Logan County Senior Living Inc

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the required supervision to prevent Resident (R) 1, a cognitively impaired resident at risk of elopement and a high risk for falls, from exiting the facility without staff knowledge or supervision. The facility also failed to ensure staff performed the required 15-30 minute safety checks; therefore, staff did not identify the resident was out of the facility for one hour and 15 minutes. On 06/06/2026 at 10:00 AM, R1 exited the facility via the North door, which was left ajar by a staff member. At 11:15 AM, Certified Nurse Aide (CNA) M alerted staff that R1 was missing. Staff located R1 lying face down in the grass of the facility at 11:45 AM, one hour and 45 minutes after the resident eloped. The weather at the time was 77-81 degrees Fahrenheit (F) with wind speeds up to 16 miles per hour (mph). [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure Resident (R) 2 was free from verbal abuse.

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents, with five reviewed for hospitalization. Based on interview, and record review, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) for four residents, (R) 1, R6, R7, R12, and R13, and failed to provide two residents, R6 and R12, with written information regarding the facility's bed hold policy when they were transferred to the hospital.

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistance organism which employ targeted gown and glove use during high contact care) were used for two residents with urinary catheters (a tube inserted into the bladder to drain the urine into a collection bag), Resident (R)3 and R6

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents, with five residents reviewed for immunizations, Resident (R) 2, R15, R16, and R27, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer and/or obtain an informed declination or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). Findings Included: - Review of the clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20 for the following residents. [...]

Inspectors wroteThe facility identified a census of 27 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to prevent staff from physically forcing Resident (R) 1 to take her medications when she refused to take her medications. On 12/15/24 at approximately 07:20 AM, Licensed Nurse (LN) G attempted to administer medications to R1. R1 swatted LN G's hand away indicating R1 did not want to take the medications. LN G pushed R1's hands away into her lap, removed R1's coffee cup asR1 attempted to grab it and replaced it with a cup of water. LN G then held R1's shoulders and attempted to spoon the medications into R1's mouth. R1 spit out the medications and LN G placed the medications that were spit out back on the spoon and attempted to administer the medications again. [...]

Inspectors wroteThe facility had a census of 27 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents. Based on record review and interview, the facility failed to provide Resident (R)5, R19, and R79 or their representative, the accurate Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. This placed the resident at risk of uninformed decisions about their skilled services.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13, with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R)22, who had dementia and behaviors. This placed the resident at risk for abuse and decreased quality of life.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to staff followed acceptable standard of practice related to wound care for Resident (R) 79, who had an infected wound. This placed the resident at risk for delayed healing and other complications.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure the environment was free of accident hazards for two sampled residents, Resident (R) 9, and R18, when the facility failed to assess the residents to safely use an electric wheelchair or to safely smoke. This placed the residents at risk for preventable accidents and injury.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents with nine reviewed for mood and behavior. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)2. This placed her at risk for impaired quality of life due to untreated and ongoing mental health concerns. Findings - R2's Electronic Health Record (EHR) revealed diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteThe facility had a census of 27 residents. The sample included 13, with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R)22, who had dementia and behaviors. This placed the resident at risk for abuse and decreased quality of life.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of out-of-parameter blood sugars for one resident, Resident (R) 18. This placed the resident at risk for unnecessary medication side effects and other related complications.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to date Resident (R)11's insulin (a hormone that allows cells throughout the body to uptake glucose) flex pen. This deficient practice placed the resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)3. This placed R3 at risk for inappropriate end-of-life care.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures for Resident (R) 79 before, during, and after wound care. This placed the resident at risk for continued wound infection, cross contamination, and other infectious disease.

Inspectors wroteThe facility had a census of 27 residents. The sample included 13 residents. Based on record review and interview the facility failed to ensure the residents received their mail on Saturdays.

Inspectors wroteThe facility identified a census of 24 residents with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to prevent a fall out of a wheelchair when staff failed to place foot pedals on the wheelchair before assisting Resident (R) 1 outside in her wheelchair. On 12/15/23 at approximately 06:20 PM, Licensed Nurse (LN) G propelled R1 down the sloped sidewalk, without foot pedals on the wheelchair, and R1 planted her feet on the sidewalk and leaned forward, causing her to fall face first on the sidewalk. The fall resulted in a forehead hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) and laceration (cut) which required sutures to close, abrasions, and a cervical (neck/spine) fracture (broken bone) of R1's first vertebrae (the first bone at the top of the spine). [...]

Inspectors wroteThe facility identified a census of 23 residents with three residents reviewed for accidents. Based on record review, observation, and interview, the facility failed to follow Resident (R) 1's care plan, which directed two staff to assist the resident for transfers with a sit to stand lift, which resulted in a very large skin tear to R1's posterior left calf which measured 4.5 centimeters (cm) by 3 cm. On 10/30/23 between 05:00 PM and 05:30 PM, Certified Nurse Aide (CNA) M transferred R1 from the toilet using the sit to stand lift by herself and R1 sustained a skin tear to her left posterior leg. CNA M did not notice R1 was bleeding from the skin tear until after she transferred R1 back to the wheelchair using the sit to stand lift by herself. This deficient practice placed R1 at risk for skin tears, pain, and delayed healing.

Inspectors wroteThe facility identified a census of 25 residents with three residents reviewed for quality of care. Based on record review, observation, and interview, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to ensure Resident (R)1 received the antibiotic treatment as ordered by the infectious disease physician. On [DATE] R1 readmitted to the facility after an acute hospital stay related to empyema (collection of pus in the pleural cavity related to bacterial pneumonia). Upon readmission, facility staff noted R1's three antibiotic medications did not have a stop date noted. [...]

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with one reviewed for infection control. Based on observation, record review, and interview, the facility failed to prevent the development and transmission of infection for one of the three residents who received blood glucose testing (a blood sample test which measures the amount of sugar in the blood) R7. The facility also failed to properly store Resident (R) 1, R22, R28 and R21's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help).

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess Resident (R) 25's side rail for safe use. This placed the resident at risk for injury.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, medical director, and physician, the inappropriate diagnosis for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for two of five sampled residents, Resident (R) 12 and R17. This placed the residents at risk for inappropriate use of an antipsychotic medication.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor behaviors for Resident (R) 18, and use an appropriate diagnosis for R12 and R17 who both received an antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions ) medication. This placed the residents at risk for lack of appropriate behavioral treatment and inappropriate use of an antipsychotic medication.