Logan Health - Conrad

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a baseline care plan, outlining pertinent information needed to care for a new resident within 48 hours of admission for 1 (#139) of 17 sampled residents. This deficient practice had the ability to affect all new admissions receiving care in the facility. Findings include: During an observation and interview on 4/22/25 at 8:16 a.m., resident #139 was sitting on the edge of his bed watching TV. The volume on the TV was very loud. Resident #139 had his legs in a dependent position, with his feet on the floor. His legs appeared to be swollen and there was an indentation on his legs from his socks. Resident #139 stated he had heart problems, and his legs were swollen all the time. Resident #139 states it can be uncomfortable at times. Resident #139 stated he needed some assistance with getting dressed, personal hygiene, and some help with setting up his meals. Review of resident #139's diagnoses list showed he had congestive heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident was showered according to their preference for 1 (#4) of 17 sampled residents. Findings include: During an interview on 4/22/25 at 11:11 a.m., NF2 stated the facility was sometimes short staffed and resident #4 would go a week and a half between showers. During an interview on 4/24/25 at 9:40 a.m., staff member B stated she was unsure if there was an error in documentation or if staff should have charted refused and selected n/a instead, but the records showed resident #4 was getting a shower about every nine days. Staff member B instituted a paper charting system to correct the deficiency. Review of resident #4's shower records, dated 1/1/25 - 4/23/25, showed the resident received 12 showers over the 96-day span. - 1/3/25 - 2/21/25 resident #4 was shown as having a shower every seven days. - 3/20/25 is the next documented shower, a 27 day gap. - 4/15/25 is the next documented shower, a 26 day gap. Review of resident #4's shower records, dated 1/1/25 - 4/23/25, showed only one documented refusal on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the pharmacist identifed and addressed an as needed psychotropic medication for an excessive duration for 1 (#20) of 17 sampled residents. Findings include: Review of resident #20's physician orders, dated 11/21/24 to 4/23/25, showed an order for Lorazepam oral concentrate 2 MG/ML. Give 0.25 ml by mouth every 8 hours as needed for anxiety. No stop date was noted on the orders. Review of resident #20's monthly medication regimen review, completed by staff member L showed: - December 2024-Resident #20, No Significant Irregularities. - January 2025-Resident #20, No Significant Irregularities. - February 2025-Resident #20, No Significant Irregularities. - March 2025-Resident #20, No Significant Irregularities. During an interview on 4/24/25 at 9:01 a.m., staff member L stated she was responsible for the facility's medication regimen reviews. Staff member L stated when the medication regimen reviews were due she looked in the chart at progress notes, vital signs, current labs, physician's orders, assessments, and noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to limit an as needed anti-anxiety medication order to 14 days or provide a physician's rationale for continued extension of the medication's use, for 1 (#20) of 17 sampled residents. Findings include: Review of resident #20's physician's orders, dated 11/21/24 to 4/23/25, showed an order for Lorazepam oral concentrate 2 MG/ML. Give 0.25 ml by mouth every 8 hours as needed for anxiety. No stop date noted on the orders. Review of physician's progress notes dated 12/18/24, 2/11/25, and 4/15/25, showed no documentation for the continued use of lorazepam past 14 days. During an interview on 4/24/25 at 9:01 a.m., staff member L stated, Psychotropic medications are frowned upon and should be minimized. Psychotropic medications have a 14-day limit and after that time the physician needs to re-evaluate the resident. Review of a facility document titled, Extended Care Consultant Pharmacist, with an effective date of 5/2021, showed: . iii. PRN Psychotropic Drugs: 1. PRN orders for psychotropic drugs are limited to 14 days, b.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have a qualified Dietary Manager. This deficient practice had the potential to affect all residents in the facility. Findings include: During an interview on 4/21/25 at 11:26 a.m., staff member N introduced himself as the Director of Food Services. Staff member N stated he had been in that position since May 2024. Staff member N stated that all of his certifications had expired, and had been for awhile, but he had been trying to get them up to date again. Staff member N stated he registered for the course in October 2024 but had not taken the test yet. During an interview on 2/23/25 at 4:00 p.m., staff member S stated they were working on getting staff member N certified. Review of a facility document titled, Food Service Director, Undated, showed: . Job requirements - Bachelor's degree or at least 5 years' experience managing a culinary department or operation. - ServSafe and State Certified in Safe Food Handling and Sanitation . - Certified Dietary Manager Preferred.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Provider Order for Life Sustaining Treatment (POLST) was completed to include the signature, date, and time the provider signed the order for 1 (#31) and failed to ensure all areas of the form were completed by the resident or the resident representative for 1 (#139) of 17 sampled residents. Findings include: Review of resident #31's POLST form showed resident #31 wanted no CPR (cardiopulmonary resuscitation) with selective treatment. Resident #31 signed the form on [DATE], but the POLST form was not signed by a physician, or an advanced practice practitioner. Review of resident #139's POLST form showed resident #139 wanted comfort focused treatment with no CPR (cardiopulmonary resuscitation). In the patient signature section of the form there appeared to be what looked like an x and a check mark. There was no printed name or date signed by the resident or resident representative. During an interview on [DATE] at 10:32 a.m., staff member H…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a registered nurse was on staff at least eight consecutive hours a day, seven days a week. This practice had the potential to affect any resident needing RN services when one was not available. Findings include: Review of the CMS [NAME] Payroll-based Journal for this facility, with a run date of 4/16/24, showed the facility triggered for not having RN coverage for eight consecutive hours each day on 39 days between the dates of 10/8/23 and 12/31/23. Review of the facility's nursing schedules, dated 10/8/23 - 12/31/23, reflected the facility did not have RN coverage for eight consecutive hours on 10/29/23. During an interview on 4/23/24 at 3:35 p.m., staff member B reviewed the schedule with the surveyor, and stated the facility did not have a registered nurse on 10/29/23. Staff member B did not know why a registered nurse was not scheduled.

Based on observations, interviews, and record review, the facility failed to ensure food was stored off the floor in the cooler and freezer; that staff wore beard covers appropriately; cleaned thermometers before use; and ensured proper hand hygiene was used and followed when serving food. These practices had the potential to affect all residents who received food from the kitchen. Findings include: 1. During an observation on 4/22/24 at 1:25 p.m., there was a stack of 13 food filled boxes on the floor of the freezer. One crate of 2% Milk was on the floor of the cooler. During an interview on 4/23/24 at 10:05 a.m., NF5 stated, food in coolers and freezers should be six inches off the floor, as a standard practice. 2. During an observation on 4/25/24 at 8:10 a.m., staff member X was wearing a beard cover, only covering his chin and mouth, not covering his full beard. Staff member X repeatedly touched his beard, beard cover, and nose while serving breakfast food at the buffet line in the main dining room. Staff member X pulled at his beard cover adjusting it 14 times in six minutes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure the 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 for 3 (#s 16, 21, and 35) of 22 sampled residents. This practice had the potential to affect anyone wanting to file a grievance or who had filed a grievance. Findings include: 1. During an interview on 4/22/24 at 2:46 p.m., resident #16 stated she had many complaints regarding staffing, the quality of the food, a wound on her ankle, not getting ice water throughout the day, and not receiving food as ordered on her meal ticket. Resident #16 stated she had notified staff member A of her concerns, but did not hear anything back on how her concerns were addressed, and many of her concerns had not been addressed at all. Resident #16 stated her husband and her both wrote letters to the administrator regarding their concerns, and they called her sometimes as well. NF3 stated he had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to provide palatable food at an appetizing temperature for 4 (#s 10, 16, 21, and 33) of 22 sampled residents. Findings include: 1. During an interview on 4/22/24 at 2:46 p.m., resident #16 stated the quality of the food was a concern for her. Resident #16 stated the food was consistently cold, and often not what she ordered. Resident #16 stated she had voiced her concerns to the management staff regarding the food temperature and spicy food. 2. During an interview on 4/23/24 at 9:38 a.m., resident #35 stated, The food is always cold, and we (resident's #33 and 35) are tired of the same things over and over. During an interview on 4/23/24 at 2:00 p.m., staff member V stated the management receives test trays from the kitchen throughout the month. The management staff then complete a questionnaire on the food's quality, appearance, taste, and temperature. Staff member V stated, The temperature continues to be an issue and residents do complain about it, with good reason. During an observation on 4/24/24 at 12:05 p.m., surveyors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide dignity and respect for residents when staff failed to knock and announce theselves prior to entering the resident rooms, causing frustration, for 2 (#s 2 and 190), and their family members, of 22 sampled residents. Findings include: 1. During an observation and interview on 4/23/24 at 8:54 a.m., resident #2 was lying in bed visiting with family members. Staff member M walked into the room without knocking. Resident #2 stated, I have no privacy, staff just walk in whenever they want. It is frustrating. NF2 stated, The staff do that all the time. I am here frequently, and it is rare to have a staff member knock before they enter [Resident #2's] room. It is frustrating that I can not even have a conversation with [Resident #2] with out someone just walking in. This is [Resident #2's] home. During an interview on 4/23/24 at 8:58 a.m., staff member M stated staff were to knock and get permission before entering a resident's room. During an observation on 4/23/24 at 9:00 a.m., staff member M walked into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 1 (#31) of 22 sampled residents. Findings include: During an observation and interview on 4/24/24 at 7:55 a.m., staff member O was performing the morning medication pass. Staff member O stated she provided all of resident #31's medications to her. During an observation and interview on 4/24/24 at 8:05 a.m., staff member O took resident #31 her morning medications. On resident #31's bedside table was a bottle of Systane eye drops. Resident #31 stated she gave herself the eye drops, when she needed them. Resident #31 could not verbalize correct administration instructions or if there were any side effects of the Systane. During an interview on 4/24/24 at 8:09 a.m., staff member O stated she did not have any residents that were able to self-administer medications. During an observation on 4/24/24 at 9:10 a.m., resident #31 was sitting on the side of her bed. On the bedside table was a bottle of Systane eye drops, the lid was not on the bottle of eye…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to support and assist 2 residents, (#s 33 and 35) who were spouses, and the couple wished to share bed space but couldn't due to the lack of staff assistance, of 22 sampled residents. Findings include: During an observation and interview on 4/23/24 at 9:38 a.m., resident #35 stated she and resident #33 (a married couple) were told they could have a double bed in their shared room, or the single beds could be put together. Resident #35 stated she had asked the floor staff several times about the double bed but had not received a double bed or assistance with having the beds pushed together. Resident #35 began to cry, and she stated there was no reason she and her husband (#33) should not be allowed to share a bed. Resident #33 stated his bed was too short, and his feet dangled off the end. This surveyor observed the single beds, in separate sections of the room, and they were across from one another. The room was a double occupancy room. Therefore, the two were unable to share the same bed. The couple made the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to thoroughly investigate and report findings following a facility reported incident of injury of unknown origin for 1 (#11) of 22 sampled residents. Findings include: Review of a facility reported incident submitted to the State Survey Agency on 11/22/23, showed an incident of unknown origin occurred with resident #11 on 11/21/23 at 12:30 p.m. In the report, resident #11 complained of pain to the right shoulder. The facility's assessment of resident #11's shoulder showed redness as well as a bruise to the left upper arm. An area was measured but no location was specified as showed in the report: Resident stated she had not fallen and could not recall what happened . The bruise was approx 10x6 cm. A request for the complete investigation and root cause analysis related to the event was requested on 4/22/24 at 1:40 p.m., and was not recieved prior to the end of the survey. No findings were submitted to the State Survey Agency within the required reporting timeline of five working days from when the incident occurred as the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to revise a resident care plan to show effective interventions following multiple falls with injury for 1 (#12) of 22 sampled residents. Findings include: During an observation on 4/22/24 at 3:26 p.m., resident #12 was pacing up and down the hallway, in the secure care unit. Resident #12 was wearing regular socks, and no shoes. Resident #12 had a large yellow and purple bruise noted to her left eye and forehead area. During an interview on 4/22/24 at 3:29 p.m., staff member J stated resident #12 fell all the time. Staff member J stated it was not unusual for residents on the secure care unit to fall and be bruised. Staff member J stated, I had asked staff member A about the bruise on resident #12, and staff member A did not give me any information. Staff member J stated she believed all staff have access to resident care plans. When asked by the surveyor about the use of shoes or non-skid socks, Staff member J stated, The interventions are never updated so most of us (staff) don't bother looking anymore.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident had access to his hearing aids for necessary communication, and the hearing aids were kept by the nursing staff when not in use, and instructions for use were provided to staff on his care plan, for 1 (#6) of 22 residents. Findings include: During an interview on 4/22/24 at 3:50 p.m., NF7 stated she came to the facility almost every morning, and resident #6's hearing aids were never put in her ears until she specifically asked for the hearing aids to be placed. During an observation and interview on 4/24/24 at 1:04 p.m., resident #6 did not have his hearing aids in, and he was was having a hard time hearing the conversation with the staff. Staff member M stated the hearing aids were typically located in resident #6's room, on a hook, near the sink. Staff member M stated, I could not find them (the hearing aids) this morning. Staff member M stated, I could not find them yesterday either. During an interview and observation on 4/25/24 at 10:51 a.m., staff member I stated hearing aids were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to address the use of resident refrigerators sufficiently, and in a manner to promote safety, for the prevention of food borne illnesses and having expired food disposed of timely, for 1 (#2) of 22 sampled residents. Findings include: During an observation on 4/22/24 at 3:04 p.m., resident #2 had a refrigerator in his room. No refrigerator temperature logs were visualized by the surveyor. During an interview on 4/22/24 at 4:08 p.m., staff member B stated the temperature checks for the refrigerators are documented in the resident's electronic medical record, under tasks, for each resident with a refrigerator. During an observation and interview on 4/23/24 at 8:54 a.m., resident #2's personal refrigerator in his room was observed to have a sticky substance stuck to the bottom, on the inside of the refrigerator. There were two open containers of vanilla yogurt, with a use by date of 4/19/24 and 4/21/24, a small, open container of milk with an expiration date of 4/21/24, and a facility dessert dish covered with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility staff failed to ensure a dependent resident had access to a call light for 1 (#105) of 5 sampled residents. This deficient practice caused the resident to feel frustrated and disrespected. Findings include: During an observation and interview on 3/6/24 at 12:55 p.m., resident #105 was seated in an electric wheelchair in the middle of the room. Resident #105's call light was plugged into the wall, clipped to itself, and was across the room. Resident #105 could not reach the call light from his seated postion in his electric wheelchair. Resident #105 stated, I never have my call light, staff never give it to me. If I need something I have to leave my room and go find someone or sit out at the nurse's station until someone sees me. I have had to yell out a couple of times for help, I should not have to resort to yelling out for help. It is frustrating and disrespectful. During an observation on 3/6/24 at 2:26 p.m., resident #105 was sitting in his electric wheelchair in the middle of the room. Resident #105 could not reach the call light,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to update and revise a care plan to show a wound, and any interventions associated with the wound, for 1 (#105) of 5 sampled residents. Findings include: During a phone interview on 3/6/24 at 9:45 a.m., NF2 stated resident #105 had a wound on his shin, since November 2023, and the wound was still not healed. During a phone interview on 3/6/24 at 10:08 a.m., NF3 stated she noticed the wound on resident #105's left shin area. NF3 stated when staff were asked about what happened they could not answer. NF3 stated, The nurse told me she did not know what happened, nothing was reported to her. During an observation and interview on 3/6/23 at 12:55 p.m., resident #105 was sitting in an electric wheelchair with a blanket across his lap. On resident #105's left lower extremity there was a dressing noted to his shin area. Resident #105 stated he had gotten the wound on his leg in November. During an interview on 3/6/24 at 1:10 p.m., staff member F stated nursing staff and the care plan team were responsible for updating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility nursing staff failed to assess, document, and provide initial wound care in a timely manner for 1 (#105) of 5 sampled residents. This deficient practice increased the risk of a deterioration of the wound for the dependent resident. Findings include: During a phone interview on 3/6/24 at 9:45 a.m., NF2 stated resident #105 had a wound on his shin since November 2023, and it was still not healed. NF2 stated whenever he had asked about the wound he was told by staff, they were not sure about it. NF2 stated, The staff in that place have no idea what is going on. When you ask a question the only answer you ever get is I don't know, that was never reported to me. NF2 stated, They (the facility) call and let me know about minor things but do not ever notify me of some of the bigger things, I have to find out from [Resident #105]. It is so frustrating. I quit asking questions because the answer is always the same, nobody knows. The same things happen over and over again. During a phone interview on 3/6/24 at 10:58 a.m., NF1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review a facility staff member verbally abused and failed to regard the need for care when requested for a resident, for 1 (#1) of 12 sampled residents. Findings include: Review of a Facility Reported Incident, sent to the State Survey Agency, dated 8/5/23, showed, DON was called this time by a nurse on the floor who was informed of a situation that happened between 10 and 11pm last night, August 5th, 2023. Allegation of verbal misconduct in a resident room. Investigation started at the time it was reported today. The CNA that is alleged has been removed from the facility pending investigation of alleged misconduct. Resident(s) Involved. [Resident #1]. . Parties Accused [NF1] (staff). [sic] The facility investigation findings, submitted on 8/11/23, showed: The employee is still suspended as we continue the investigation; [NF1] has not had any contact with our residents since 8/5/2023. Interviews by the HR department continues with other associates. We will follow the disciplinary/corrective action steps when investigation is completed. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.