resulted in a substantiated deficiency affecting all residents reviewed during the survey.
Failure to Protect Residents from Abuse and Nonconsensual Contact
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in immediate jeopardy situations. Resident #75 was subjected to verbal abuse by LPN #28, causing fear and anxiety among the residents. Witnesses reported that LPN #28 yelled and used inappropriate language towards Resident #75, discussing personal medical information in front of others. Despite multiple witness statements confirming the verbal abuse, the facility did not initially substantiate the report, and LPN #28 continued to work at the facility. Resident #91, who suffers from end-stage dementia and is rarely understood, was involved in a nonconsensual sexual contact incident with another resident, Resident #61. The facility's staff, including the social worker and DON, failed to assess Resident #91's ability to consent to sexual contact, relying instead on the resident's wandering behavior as a form of consent. The healthcare decision maker's approval was inappropriately used to justify the lack of investigation into the incident, and the facility's care plan included provisions for privacy during such encounters, which was inappropriate given the residents' inability to consent. The facility's inaction in both cases placed all residents at risk, as the staff failed to recognize and address the abuse and neglect. The lack of proper assessment and understanding of consent, combined with the failure to take immediate corrective action, resulted in a serious deficiency in the care and protection of the residents.
Removal Plan
- The administrator, Director of Nursing and Human Resources Director terminated employee #28. All staff were informed that all or any form of abuse or neglect toward a resident would result in immediate termination.
- All residents were interviewed by administrative staff to ensure that they felt safe and had never endured any type of abuse or neglect. Any residents unable to be interviewed were assessed for any visible signs of abuse or neglect with any corrective action immediately upon discovery.
- The Director of Nursing and Social Worker has begun in-servicing ALL staff about facility abuse and neglect zero tolerance policy and procedure and failure to comply resulting in immediate termination. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Abuse and Neglect Policy and Procedure, ensure that any employee who commits any act of abuse or neglect will be terminated immediately. The Social Worker will complete the log attached for all reports of abuse and neglect and turn the log in to the Administrator each time a complaint is made so the Administrator can handle corrective action of the staff immediately. To ensure continued compliance, the monitoring log will be re-evaluated.
- The administrator assigned 1:1 staffing at all times for resident #91 to ensure she is free from non-consensual sexual acts. All staff were informed that all residents are to be kept free from non-consensual sexual harm despite their mental capacities.
- All residents were interviewed by administrative staff to ensure that they had never been subject to non-consensual acts of sexual nature with any corrective action immediately upon discovery.
- The Director of Nursing and Social Worker has begun in-servicing ALL staff about facility's policy and procedure about resident engaging in sexual acts and what is prohibited. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Resident Sexual Acts Policy and Procedure, ensure that staff intervene prior to any non-consensual sexual acts occur between residents. All residents within the building will be evaluated for their capabilities to consent to sexual acts. A monitoring log will be completed to ensure that all residents are evaluated for their capabilities to consent to sexual acts upon admission, at any cognitive change, and/or quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting.
Facility Fails to Secure Hazardous Materials and Implement Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment by leaving the Central Supply room door open and the cabinet inside unlocked, exposing residents to potentially hazardous materials. During an observation, it was noted that the door to the Central Supply room was left open, and staff members did not take action to close it. Inside the room, various hazardous items such as disposable razors, rubbing alcohol, iodine prep solution, and syringes with needles were accessible to residents. This situation posed a significant risk to residents, particularly those identified as wanderers, who could potentially access these dangerous items. Interviews with staff revealed a lack of awareness and adherence to safety protocols. A nurse aide expressed uncertainty about whether the door was usually left open, while a licensed practical nurse suggested that maintenance might have left it open. The nurse also mentioned that the cabinet containing needles was likely left unlocked due to a nurse being distracted by other staff. This indicates a breakdown in communication and responsibility among staff members, contributing to the unsafe environment. Additionally, the facility failed to implement adequate fall prevention measures for a resident at risk of falls. Observations showed that fall mats were obstructed by furniture, and a bed alarm was not properly connected, rendering it ineffective. This oversight further highlights the facility's failure to ensure resident safety, as the necessary interventions to prevent falls were not consistently applied or monitored.
Removal Plan
- The administrator ensured that all razors, needles, scalpels, medicated powders, creams, and any other solution if consumed could be harmful was moved from the Central Supply Room to the East Wing Medication Room. All staff were informed that the items were relocated and even though those items are being placed elsewhere the Central Supply Room door is to remain closed at all times and locked.
- Video footage with full view of the Central Supply Room door was reviewed to ensure no residents entered the room for potential to have consumed any toxic substance with any corrective action immediately upon discovery.
- The administrator completed an in-service for all staff to ensure they are aware that the Central Supply Room door is to remain closed and locked at all times and the new location of the potentially harmful substances in the East Wing Medication Room. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Keeping Residents Free from Potentially Harmful Substances and Items Policy and Procedure, ensure that staff keep all doors locked and all substances out of reach as appropriate. A monitoring log will be completed to ensure that all doors with locks are locked and all potentially harmful substances are kept in a safe area out of residents reach daily for 30 days, weekly for one month, and quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting.
Deficiencies in Resident Dignity and Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during the dining experience and by improperly transporting a resident. An observation revealed a nurse aide pulling a resident backwards in a Geri chair down a hallway, which was confirmed by the nurse aide as a regular practice. A registered nurse confirmed that staff should not be pulling residents backwards, indicating a lack of adherence to proper resident handling procedures. Additionally, during meal services, there were significant delays and inconsistencies in serving meals to residents. In the main dining room, 19 residents were left waiting for their meals while others were served, leading to a 15-minute delay. On the East Wing, residents were not served simultaneously within the same room, resulting in one resident waiting 13 minutes longer than their roommate for a meal. These observations were corroborated by staff interviews, which acknowledged the irregularities and the need for correction.
Failure to Safeguard Resident Medical Record Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical records in the [NAME] wing. During a tour, it was observed that the medication computer screen was left unlocked and visible to anyone passing by, displaying residents' pictures and names. This incident involved multiple residents, as indicated by the list of resident numbers provided. A Licensed Practical Nurse (LPN) acknowledged the oversight, stating they thought the screen was locked. A Registered Nurse (RN) was later informed of the situation and confirmed that the screen should have been locked, indicating awareness of the protocol that was not followed.
Failure to Ensure Resident is Free from Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of an antipsychotic medication, Ziprasidone, to a resident before showers. The medication was given to prevent the resident from becoming combative during the showering process. This practice was identified during a record review and staff interview, where it was noted that the medication was administered intramuscularly every Tuesday, Thursday, and Saturday, 20 minutes prior to the resident's shower. The medication regimen review from May 2023 recommended either specifying the diagnosis or discontinuing the medication, but the order remained unchanged. During an interview with the Director of Nursing, it was revealed that the medication was deemed necessary to manage the resident's combative behavior during showers, as the resident had a history of hitting and scratching staff, posing a risk of harm to herself and others. The facility's census at the time was 111, and this issue was identified for one resident reviewed for chemical restraints during the survey process.
Inadequate Investigation of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, identified as Resident #91 and Resident #61. The incident occurred when staff members witnessed the two residents in a sexual position in Resident #61's bed. Despite the presence of four staff members during the incident, the facility's investigation was inadequate, as it did not include interviews with the alleged victim, the alleged perpetrator, or any witnesses. The facility's five-day follow-up report lacked detailed summaries of interviews and failed to provide relevant information from the residents' clinical records or other documents. The social worker involved in the case did not take statements from the staff who witnessed the incident until after surveyor intervention. The social worker's rationale for not obtaining statements was based on a conversation with the healthcare decision maker, who indicated that the interaction was acceptable if consensual. However, the social worker did not assess whether Resident #91, who has dementia, was capable of giving consent. The social worker's actions and assumptions contributed to the deficiency in the investigation process. The facility's response to the incident was insufficient, as it did not verify or refute the allegation of abuse. The investigation lacked thoroughness, with no evidence collected to support or dismiss the claim. The facility's conclusion that there was no abuse or neglect was based on inadequate investigation and documentation, failing to address the seriousness of the situation and the potential vulnerability of the residents involved.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to implement hydration interventions for a resident at risk for dehydration. The resident expressed that she did not receive juice and snacks as before, and no water pitcher was observed in her room during multiple visits. The care plan indicated the resident was at risk for dehydration and required encouragement to drink fluids, but these interventions were not implemented. The Director of Nursing acknowledged the absence of a water pitcher and was unsure about the need for adaptive equipment. Another resident expressed a desire to participate in activities such as singing, but was not invited to these events. The activity director confirmed that the resident was scheduled for in-room visits, but the care plan did not specify the frequency of these visits. The resident's activity notes indicated confusion and participation in some activities, but there was no clear plan for regular engagement in preferred activities. A third resident's fall prevention plan was not properly implemented. Observations revealed that fall mats were obstructed by furniture and equipment, and the bed alarm was not connected, rendering it ineffective. Despite the care plan's focus on fall prevention, these interventions were not consistently applied, as confirmed by staff during observations.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for five residents, as identified during the survey process. For Resident #15, the Medication Administration Record (MAR) for May 2024 was not initialed by the nurse, indicating that medications were not administered as ordered on multiple occasions. The Director of Nursing (DON) and Licensed Practical Nurses (LPNs) were unable to provide evidence of medication administration or documentation on downtime forms, suggesting a lapse in following protocol when electronic systems were unavailable. Resident #85 experienced a discrepancy in medication administration timing, where the MAR indicated medication was given before it was actually administered. Additionally, the LPN failed to check the resident's pulse before administering Toprol XL, as required by the physician's order. This oversight was acknowledged by the LPN, who attributed the error to prematurely checking off the medication due to the resident's request to smoke. For Resident #19, the LPN did not follow the physician's order for a 60-milliliter water flush before administering feeding and medications, instead using a portion of the 200-milliliter flush. Resident #57's medications were repeatedly administered outside the prescribed time frames, with delays ranging from over an hour to more than six hours. Lastly, Resident #361's MAR showed a blank space for a medication pass, with no documentation to confirm administration, and the DON could not provide additional evidence. These findings indicate a systemic issue with medication administration and documentation within the facility.
Unnecessary Use of Psychotropic Medication Before Showers
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free of unnecessary psychotropic medications. Specifically, an antipsychotic medication, Ziprasidone, was prescribed to a resident before showers. The medication was administered intramuscularly every Tuesday, Thursday, and Saturday, 20 minutes prior to the resident's shower. The recommendation from a medication regimen review in May 2023 suggested that the diagnosis should be more specific or the medication should be discontinued. Despite this, the medication was continued, and the resident received the injection on multiple occasions from May to July 2023. During an interview, the Director of Nursing (DON) explained that the medication was necessary to manage the resident's combative behavior during showers, as the resident would hit and scratch staff, posing a risk of harm to herself and others. This indicates that the facility did not explore or implement gradual dose reductions or non-pharmacological interventions as required, leading to the continued use of the psychotropic medication without sufficient justification.
Deficiency in Serving Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to serve food and drink that was palatable, attractive, and at a safe and appetizing temperature, as observed during an evening meal service. Staff were seen bringing trays into the dining room and placing them in a meal cart, which delayed the serving of meals to residents. When the last tray was served, the Certified Dietary Manager recorded temperatures that were below acceptable levels: chicken at 113.0 degrees Fahrenheit, mashed potatoes at 117.0 degrees Fahrenheit, and milk at 54.8 degrees Fahrenheit. These temperatures were confirmed to be outside the required range for safe consumption. Multiple residents expressed dissatisfaction with the temperature of their meals. One resident's meal was served without a cover, leading to contamination concerns, and was later reheated after the resident complained about it being cold. Other residents also reported that their food was often served cold, indicating a recurring issue with meal temperature. These observations and resident interviews highlight a systemic problem with meal service in the facility, affecting the quality of care provided to the residents.
Infection Control Deficiencies in Medication, Linen, and Meal Service
Penalty
Summary
The facility failed to maintain appropriate infection control standards in several areas, including medication administration, disposal of soiled linen, and dinner service. During a dinner service observation, a nurse aide placed a contaminated dinner tray back on the cart with clean trays after realizing it lacked a cover. This breach was confirmed by the Assistant Nurse Aide Supervisor and reported to the Licensed Practical Nurse and the Administrator. Additionally, during medication administration for a resident, an LPN failed to use a barrier before placing a medicine cup on the medication cart, acknowledging the oversight when notified. Further observations revealed issues with soiled linen management. A soiled towel was found under the sink in a resident's bedroom, and used bed linen was observed on the floor under the sink in another room during meal tray pass. Both instances were confirmed by staff members, including an LPN and the Administrator, who acknowledged that the linen should not have been left on the floor. These observations indicate lapses in infection control practices within the facility.
Failure to Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report an allegation of verbal abuse for a resident and a bruise on another resident. In the first case, a nurse noticed a bruise under the eye of a resident who was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The resident claimed to have bumped her eye on a cabinet, and the nurse informed the emergency contact. However, the incident was not reported to the appropriate authorities as required, with the social worker and administrator stating it was not reported because it was not considered harm, and the nurse did not witness the incident. In the second case, a resident made an accusation against a male staff member, claiming he threatened her. The resident was noted to be agitated and talking to herself, with attempts at redirection being unsuccessful. The progress note documenting this was made by an LPN, but the social worker was unaware of the incident and questioned whether it should be reported. The Chief Operating Officer and Quality Assurance Director confirmed that the allegation should have been reported, but it was not. An interview with the resident did not yield further information as she denied any inappropriate behavior from staff.
Inaccurate Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide an accurate bed hold policy to a resident and their responsible party upon discharge to the hospital. This deficiency was identified during a review of the medical records and staff interviews for a resident who was hospitalized. The resident initially went to the hospital and used three of her Medicaid bed hold days. Upon a subsequent discharge to the hospital, the facility issued a bed hold notice indicating the resident still had 12 Medicaid bed hold days available, which was incorrect. The business office manager confirmed that the resident only had nine bed hold days left at the time, and the discrepancy was due to the incorrect information on the bed hold notice, despite the correct number being communicated verbally.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to a dependent resident, specifically in maintaining good personal hygiene. During an observation, it was noted that a resident had chin hair approximately 3 centimeters long, which covered most of her chin. The resident expressed that the chin hairs bothered her and mentioned that her nails were only recently cut. A nurse aide who provided care to the resident stated that the resident sometimes refused care, but was unsure when the chin hair was last shaved. A review of the resident's records showed no refusals of care for the past 30 days and no care plan addressing refusals of care. The Director of Nursing confirmed that the resident's chin hairs should have been shaved.
Illegible Activity Program Calendar
Penalty
Summary
The facility failed to provide an activity program calendar that was clearly visible and legible to residents. On June 3, 2024, at 1:04 PM, two surveyors observed that the May activity program calendar was displayed near the main dining room and activity office. The calendar was written in bright colors such as bright orange, lime green, hot pink, and purple, which made it difficult to read. This observation was confirmed during an interview with a resident at 1:30 PM, who stated that the colors were too bright to read, even with glasses. At 1:40 PM, the Activity Director acknowledged the issue, agreeing that the colors made the schedule hard to read.
Failure to Ensure Proper Hydration for a Resident
Penalty
Summary
The facility failed to ensure proper hydration for a resident, identified as Resident #27, during the survey process. The deficiency was identified through record review and interviews with the resident and staff. Resident #27 reported not receiving juice and snacks as before and expressed experiencing a dry mouth. Observations conducted on multiple occasions revealed the absence of a water pitcher in the resident's room, indicating a lack of access to water. The care plan for Resident #27 highlighted a risk for dehydration, with specific interventions to encourage fluid intake, yet these were not being implemented effectively. The Director of Nursing (DON) acknowledged the absence of a water pitcher in Resident #27's room during an observation. Despite the resident's care plan indicating a risk for dehydration, there were no adaptive equipment orders to address potential difficulties the resident might have in handling regular water pitchers. The DON was unable to provide an explanation for the absence of a water pitcher or adaptive equipment, indicating a lapse in ensuring the resident's hydration needs were met.
Incomplete Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to ensure that yearly performance evaluations were completed for each nurse aide, as evidenced by the review of nurse aide performance evaluations during the survey process. Specifically, two out of five nurse aide evaluations were found to be incomplete. The evaluation for one nurse aide was filled out but lacked a date indicating when it was completed. Another nurse aide's evaluation did not have a completed characteristics portion, with none of the options (unsatisfactory, satisfactory, good, excellent) selected, and it was also undated. During an interview, the Nurse Aide Supervisor acknowledged the incomplete evaluations and attributed them to a mistake.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents during the survey process. For one resident, a discrepancy was observed during medication administration. The resident requested their medication, and the LPN noted that the medication had already been documented as given in the Medication Administration Record (MAR), despite not having administered it. The LPN later realized they had prematurely checked off the medication as given before the resident went to smoke. This incident was reported to the Director of Nursing (DON), who acknowledged the discrepancy without further comment. Another resident's medical record review revealed inconsistencies in the Physician's Scope of Treatment (POST) forms. Two forms were found with conflicting information regarding the resident's wishes for a feeding tube. The DON confirmed that the physician's order was incorrect, as it did not reflect the most recent POST form. Additionally, the POST form for this resident was incomplete, lacking the section for the professional assisting in its completion, despite evidence that assistance was provided. A registered nurse confirmed they were unaware of the requirement to complete this section if the resident had capacity.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Logan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Hillcrest Healthcare Center | 15.3 mi | ★★★★★ | 0 | 0 |
| Trinity Health Care Of Mingo | 21.6 mi | ★★★★★ | 11 | 0 |
| Tug Valley Arh Skilled Nursing Facility | 22.4 mi | ★★★★★ | 0 | 0 |
| Lincoln Healthcare Center | 27.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.