Trinity Health Care of Logan

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASSAR) accurately reflected each resident's diagnoses. This was true for four (4) of six (6) residents reviewed for the care area of PASSAR during the long-term care survey. Resident Identifiers: #9, #13, #23, and #51. Facility Census: 112 a) Resident #9 A review of Resident #9's medical record on 02/10/26 found the following relevant diagnoses Adjustment Disorder with depressed mood and schizoaffective disorder bipolar type. A review of the most recent PASSAR, dated 09/09/25, found the aforementioned diagnoses were not included on the PASSAR. An interview with the Director of Nursing (DON), at 10:00 AM on 02/10/26, confirmed the PASSAR did not accurately reflect the resident's current diagnoses. [...]

Inspectors wroteBased on observation, temperature measurements, and staff interview, the facility failed to ensure they held food for service at a safe temperature to prevent the spread of food borne illnesses. In addition, when the food was identified as having a temperature within the danger zone the facility failed to reheat to an appropriate temperature before serving the food. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 112. An observation of the noontime meal service, on 02/09/26 beginning at 11:17 AM, in the facility's kitchen found the following issues: 1. [NAME] Slaw Temperature The first temperature of the coleslaw was 45.9 degrees Fahrenheit (F). This temperature was obtained when it was taken from the cooler and was placed near the steam table on a cart in preparation of service. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to obtain consent for a psychotropic medication for Resident #2. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #2. Facility Census: 112. Findings Include: a) Resident #2 On 02/09/26 at 8:44 PM, a record review was completed for Resident #2. The review found a physician's order for Klonopin 0.5 milligrams (mg) by mouth every day for anxiety that was started on 08/27/25. The facility did not obtain a consent for this psychotropic medication until 02/09/26. On 02/10/26 at 8:55 AM, the Director of Nursing (DON) confirmed the medication was administered without consent from the resident's legal representative.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an updated Physician's Order for Scope of Treatment (POST) form was completed for Resident #50. This was true for one (1) of four (4) residents reviewed under the care area of Advanced Directives. Resident identifier: #50. Facility census: 112.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure medical records were kept private and confidential. This was a random opportunity for discovery. Facility Census: 112. Findings Include:a) Facility PolicyThe Director of Nursing (DON) provided a document entitled, HIPPA Education: Computer Screen Security. Under the heading of Computer Screen Security Requirements, the first bullet states, All workforce members must: Lock their computer screen whenever stepping away, even briefly.b) Hallway ComputerOn 02/03/26 at 3:00 PM, during a tour of the facility, a computer screen was left unlocked and open to view. No staff member was near the computer. On 02/03/26 at 3:05 PM, Nurse Aide (NA) #153 returned to the computer. At this time, NA #153 closed the computer. NA #153 stated, I never leave my computer up. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to report the results of all investigations to the appropriate state officials within five (5) working days of a Facility Reported Incident involving an unusual occurrence. Resident Identifier: #23 Facility Census: #112. Findings Include:a) Resident #23 (FRI #240863)On 02/03/26, a review of a Facility Report Incident involving Resident #23 showed an incident occurred on 09/15/24 at 4:00 AM and was reported to the Office of Health Facility Licensure and Certification (OHFLAC) on 09/16/24 at 8:00 AM.The unwitnessed incident involved Resident #23 removing the toilet seat from his toilet and crashing it into a mirror, breaking it. Staff responded to the resident's room after hearing the loud noise and provided safety for the resident. The resident had verbal behaviors towards the staff. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan for Resident #92 and Resident #51. This was true for two (2) of five (5) residents reviewed under the care area of abuse. Resident Identifier: #92 and #51. Facility Census: 112. Findings Include:a) Resident #92On 02/03/26 at 12:20 PM, a record review was completed for Resident #92. The review found the care plan had not been revised regarding eyes on resident for monitoring of behaviors. The resident has a history of multiple events with other residents. On 02/03/26 at 12:58 PM, the Director of Nursing (DON) was notified and confirmed this type of monitoring was in effect.b) Resident #51On 02/04/26 at 9:03 AM, a record review was completed for Resident #51. The review found the care plan had not been revised to include the diagnosis of Generalized Anxiety Disorder (GAD). [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide activities of daily living (ADL) care for a dependent resident #45. This was true for one (1) of one (1) residents reviewed under the care area of ADLs. Resident Identifier: #45. Facility Census: 112Findings Include: a) Resident #45On 02/02/2026 at 2:07 PM, Resident #51 was yelling out. Upon entering the room, a strong urine smell was noted. Upon further observation, the resident was soiled and wet. Dried, brown rings were seen on the fitted sheet. On 02/02/26 at 2:12 PM, Licensed Practical Nurse (LPN) #53 stated, I don't know when she was changed last .we will get her cleaned up. On 02/02/26 at 3:15 PM, the Director of Nursing (DON) was notified and confirmed the resident should have been changed sooner. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure all supplies used in the facility were stored in accordance with current accepted professional practices. This was true for one (1) of two (2) medication/supply storage rooms. The facility failed to ensure expired supplies were discarded and maintained within the acceptable expiration dates. This practice had the potential to affect a minimal number of residents. Facility Census: #112.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure Resident #12 received liquid which was thick enough to meet his individual needs to prevent the risk of aspiration. This was a random opportunity for discovery and was true for Resident #12. Facility Census: 112. Findings Include:The facility failed to ensure Resident #12 was served liquid in a consistency which met his individual needs. He had an order for pudding thickened liquids and was given liquids which were not pudding thickened. Observations of Resident #12, during the noon time meal on 02/09/26 at 1:04 PM, found Licensed Practical Nurse (LPN) #144 was adding thickener to his orange Kool Aid. The Kool aid was in a 12-ounce cup and was just shy of being completely full. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain accurate and complete record for Resident #92. This was true for one (1) of five (5) residents reviewed under the care area of abuse. Resident Identifier: #92. Facility Census: 112. Findings Include:a) Resident #92On 02/03/26 at 12:20 PM, a review of the care plan was completed for Resident #92. The review found under the focus area of the resident uses psychotropic medications, the incorrect dates of an inpatient psychiatric stay. The dates listed were 12/17/25 until 01/10/25. The correct dates should have been 12/17/24 until 01/10/25. On 02/03/26 at 12:58 PM, the Director of Nursing (DON) was notified and confirmed the dates would be corrected on the care plan.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an effective infection control program for urinary storage bags. This was a random opportunity for discovery. Resident Identifier: #10. Facility Census: 112. Findings Include: a) Resident #10 On 02/02/2026 at 2:05 PM, an observation found Resident #10's urinary storage bag on the floor. On 02/02/26 at 2:09 PM, Licensed Practical Nurse (LPN) #53 was notified and stated, it's because it's a low bed. LPN #53 then stated, I'll take care of it. On 02/02/26 at approximately 3:30 PM, the Director of Nursing (DON) was notified and confirmed the urinary storage bags should not be touching the floor.

Inspectors wroteBased on record review, staff interview, the facility failed to ensure residents were free from physical abuse when Resident#12 physically assaulted another resident , resulting in actual physical injury. This failure resulted in actual harm and had the potential to affect all residents residing in the Long Term Care facility. Residetn Identifier: #11 and #12 Facility Census: 111This failed practice was consider to be at past non-compliance, as the facility identified and corrected the failed practice prior to surveyors entering the building. Findings Include:Review completed on 10/21/25 of Resident #12 clinical record revealed a history of psychiatric illness with repeated verbal and physical aggression toward staff and peersThe care plan (initiated 12/26/24, updated 6/04/25) addressed Verbal/Physical Aggression with interventions to:Redirect using a calm, non-threatening tone. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure that residents were free from skin irritation and rashes associated with the use of a laundry detergent known to cause skin irritation. This deficient practice has the potential to affect all residents within the nursing home and was substantiated for 3 of 3 residents reviewed during the long-term care survey process.

Inspectors wroteBased on record review, resident observations and staff interviews the facility failed to ensure Resident #91 was free from nonconsensual sexual contact. In addition the facility failed to ensure Resident #75 was free from verbal abuse. The occurances with Resident #91 and Resident #75 both constituted an Immediate jeopardy (IJ) situation. The state agency (SA) determined the failure to protect Resident #75 from verbal abuse caused Resident #75 fear and anxiety due to verbal abuse from Licensed Practical Nurse (LPN) #28. At the time of the incident Resident #75 was unable to verbalize how this made her feel due to thinking the Facility administration would retaliate against them. Emotional and psychological abuse can have severe short- and long-term effects. This type of abuse can affect both your physical and your mental health. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible, by leaving the Central Supply room door open, and the cabinet inside the Central Supply room unlocked, exposing residents to hazards that could potentially cause serious injury or death. This was a random opportunity for discovery. Resident identifier: 91, 73, 95, 106, 70, 30 and 65. Facility census: 111. The State Agency (SA) determined these failures put the residents residing in the facility at risk for serious harm/death due to residents in the facility having access to the Central Supply room which contained potentially hazardous chemicals that could be ingested, and needles and scalpels that could cause serious injury or death. [...]

Inspectors wroteBased on observation and staff interview the facility failed to treat residents with respect and dignity during the dining experience and by pulling a resident down the hall backwards. These failed practices were random oppurtunities for discovery and had the potential to affect more than an limited number of residents currently resding in the facility. Resident Identifier # 36 Facility Census 111. Findings Include: a) Resident #36 An observation on 06/04/24 at 11:25 AM, of hall 400, revealed Nurse Aide (NA) # 58 pulling Resident #36 down the hallway backwards in a Geri chair about 30 feet. During an interview on 04/04/24 at 11:26 AM, NA #58 stated, This is the way I always do it. During an interview on 04/04/24 at 1:45 PM, registered Nurse (RN) #4 confirmed, staff should not be pulling residents backwards. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to safeguard the privacy of the back hall of the [NAME] wing resident's medical record. This was a random opportunity for discovery. Resident #83, #108, #97, #65, #60, #35, #98, #44, #45, #66, #68, #94, #66, #69, #30, #19, #58, #18, #3, #35, #96, #86, #80, #57, #10, #79, #53, #512, and #24. Facility Census: 111. Findings Include: a) [NAME] Wing Medication Computer On 05/29/24 at 9:45 PM, a tour of the facility was completed. Upon approaching the [NAME] wing medication computer on the back hall, the computer screen was visible with the resident's pictures and names. On 05/29/24 at 9:48 PM, Licensed Practical Nurse (LPN) #125 approached the cart and stated, I thought I locked the screen. On 06/04/24 at 1:00 PM, Registered Nurse (RN) #4 was notified of the computer screen being visible to anyone passing by the medication cart. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident was free from chemical restraint. Resident #27 was given an antipsychotic injection before showers, to prevent the resident from becoming combative during the shower. This was true for one (1) of one (1) residents reviewed for chemical restraints during the survey process. Resident identifier: 27. Facility census: 111.

Inspectors wroteBased on record review and staff interview the facility failed to thoroughly investigate an allegation of sexual abuse involving Resident #91 and Resident #61. This was true for two (2) of six (6) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: 91 and 61. Facility Census: 111. Findings Include: a) Resident #91 and #61 incident date 04/07/24 A review of a Facility Reported Incident which was received by the state agency on 04/07/24 found the following: Type of Incident was a resident to resident incident. The type of abuse was specified as Sexual. The incident form indicated the the staff became aware of the abuse at 9:00 AM on 04/07/24. Resident #91 was listed as the alleged victim. The perpetrator was listed as Resident #61. The reportable listed four (4) staff members as witnesses to the incident. [...]

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure care plans were developed/implemented for each resident due to hydration interventions not being implemented for Resident #27, Activities visits not being developed for Resident #6, and fall interventions not being implemented for Resident #65. This was true for three (3) of 32 residents reviewed for care plans during the survey process. Resident identifiers: 27, 6, 65. Facility census: 111.

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician's orders for medication administration. This was true for five (5) of five (5) residents reviewed during the survey process. Resident Identifier: #15, #85, #19, #57 and #361. Facility Census: 111. Findings Include: a) Resident #15 On 06/04/24 at 11:25 AM, a record review was completed for Resident #15. The review found the Medication Administration Record (MAR) for May, 2024 had not been initialed off by the nurse and were left blank, which indicates the medication was not administered as ordered. The following medications are as follows: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident ' s drug regimen was free of unnecessary psychotropic medications by prescribing Resident #27 an antipsychotic medication before showers. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: 27. Facility census: 111.

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to serve food and drink that was palatable, attractive and at a safe and appetizing temperature. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 111. Findings Include: A) Dining Room evening time meal. During an observation of the evening meal on 05/28/24 beginning at 6:00 PM it was noted staff from the units were bringing trays into the dining room and placing them in a meal cart that was in the dining room. This continued until the dining room meal cart arrived from the kitchen at approximately 6:20 PM. At this time they began serving 19 residents who had been waiting on their meal. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain appropriate infection control standards for medication administration, disposal of soiled linen and dinner service. These were random opportunities for discovery. Resident Identifiers: #512, #85, and #13. Facility Census: 111. Findings Include: a) Resident #512 On 05/28/24 at 5:45 PM, observation of the dinner service was observed on the [NAME] wing. The dinner tray was removed from food cart without a lid to cover food. Nurse Aide (NA) #110 realized the plate did not have a cover and placed the contaminated tray back on the cart with clean trays. On 05/28/24 at 5:50 PM, Assistant Nurse Aide Supervisor #31 verified the tray should not have been placed back on the cart. On 05/28/24 at 6:00 PM, Licensed Practical Nurse (LPN) #34 was notified of the infection control breach during the dinner service. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to report an allegation of verbal abuse for Resident #22 and a bruise on Resident #93. This was a random opportunity for discovery. Resident Identifier: #93 and #22. Facility Census: 111.

Inspectors wroteBased on record review and staff interview the facility failed to provide the resident and/or responsible party an accurate bed hold policy upon discharge from the facility. This was true for one(1) of six (6) residents reviewed for the care area of hospitalizations during the long term care survey. Resident Identifier: #57. Facility Census: 111. Findings Include: A) Resident #57 A review of Resident #57's medical record found she went to the hospital on [DATE] at which time the facility was at bed hold capacity. The resident returned to the facility on [DATE]. She used a total of three (3) of her 12 medicaid bed hold days for this hospital stay. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility failed to provide activities of daily living (ADL) to dependent residents to maintain good personal hygiene. This failed practice was found true for (1) one of (6) six residents looked at for ADL care area during the Long-Term Care Survey Process. Resident identifier #45. Facility Census 111.

Inspectors wroteBased on observation, and interviews the facility faild to provide an activity program calendar that is clearly visible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 111 Resident identifier:

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure each resident received proper hydratio, due to no water being passed to Resident #27. This was true for one (1) of two (2) residents reviewed for hydration during the survey process. Resident identifier: 27. Facility census: 111.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that yearly performance evaluations were completed for each nurse aide. This was true for two (2) of five (5) nurse aide performance evaluations reviewed during the survey process. Facility census: 111. Findings Include: A) Incomplete Evaluations At approximately 11:30 AM on 06/05/24, a review was conducted of nurse aide performance evaluations completed by the facility for the last year. During review, it was determined that two evaluations were incomplete. The evaluation for Nurse Aide (NA) #49 was filled out but there was no date indicating when the performance evaluation was completed. The evaluation for NA #48 did not have a complete characteristics portion of the evaluation. Under the characteristics portion, there are four (4) choices, unsatisfactory, satisfactory, good, excellent. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an accurate and complete medical record for Resident #85, #95 and #58. This is true for three (3) of 32 residents reviewed during the survey process. Resident Identifier: #85 and #95. Facility Census: 111. Findings Include: a) Resident #85 On 06/04/24 at 9:13 AM, while observing medication administration, Resident #85 stated, I want my medication now. LPN #26 stated, (Name of Resident) let me get them for you. Upon opening the Medication Administration Record (MAR) in the computer, the medications were noted to be given at 9:09 AM. LPN #26 was asked, why does the computer show the medication has already been given? LPN #26 stated, I haven't given his medication this morning .I don't know why it is checked off. LPN #26 stated, let me look and see who documented them. It was me. stated LPN #26. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The signage for residents on transmission-based precautions (TBP) did not indicate the specific type of precaution and the personal protective equipment (PPE) needed. Additionally, PPE was not readily available at the entrance to the room of a resident in TBP. Also, the facility failed to have a water management program designed to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. These deficient practices had the potential to affect all residents residing in the facility. Resident identifiers: #46, #52, #32. Facility census: 98.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was developed for oxygen therapy and smokeless tobacco. This was true for three (3) of 24 sampled residents reviewed during the long term care survey process. Resident Identifiers: Resident #94, #60 and #8 . Facility Census: 98. Findings Included: a) Resident #94 On 12/06/22 at 9:00 AM, a review of the current physician's orders found an order for O2 (oxygen) at 2 (two) L/M (liters per minute) NC (via nasal canula) PRN (as needed) dyspnea (shortness of breath) dated 11/30/22. (Typed as written.) On 12/06/22 at 9:58 AM, a record review was completed for Resident #94. Upon completion of the review, the care plan did not list the oxygen therapy as a focus area. On 12/06/22 at 12:56 PM, the Director of Nursing (DON) confirmed oxygen therapy was not listed on the care plan. [...]

Inspectors wroteB. ased on observation, medical record review, and staff interview the facility failed to ensure residents' received treatment and care in accordance with professional standards. This was a failed practice in the care areas of not following physician's orders to elevate the head of bed, failing to have a physician order for hospice care, and incomplete neurological checks after an unwitnessed fall. This was true for three (3) of 24 sampled residents. Resident Identifiers: #69, #76, and #72 Facility Census: 98 Findings Included: a) Resident #69 On 12/06/22 at 11:50 AM, while reviewing the medical records, it was noted Resident #69 was under hospice care for renal cancer. This is reflected on the matrix and the residents care plan. A review of his current physician orders found no order for hospice care. This was confirmed with the Director of Nursing on 12/06/22 at 11:55 AM. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for pneumococcal immunizations. This deficient practice had the potential to affect any resident who had not had pneumococcal immunizations but wanted to receive them. Facility census: 98.

Inspectors wroteBased on resident interview, staff interview, and observation, the facility failed to ensure a safe, clean, comfortable and homelike environment for residents. The hot water temperature in the sink was not comfortable for one (1) resident who received bed baths. This was a random opportunity for discovery. Resident identifier: #46. Facility census: 98.

Inspectors wroteBased on observation, resident interview, medical record review and staff interview the facility failed to revise the care plan in a timely manner. This was true for three (3) out of 24 care plans reviewed during the survey. Resident Identifiers: #69 and #8. Facility census: 98 Findings Included: a) Resident #69 On 12/06/22 at 9:00 AM, a review of Resident #69's care plan found, a care plan with with an initiated date of 11/23/22, which read as follows: #16 french urinary catheter to bedside drain with a thirty (30) milliliter balloon. Change as needed for occlusion/leakage/sediment. During an observation and interview with Resident #69 on 12/06/22 at 10:08 am, it was discovered he no longer has a urinary catheter. He stated, I did not have it long and I insisted they remove it. [...]

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to provide the proper assistive device required to maintain the Resident's ability to communicate effectively. This was true for one (1) out of one (1) residents reviewed for communication. Resident Identifier: #25 Facility Census: 98. Findings Included: a) Resident #25 On 12/06/22 at 11:40 AM, a review of Resident #25's medical record showed a current order dated 6/23/21 which read as follows : Resident may use pocket-talker hearing amplifier device as tolerated. On 12/06/22 at 11:45 AM, Licensed Practical Nurse (LPN) #127, stated she hasn't seen him with it for a while. It also could not be located in the residents room. This was confirmed with the Director of Nursing on 12/06/22 at 1:30 PM. .

Inspectors wroteBased on observation, resident interview, medical record review, and staff interview the facility failed to ensure Resident #69 who was receiving oxygen therapy had a physicians order. This was a random oppurtunity for discovery. Resident Identifier: # 69. Facility Census: 98. Findings Included: a) Resident #69 On 12/05/22 at 1:30 PM during the interview phase of the long term survey process, Resident #69 was observed with oxygen in use and states he needs it at times due to shortness of breath. On 12/05/22 at 1:55 PM upon review of the current orders for Resident #69, found no current order for oxygen therapy. On 12/05/22 at 2:55 PM, the above information was confirmed with the Director of Nursing. .

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to provide hemodialysis services consistent with professional standards of practice. This was discovered for one (1) of one (1) resident reviewed for dialysis services during the Long-Term Care Survey Process. Resident identifier: #76. Facility census: 98.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the controlled substance count was completed and documented by two (2) nurses during shift change. This was a random opportunity for discovery. Facility Census: 98. Findings Included: a) Medication Administration On 12/06/22 at 8:00 AM, a review of the controlled substances count was completed. The following dates were not signed by two (2) nurses during shift change and the narcotic count was not completed: --11/22/22 day shift not signed by the on coming nurse. --11/22/22 evening shift not signed by the off going nurse. --11/28/22 day shift the number of narcotic pages were not counted. On 12/06/22 at 8:10 AM, the Director of Nursing (DON) confirmed the above dates were not signed by two (2) nurses at the end of each shift and the number of pages was not complete. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete an accurate medical record in the care area of showers for Resident #46. In the area of tobacco use for Residents #26. This deficient practice had the potential to affect two (2) of 24 sampled residents during the long-term care survey process. Resident identifiers: #46, #26. Facility census: 98.