Embassy of Logan

Inspectors wroteBased on observation, staff interview, and facility policy and procedure, the facility failed to prepare and serve food under sanitary conditions. This had the potential to affect the 92 of 92 residents who receive trays from the kitchen. The census was 92.

Inspectors wroteBased on interviews, observation, policy and audit reviews, the facility failed to ensure water temperatures did not exceed 120 degrees Fahrenheit (F) in the shower rooms on hallways 200 and 400. This had the potential to affect 42 residents (200 Hallway-Resident #51, Resident #27, Resident #64, Resident #39, Resident #15, Resident #33, Resident #89, Resident #41, Resident #45, Resident #85, Resident #34, Resident #79, Resident #08, Resident #54, Resident #01, Resident #40, Resident #23, Resident #36, Resident #12, and Resident #72. 400 Hallway-Resident #65, Resident #29, Resident #20, Resident #77, Resident #71, Resident #92, Resident #58, Resident #26, Resident #81, Resident #07, Resident #67, Resident #18, Resident # 74, Resident #93, Resident #101, Resident #75, Resident #48, Resident #80, Resident # 52, Resident #82, Resident #04, and Resident #69). The census was 92. [...]

Inspectors wroteBased on interview, record review and policy review the facility failed to show documented evidence of resident and family participation in the care planning process. This affected one resident (#50) of one sampled for care planning. The facility census was 92.

Inspectors wroteBased on interviews, and record review, the facility failed to follow up on appropriate and timely completion regarding correct eyeglass prescription. This affected one resident (Resident #11) of two residents reviewed for activities of daily living. The census was 92. Review of the medical record for Resident #11 revealed an admission date of 04/30/25. Diagnoses include schizoaffective disorder and chronic obstructive pulmonary disease (COPD). Further review of the medical record revealed Resident #11's eyeglasses were obtained while at the facility and added to Resident #11's inventory sheet on 09/19/25. Glasses adjustment by 360 Care completed on 11/04/25. On 03/16/26 interview with Resident #11 revealed eyeglasses are not the correct prescription, and I have told someone about this. On 03/17/26 at 2:10 P.M. [...]

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure the physician ordered treatment was implemented. This affected one resident (#9) of three residents reviewed for skin conditions. The facility census was 92. Findings Include:Review of the resident's medical record for Resident #9 revealed an initial admission date of 02/17/21 with the latest readmission date of 08/03/21 with the diagnoses including but not limited to polyneuropathy, chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, speech disturbances, anxiety disorder, schizophrenia, hyperlipidemia, dry eye syndrome, GERD, PTSD, major depressive disorder, BPH and insomnia. Review of the plan of care dated 11/28/25 revealed the resident had impaired skin integrity related to a skin tear to the left outer knee. [...]

Inspectors wroteBased on medical record review, interview and policy review the facility failed to follow physician recommended parameters for medication. This affected one resident (Resident #5) of five residents reviewed for unnecessary medication. The census was 92. Review of the medical record for Resident #5 revealed an admission date of 10/31/25 and diagnoses of cerebral infarction, unspecified and unspecified asthma, uncomplicated. Review of medical orders revealed an order from 01/30/26 for Metoprolol Tartrate Oral Tablet 25 milligrams (MG) oral tablet 25 MG (Metoprolol Tartate). Give 1.5 tablet by mouth two times a day for hypertension (HTN). Hold if static blood pressure (SBP) below 110 or heart rate (HR) below 60. Review of the medical administration record revealed no documented SBP or HR from 01/30/26-02/26/26. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to maintain a complete and accurate medical record. This affected three residents (#5, #9 and #12) of 19 sampled residents. The facility census was 92. Findings Included:1. Review of the resident's medical record for Resident #9 revealed an initial admission date of 02/17/21 with the latest readmission date of 08/03/21 with the diagnoses including but not limited to polyneuropathy, chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, speech disturbances, anxiety disorder, schizophrenia, hyperlipidemia, dry eye syndrome, GERD, PTSD, major depressive disorder, BPH and insomnia. Review of the plan of care dated 11/28/25 revealed the resident had impaired skin integrity related to a skin tear to the left outer knee. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to document treatments completed on two pressure ulcers for one resident (#111) of three residents reviewed. The facility census was 96.

Inspectors wroteBased on record review ,staff interview, and facility policy review, the facility failed to ensure the physician was notified after a change in condition of a new wound or the worsening of a current wound. This affected four residents (#3, #74, #89, and #93) of seven reviewed for skin impairments. Facility census was 98.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents' rooms were maintained in a safe, functional, and sanitary manner. This affected six residents (Resident #6, #21, #53, #62, #63, and #152) of 32 that were observed for room conditions. The facility census was 98.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #6) of one residents reviewed for PASRR documents. The facility census was 98. Findings Include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation/ mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder. Review of Resident #6's Preadmission Screening and Resident Review (PASRR) Identification Screen dated 11/30/23 revealed under Section (D.) the resident was identified as having a diagnosis of dementia. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #6) of one residents reviewed for PASRR documents. The facility census was 98. Findings Include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation/ mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder. Review of Resident #6's Preadmission Screening and Resident Review (PASRR) Identification Screen dated 11/30/23 revealed under Section (D.) the resident was identified as having a diagnosis of dementia. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure skin and wound assessments were completed thoroughly, accurately, and timely for three residents (#3, #74 and #89) of four reviewed for non-pressure wounds. The facility census was 98.

Inspectors wroteBased on medical record, skin assessment review, staff interview, and facility policy review, the facility failed to properly document a newly identified pressure wound. This affected one (Resident #93) of the seven residents reviewed for skin assessment accuracy. The facility census was 98.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident receiving a narcotic pain medication ordered on an as needed basis (prn) had parameters ordered from the physician on when to administer the medication. This affected one (Resident #6) of five residents reviewed for unnecessary medications. The facility census was 98.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure laboratory tests were completed as ordered by the physician. This affected one (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 98.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain the outside physical environment in a safe manner to prevent Resident #2 from sustaining a fall with injury. Actual harm occurred on 03/25/23 when Resident #2, who was independent with the use of a motorized (power) wheelchair sustained a fall in the parking lot, when his wheelchair fell into a pot hole resulting in a proximal humerus fracture to his right arm. The resident had increased pain to the area and was unable to use the motorized wheelchair for independent mobility for a period of time following the incident/injury. This affected one resident (#2) of five residents reviewed for accidents. The facility census was 98.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two (Resident #59 and Resident #61) of four residents reviewed for PASRR documents. The census was 98. Findings Include: 1. Resident #59 was admitted to the facility on [DATE]. Her diagnoses were neurocognitive disorder with lewy bodies, chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, occlusion and stenosis of unspecified carotid artery, psychotic disorder with delusions due to known physiological condition, other symbolic dysfunctions, insomnia, anxiety disorder, cognitive communication deficit, and mood disorder. Review of her Minimum Data Set (MDS) assessment, dated 04/19/23, revealed she had a mild cognitive impairment. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected two (Resident #59 and Resident #61) of three residents reviewed for PASRR documents. The census was 98. Findings Include: 1. Resident #59 was admitted to the facility on [DATE]. Her diagnoses were neurocognitive disorder with lewy bodies, chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, occlusion and stenosis of unspecified carotid artery, psychotic disorder with delusions due to known physiological condition, other symbolic dysfunctions, insomnia, anxiety disorder, cognitive communication deficit, and mood disorder. Review of her Minimum Data Set (MDS) assessment, dated 04/19/23, revealed she had a mild cognitive impairment. [...]

Inspectors wroteBased on interview and record review the facility failed to implement a care plan related to non compliance/refusal of activities of daily living care for Resident #61. This affected one resident (Resident #61) of four residents reviewed for activities of daily living care. The facility census was 98.

Inspectors wroteBased on observation, interview and record review the facility failed to revise the plan of care of Resident #2 related to being up in his power wheelchair. This affected one ( Resident #2) of five residents reviewed for updated care plan. The facility census was 98.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents received care and services to prevent worsening of contracture's. This affected two residents (#18 and #34) out of the four residents reviewed for limited range of motion during the annual survey. The facility census was 98.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide proper justification for the use of psychotropic medications. This affected two (Residents #21 and #64) of five residents reviewed for unnecessary medications. The census was 98. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were dementia, pneumonitis, delirium, muscle weakness, repeated falls, shortness of breath, anxiety disease, major depressive disorder, dysphagia, hyperlipidemia, hypertension, osteoarthritis, cognitive communication deficit, and traumatic subdural hemorrhage. Review of her Minimum Data Set (MDS) assessment, dated 04/02/23, revealed she had a significant cognitive impairment. [...]