Inspection Reports for Trinity Health Care of Logan

The visit was conducted as an annual recertification and relicensure revisit survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, Trinity Health Care of Logan, was found to be in substantial compliance with the regulatory requirements, with plans of correction and credible evidence accepted in lieu of an onsite revisit.

An onsite revisit occurred at Trinity Health Care of Logan from 07/08/24 to 07/09/24 for the annual recertification and annual relicensure survey concluding on 06/05/24.

The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. One citation was recited at 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The document is a Statement of Deficiencies and Plan of Correction related to a facility survey completed on July 2, 2024.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

The survey was conducted as an unannounced recertification and complaint survey to investigate allegations of abuse, neglect, medication errors, infection control breaches, and other regulatory compliance issues.

The facility was found to have multiple deficiencies including failure to report allegations of abuse timely, failure to treat residents with dignity, privacy breaches, incomplete nurse aide evaluations, failure to protect residents from verbal and sexual abuse, unsafe environment hazards, inaccurate medical records, improper medication administration, inadequate hydration and activities care, and infection control breaches.

The complaint investigation included allegations of verbal abuse by Licensed Practical Nurse #28 towards Resident #75, and sexual abuse involving Resident #91 and Resident #61. The facility failed to report verbal abuse timely and failed to protect residents from nonconsensual sexual contact. The investigation was initially incomplete as the Social Worker did not obtain witness statements until surveyor intervention. The facility terminated the employee involved in verbal abuse and implemented 1:1 staffing for Resident #91 to prevent nonconsensual sexual acts. The State Agency determined an Immediate Jeopardy situation existed but was abated after corrective actions.

The inspection was conducted to assess compliance with NFPA 101 sprinkler system installation requirements and to evaluate the facility's fire safety measures.

The facility failed to ensure full sprinkler protection in an alcove at the East Nurse Station, which could affect all residents, staff, and visitors. The deficiency was verified by staff and corrected with a plan to monitor sprinkler heads regularly.

An unannounced complaint investigation survey was conducted at Trinity Health Care of Logan on 08/28/23.

The complaint #28464 was unsubstantiated with no related or unrelated deficiencies found during the survey based on observations, clinical record reviews, interviews, and documentation review.

Complaint #28464 was unsubstantiated with no related or unrelated deficiencies.

The inspection was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, Trinity Health Care of Logan, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Trinity Health Care of Logan from December 5-7, 2022.

The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment, failure to provide dialysis services consistent with professional standards, failure to establish an infection prevention and control program, failure to develop and implement comprehensive person-centered care plans, failure to ensure respiratory care orders, failure to maintain accurate medication and narcotic records, failure to provide quality care consistent with physician orders, failure to follow CDC guidelines for pneumococcal immunizations, failure to maintain accurate resident records, and failure to provide proper assistive devices for communication.

Complaint 27041 was unsubstantiated with no related or unrelated deficiencies cited. Complaint 26504 was substantiated with a related deficiency cited at F684. Complaint 26263 was unsubstantiated with no related or unrelated deficiencies cited.

The inspection was conducted as an annual survey to assess compliance with federal and state regulations, including fire safety, smoking policies, and electrical system maintenance.

The facility was found deficient in maintaining fire extinguishers according to NFPA 10 standards, failing to adopt and follow a smoking policy per NFPA 101, and not maintaining/testing electrical receptacles at patient bed locations as required by NFPA 99. Corrective actions were implemented promptly.

Review of plans of correction and credible evidence was accepted in lieu of an onsite revisit for the annual recertification and relicensure survey concluding on 09/01/21.

The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule, and with the previously cited deficient practices.

The inspection was conducted to assess compliance with NFPA 101 and NFPA 99 electrical systems maintenance and testing requirements at the facility.

The facility failed to provide maintenance and testing of non-hospital grade electrical receptacles at patient bed locations and failed to maintain testing and maintenance of electrical equipment in accordance with NFPA standards. These deficiencies could potentially affect all residents, staff, and visitors.

An unannounced annual re-certification and annual re-licensure survey was conducted at Trinity Health Care of Logan from August 30 to September 1, 2021.

The facility was found deficient for failing to ensure dialysis services were provided according to professional standards for one dialysis resident. Specifically, blood pressures were taken in the arm with a hemodialysis fistula and the resident was not properly educated on fluid restrictions.

Complaint #25731 was unsubstantiated with no deficiencies cited.

An unannounced revisit was conducted at Trinity Health Care of Logan on May 24, 2021 for the complaint investigation survey concluding on January 28, 2021.

The facility was found to have corrected the previously cited deficient practices from the complaint investigation survey, and no citations were issued during this revisit.

Complaint reference: #25028. The revisit complaint survey F 689 was cleared with no citations.

An unannounced complaint investigation was conducted at Trinity Health Care at Logan on March 3-4, 2021.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.

Complaint #24041 and #24753 were unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, Trinity Health Care of Logan, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual re-certification and annual re-licensure survey was conducted at Trinity Health Care of Logan from February 1 - 3, 2021.

The facility was found deficient in accurately coding the nutrition section of the Minimum Data Set (MDS) assessments for weight change for two residents, and in ensuring medications were stored and labeled according to professional standards, including discovery of an expired medication.

The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

A complaint investigation was conducted on 01/26-27/21 due to a health program citing an immediate jeopardy under smoking regulations following an incident involving a resident vaping device fire.

The facility failed to ensure the resident environment was free from accident hazards, resulting in a resident sustaining facial and respiratory burns from a vaping device fire while on oxygen. Multiple residents were provided electronic cigarettes to use in their rooms during the COVID-19 outbreak, which posed a fire risk. The immediate jeopardy was abated after the facility relinquished all vaping devices, educated staff, and implemented monitoring and smoking policy adherence.

Complaint #WV00025028 was substantiated. The investigation was triggered by a resident fire incident involving a vaping device on 01/15/21, which caused facial and respiratory burns. The facility was found to have provided multiple residents with electronic cigarettes to use in their rooms during the COVID-19 outbreak, creating a fire hazard.

A complaint investigation was conducted on 01/26-27/21 under the life safety regulations except for the smoking regulation, due to the health program citing an Immediate Jeopardy under the smoking regulations.

The investigation focused on life safety regulations with an emphasis on smoking regulations where an Immediate Jeopardy was cited by the health program.

Investigation was complaint-driven and involved life safety regulations; Immediate Jeopardy cited under smoking regulations.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency from August 31 to September 2, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on August 14 - 18, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on 5/5/20 to assess compliance with infection control and emergency preparedness regulations related to COVID-19.

The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and 42 CFR 483.73 emergency preparedness regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.

An unannounced revisit was conducted for the annual recertification and relicensure survey concluding on 10/23/19.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

An unannounced annual re-certification and annual re-licensure survey was conducted at Trinity Health Care of Logan from 10/21/19 through 10/23/19.

The survey identified multiple deficiencies including incomplete advance directive POST forms, inaccurate Minimum Data Sets (MDS), incomplete comprehensive care plans, failure to follow isolation precautions, delayed hearing aid assistance, unclamped PEG tube, outdated medication storage, unsanitary kitchen and ice machine, and incomplete resident weight documentation.

The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Emergency Preparedness requirements.

The visit was conducted as an annual recertification and relicensure survey for Trinity Health Care of Logan.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit.

An unannounced six month Special Focus Facility survey was conducted at Trinity Health Care of Logan from 03/25/19 through 03/27/19. The survey included complaint investigations which were unsubstantiated.

The survey identified multiple deficiencies including failure to notify resident or responsible party of hospital transfers, inaccurate completion of Minimum Data Set (MDS), failure to obtain ordered laboratory testing, inadequate pain management documentation, improper psychotropic medication orders, unlabeled multi-use medication vial, inaccurate medication administration records, and infection control issues related to laundry room air flow and storage practices.

Complaint investigations #20645, #21560, and #21666 were unsubstantiated with no related or unrelated deficiencies cited.

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and to evaluate compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced revisit was conducted for the annual recertification, relicensure, and complaint survey concluding on June 12, 2018.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

An unannounced annual recertification survey, annual relicensure survey and two complaint investigations were conducted at Special Focus Facility Trinity Health Care of Logan from June 5, 2018 through June 12, 2018.

The facility was found deficient in multiple areas including resident rights, dignity, bathing and showering preferences, abuse and neglect reporting, medication administration, infection control, and care plan accuracy. Several residents experienced psychosocial harm due to staff actions and facility practices. The facility failed to maintain accurate medical records and ensure proper staff competency and supervision.

Complaint #19437 and #19546 were substantiated with related deficiencies cited. Multiple allegations of abuse, neglect, and mistreatment were reported late or not investigated properly. The facility failed to report to appropriate state agencies in a timely manner.

The inspection was conducted to review compliance with electrical system maintenance and testing requirements, specifically focusing on the proper documentation of storage battery testing for the facility's generator.

The facility failed to properly document testing of the storage battery electrolyte specific gravity for each cell individually, instead recording a collective reading for all cells. This deficiency potentially affects all residents, staff, and visitors.

An unannounced revisit was conducted at Trinity Health Care of Logan from June 5, 2017 to June 6, 2017 for the Quality Indicator Survey concluding on April 11, 2017.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Trinity Health Care of Logan from 04/03/17 through 04/11/17 to assess compliance with state and federal regulations.

The facility was cited for multiple deficiencies including failure to timely notify responsible parties of Medicare termination, improper management of resident personal funds, failure to convey personal funds within 30 days of death, failure to maintain resident privacy, failure to provide timely and accurate lab services and physician notifications, failure to ensure resident rights including mail delivery and dignity during dining, and failure to maintain accurate and complete medical records and care plans.

The inspection was conducted to assess compliance with NFPA standards related to sprinkler system maintenance, smoke barrier construction, building system risk assessments, and electrical equipment testing and maintenance.

The facility failed to maintain automatic sprinkler and standpipe systems, ensure smoke barriers met fire resistance ratings, follow and document risk assessment procedures for building systems, and maintain testing and maintenance records for electrical patient-care equipment. These deficiencies could affect all residents, staff, and visitors.

The document is a plan of correction submitted in response to a Quality Indicator Survey concluding on 2016-01-28, accepted in lieu of an onsite revisit.

The facility, Trinity Health Care of Logan, is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with previously cited deficient practices addressed.

An unannounced annual Quality Indicator Survey was conducted at Trinity Healthcare of Logan from January 25, 2016 through January 28, 2016 to assess compliance with federal regulations.

The survey identified multiple deficiencies including failure to notify physician and responsible party of resident injury, inadequate housekeeping and maintenance, failure to promote dignity during meals, inaccurate assessments, incomplete care plans, medication errors, failure to monitor drug regimens and labs, and incomplete clinical records.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on fire drill procedures and generator maintenance.

The facility failed to conduct fire drills at unexpected times and under varying conditions for the third shift for all four quarters of 2015, and failed to maintain documentation for generator storage battery testing and maintenance as required by NFPA 110.

An unannounced complaint investigation was conducted from 2015-11-17 to 2015-11-21 at Trinity Health Care of Logan for Complaint Reference 14490.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

Review of plans of correction and credible evidence was accepted in lieu of an onsite revisit for the Minimum Data Set (MDS)/Staffing Survey concluding on 08/13/15.

The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and with the previously cited deficient practices.

An unannounced minimum data set (MDS) focused survey was conducted at Trinity Health Care of Logan from August 11, 2015 through August 13, 2015 to assess compliance with regulatory requirements.

The facility was found deficient in several areas including failure to ensure resident privacy during catheter care, improper aseptic technique during catheter care leading to potential UTI risk, incomplete nurse staffing postings, and failure to promptly notify the attending physician of lab results for a resident.

The inspection was conducted as a complaint investigation, reviewing plans of correction and credible evidence in lieu of an onsite revisit for complaint reference 13597.

The facility, Trinity Health Care of Logan, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint investigation concluded on 05/22/15 with substantial compliance found; complaint reference number 13597.

An unannounced complaint survey was conducted at Trinity Health Care of Logan from May 15, 2015 through May 21, 2015, triggered by complaint #13597 which was substantiated with related and unrelated deficiencies cited.

The facility was found deficient in investigating and reporting an allegation of neglect related to resident #64's implanted port care, which led to infection, hospitalization, and surgery. Additionally, the facility failed to provide necessary care to maintain the highest practicable well-being for resident #64 by not ensuring proper physician orders and care plan updates for the implanted port. Infection control deficiencies were also noted with isolation supply carts improperly placed in resident rooms.

Complaint #13597 was substantiated. The facility failed to investigate and report an allegation of neglect for resident #64 regarding implanted port care, which resulted in infection, hospitalization, and surgery. Immediate reporting procedures were initiated during the survey process.

An unannounced revisit was conducted at Trinity of Logan on January 26-27, 2015 for the Quality Indicator Survey concluding on November 19, 2014.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.

Unannounced annual Quality Indicator Survey conducted from November 17, 2014 through November 19, 2014 at Trinity Health Care of Logan.

The facility had deficiencies related to comprehensive care plans for pressure ulcers, failure to implement care plans for fall prevention and dietary orders, failure to provide appropriate pressure relieving devices for a resident with pressure ulcers, and failure to maintain effective quality assurance processes.

An unannounced complaint survey was conducted at Trinity Health Care of Logan from June 23, 2014 to June 26, 2014 in response to Complaint #11246.

The complaint was unsubstantiated with no related or unrelated deficiencies cited during the investigation.

Complaint #11246 was unsubstantiated with no related or unrelated deficiencies cited. The complaint sample consisted of 9 residents.

An unannounced complaint investigation was conducted from 03/17/14 to 03/19/14 at Trinity Health Care of Logan for Complaint Reference 10617 / 14044.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

The complaint was unsubstantiated.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for Trinity Health Care of Logan, accepted in lieu of an onsite revisit.

The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with previously cited deficient practices addressed and corrected as of 01/16/14.

An unannounced annual Quality Indicator and State Licensure Survey was conducted from January 6, 2014 through January 16, 2014 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including housekeeping and maintenance, temperature control, comprehensive assessments, care planning, pain management, accident hazards related to bed safety, medication management, infection control, and quality assurance processes.

The inspection was conducted to assess compliance with NFPA 96 standards for the maintenance and inspection of the facility's range hood extinguishing system.

The facility failed to maintain and inspect the range hood extinguishing system as required by NFPA 96, with no record of inspections conducted in the previous six months as required.

The inspection was conducted as a complaint investigation based on complaint reference 13081 / 7935.

The complaint was unsubstantiated and no citations were issued.

Complaint reference 13081 / 7935 was investigated and found to be unsubstantiated with no citations.

The inspection was conducted as a complaint investigation based on complaint reference numbers 7657 and 13031.

The complaint was substantiated; however, no citations were issued as a result of the investigation.

Complaint Reference: 7657 / 13031. Substantiated complaint record with no citations.

This was a first revisit to the recertification survey conducted on 05/25/12, to verify correction of previously cited deficiencies.

On-site revisit conducted on 07/12/12 found that citations were corrected.

Recertification survey conducted from 05/21/12 to 05/25/12 to assess compliance with federal regulations for nursing home care.

The facility was found deficient in multiple areas including residents' rights, grievance resolution, use of restraints, abuse investigations, dignity and respect, care planning, medication administration, infection control, food service sanitation, and staff training. Significant issues included failure to assist residents with voting, unresolved grievances, improper use of restraints without assessments, inadequate abuse investigations, poor nutrition monitoring, medication errors, and unsanitary kitchen conditions.

Routine inspection to assess compliance with NFPA Life Safety Code standards and other regulatory requirements for the facility.

The facility failed to ensure two patient room doors closed and latched properly, did not maintain fire alarm system testing and sensitivity checks as required, had an obstructed egress corridor due to an unattended patient lift, and failed to maintain emergency lighting in the generator transfer switch room.

The visit was conducted as a complaint investigation for Complaint #11304 at Trinity Health Care of Logan.

The complaint was unsubstantiated and no unrelated citations were cited during the investigation.

Complaint #11304 was investigated and found to be unsubstantiated with no unrelated citations cited.

The inspection was conducted in response to complaint references #10356 and #10377.

The complaint records were found to be unsubstantiated with no deficiencies cited.

Complaint references #10356 and #10377 were investigated and found to be unsubstantiated with no deficiencies cited.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Trinity Health Care of Logan.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in a language they understand, both orally and in writing, prior to or upon admission and during their stay.

The inspection was conducted as a complaint investigation triggered by complaint reference #10039, which was substantiated with deficiencies cited.

The facility failed to assure that one of four sampled residents was afforded the right to voice grievances via their legal representative without reprisal. Specifically, Resident #2's legal representative expressed concerns about care but refrained from further complaints due to fear of forced relocation.

Complaint reference #10039 was substantiated with deficiencies cited. The legal representative of Resident #2 reported fear of reprisal after expressing concerns about care, including a double dose of medication. The facility offered assistance with alternate placement if dissatisfied.

Annual inspection of Trinity Health Care of Logan nursing facility to assess compliance with federal regulations including resident care, safety, and administrative requirements.

The facility was found deficient in multiple areas including failure to adequately screen employees for criminal history, failure to promote resident dignity and respect, inadequate accommodations, unsafe environment conditions, inaccurate resident assessments, incomplete care plans, medication errors, failure to comply with PASRR requirements, inadequate care and services to maintain resident well-being, infection control lapses, non-functional nurse call system, failure to comply with state laws regarding hospice care, and failure to obtain ordered laboratory tests timely.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Trinity Health Care of Logan.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation referenced by complaint #9231, which was found to be unsubstantiated with unrelated deficiencies cited.

The facility failed to screen an applicant for employment for evidence of past criminal prosecutions outside of West Virginia, despite the individual having resided in at least three other states. This deficiency was identified in one of seven sampled employees.

Complaint reference #9231 was unsubstantiated with unrelated deficiencies cited.

The inspection was conducted in response to complaint reference #9143.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #9143 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a comprehensive annual survey of the nursing facility to assess compliance with federal regulations and standards of care.

The facility was found deficient in multiple areas including failure to provide adequate toenail care, medication errors, unsafe resident environment, infection control lapses, untimely laboratory services, and incomplete clinical documentation.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the construction and maintenance of smoke barrier walls with at least a one-half hour fire resistance rating.

The facility failed to maintain smoke barrier walls to provide the required fire resistance rating. Multiple openings and unsealed penetrations through the smoke barrier walls were observed in various attic locations near resident rooms and other areas.

The inspection was conducted as a comprehensive annual survey of Trinity Health Care of Logan to assess compliance with federal regulations governing nursing facilities.

The facility was found deficient in multiple areas including improper completion of Physician Orders for Scope of Treatment (POST) forms, failure to place resident funds in interest-bearing accounts, inadequate nail care for residents, failure to complete Pre-Admission Screening and Resident Review (PASRR) for some residents, ineffective pain management, failure to provide ordered treatments to prevent pressure sores, unsafe resident environment leading to fall hazards, use of unnecessary drugs with excessive dosing, infection control lapses during wound care and medication administration, delays in laboratory services, and incomplete clinical documentation.

This document is a plan of correction submitted in response to a prior survey deficiency related to resident rights and notification requirements.

The facility was cited for failing to properly inform residents of their rights, rules, services, and charges both orally and in writing as required by regulations.

The inspection was conducted as a complaint investigation related to allegations of abuse involving Resident #42.

The facility failed to timely report an alleged incident of abuse, failed to investigate the incident upon initial discovery, and failed to assure that the resident was protected from further abuse. The incident occurred on 10/05/07 but was not reported to state agencies until 10/08/07, and the alleged perpetrator was not suspended until after the report was made.

Complaint reference #2-7244 was substantiated with deficiencies cited. The facility failed to immediately report and provide protection for the resident at the time the alleged incident was reported to the unit charge nurse on 10/05/07. Statements were taken from involved staff on 10/08/07. The alleged perpetrator was suspended pending investigation when the social services director became aware of the situation on 10/08/07.

The visit was a paper revisit to the facility.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. Specific deficiencies are not detailed beyond the initial comments.

The inspection was conducted as a complaint investigation referenced as #2-7185, focusing on allegations of verbal abuse, neglect, and other related deficiencies at the facility.

The facility failed to report and follow up on an allegation of verbal abuse and neglect involving Resident #101, improperly used a Posey roll belt restraint without side rails for Resident #119, and had incomplete and inaccurate clinical records for Resident #121, including medication administration errors and lack of behavior documentation.

Complaint reference #2-7185 was unsubstantiated but revealed unrelated deficiencies including failure to report verbal abuse and neglect, improper restraint use, and incomplete clinical records.

Paper revisit to review the facility's plan of correction following a prior inspection.

The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on the facility's obligation to inform residents of their rights and services.

The inspection was conducted as a comprehensive annual survey of Trinity Health Care of Logan to assess compliance with federal regulations related to resident rights, care, safety, and facility environment.

The facility was found deficient in multiple areas including failure to ensure residents' rights were exercised according to state law, inadequate notification of Medicare non-coverage, lack of accessibility to survey results, failure to provide written notice of bed hold policy, failure to follow abuse reporting policies, dignity issues during dining, failure to accommodate individual resident needs, inadequate social services, inaccurate resident assessments, incomplete care plans, failure to monitor blood pressure as ordered, inadequate urinary incontinence management, unsanitary food preparation conditions, missing privacy curtains, and unsafe environmental conditions.

The inspection was conducted as a routine survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements for the facility.

The facility was found to have multiple deficiencies related to fire safety, including failure to maintain self-closing hazardous room doors, obstruction of exit access corridors, malfunctioning delayed-egress locking devices, incomplete sprinkler coverage, missing sprinkler wrench, inadequate smoking area safety measures, failure to maintain range hood extinguishing system inspections, and improper electrical wiring with use of two-conductor extension cords.

The inspection was conducted as a substantiated complaint investigation regarding staff treatment of residents and failure to provide timely interventions and physician notifications.

The facility failed to timely assess, monitor, and notify physicians of acute changes in condition for residents #112 and #113, resulting in severe dehydration, acute renal failure, and hospitalization. Laboratory tests were delayed, physician orders were not properly documented or followed, and clinical records were incomplete and inaccurate.

Complaint reference #2-7060 was substantiated with deficiencies cited related to staff treatment of residents, delayed physician notification, and inadequate clinical documentation.

The visit was a paper revisit to follow up on previous deficiencies.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements, with no detailed findings provided in this excerpt.

The inspection was conducted as a complaint investigation referenced as #2-6187, substantiated with deficiencies cited.

The facility failed to adequately screen new employees by not verifying with the State nurse aide registry that nursing assistants' registrations were active and in good standing prior to hire, and by not ensuring applicants were free of findings related to abuse, neglect, or misappropriation on the nurse aide abuse registry. This failure was evident for six of seven employees reviewed.

Complaint reference #2-6187 was substantiated with deficiencies cited related to staff treatment of residents and employee screening failures.

The inspection was conducted as a complaint investigation referenced as #2-6142.

The complaint was substantiated; however, no deficiencies were cited during the investigation.

Complaint reference #2-6142 was substantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-6103.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-6103 was unsubstantiated with no deficiencies cited.

The visit was a paper revisit to follow up on previously identified deficiencies at the facility.

The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on informing residents of their rights and services. No new detailed findings are provided in this excerpt.

The visit was a paper revisit to follow up on previous deficiencies.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements, but no specific deficiencies or severity levels are detailed in this excerpt.

The inspection was conducted as a substantiated complaint investigation referenced as #2-6036, focusing on deficiencies related to food preparation and quality.

The facility failed to ensure that foods were prepared to conserve nutritive value and to be flavorful, palatable, and attractive. Specific issues included pureed green beans that were only heated and not cooked or seasoned properly, overcooked broccoli, indistinguishable pureed meat with poor flavor, and lack of variety in pureed diets compared to regular diets.

Complaint reference #2-6036 was substantiated with deficiencies cited related to food preparation and quality.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations related to resident care, sanitary conditions, infection control, and clinical record maintenance.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans addressing significant resident needs, unsanitary food preparation and storage practices, inadequate infection control procedures, and incomplete clinical records for several residents.

The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities, including resident rights, care plans, infection control, accident prevention, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to maintain resident confidentiality, dignity, and privacy; inadequate accommodation of resident needs; incomplete or outdated comprehensive care plans; failure to follow physician orders; inadequate infection control practices; unsafe resident environment with accident hazards; malfunctioning nurse call systems; and failure to notify employees of the Central Abuse Registry. Several residents experienced lapses in care such as improper wound care, lack of restraint reduction plans, and failure to prevent falls and pressure sores.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance, inspection, and testing of the facility's automatic sprinkler system.

The facility failed to maintain the sprinkler system in reliable operating condition as required by NFPA 25. Inspection reports showed no testing during the first quarter of 2005, and eight sprinkler heads were found corroded during the facility tour.

The document is a plan of correction related to a paper revisit survey conducted at the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted in response to complaint reference #2-5115.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-5115 was unsubstantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-5117, which was substantiated with deficiencies cited.

The facility failed to maintain a safe, functional, and comfortable environment for residents and staff due to fluctuating hot water temperatures ranging from 79 to 138 degrees Fahrenheit in twelve resident rooms, and the hot water supply line for the hot water tank being shut off.

Complaint reference #2-5117 was substantiated with deficiencies cited.

The document is a plan of correction related to a paper revisit survey conducted at the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand. The deficiency is identified under F 156 with a severity of SS=C.

The inspection was conducted as a complaint investigation based on complaint references #2-5016 and #2-5020, with substantiated complaints regarding the stoppage of Physical Therapy services.

The facility failed to provide Physical Therapy services from 12/30/04 to 01/18/05 for at least six of ten residents with physician orders for the service. No actual harm was identified as a result of the service interruption.

Complaint reference #2-5016 was substantiated with deficiencies cited related to the stoppage of Physical Therapy services. Complaint reference #2-5020 was substantiated with no related deficiencies cited.

The inspection was conducted to assess compliance with physical environment standards, including ventilation in the resident designated smoking area and safety measures such as securing electrical panels.

The facility failed to provide adequate ventilation in the resident designated smoking area, resulting in persistent cigarette smoke odors in the East wing lounge and corridors. Additionally, electrical panels were found unsecured, posing a safety risk to residents, staff, and the public.

Complaint investigations were conducted related to resident rights, quality of life, infection control, and care planning at Trinity Health Care of Logan.

The facility had multiple deficiencies including failure to ensure legal surrogates were properly appointed and exercised, residents not treated with dignity and respect, inadequate positioning during meals, inaccurate resident assessments, incomplete care plans, failure to follow physician orders, inadequate infection control practices, unsafe physical environment, and failure to maintain complete clinical records.

Complaint reference #2-4339 was unsubstantiated with no related deficiencies cited. Complaint reference #2-4343 was substantiated with unrelated deficiencies cited.

Routine inspection of the facility's compliance with NFPA 101 Life Safety Code standards and other regulatory requirements.

The facility was found deficient in multiple areas including failure to maintain self-closing devices on hazardous room doors, improper operation and signage of delayed-egress locks on exit doors, inadequate illumination of exit signs, failure to inspect portable fire extinguishers monthly, lack of maintenance on the rangehood wet chemical extinguishing system, improper storage of oxygen cylinders, and failure to properly exercise the emergency power supply system under load.

The inspection was conducted as a complaint investigation referenced as #2-4256.

The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-4256 was unsubstantiated with no deficiencies cited.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the facility.

The report identifies a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.

The inspection was conducted in response to complaint references #2-4221 and #2-4222.

The complaint records were found to be unsubstantiated with no deficiencies cited.

Complaint references #2-4221 and #2-4222 were investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation involving two complaint references (#2-4164 unsubstantiated and #2-4168 substantiated) with deficiencies cited.

The facility was found to have multiple deficiencies including a nursing assistant administering an enema without a physician's order, unsafe fluctuating hot water temperatures exceeding regulatory limits, and infection control lapses related to uncovered gastrostomy feeding set tips allowing contamination.

Complaint reference #2-4164 was unsubstantiated with unrelated deficiencies cited. Complaint reference #2-4168 was substantiated with deficiencies cited.

The inspection was conducted in response to complaint reference #2-4102.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-4102 was investigated and found to be unsubstantiated with no deficiencies cited.

Complaint investigation referenced as #2-4067.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-4067 was unsubstantiated with no deficiencies cited.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 1981.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1981.

Routine inspection of Trinity Health Care of Logan to assess compliance with federal regulations including resident assessments, care planning, infection control, and documentation.

The facility was found deficient in multiple areas including inaccurate resident assessments and coding (notably for restraints and delirium), failure to implement physician orders and care plans consistently, improper infection control practices related to syringe rinsing, and inaccurate clinical record documentation.

The inspection was conducted to evaluate the facility's compliance with infection control procedures and clinical record administration during routine observations and medication passes.

The facility failed to ensure proper infection control during wound treatment for Resident #57, including failure to remove gloves and wash hands between contaminated and clean tasks. Additionally, the facility failed to maintain accurate clinical records for Resident #96, with medication orders not clearly documented and discrepancies in medication administration sheets.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 1981.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1981.

The inspection was conducted as a complaint investigation related to notification of a resident's legal representative about a change in the resident's skin integrity.

The facility failed to ensure that the legal representative of one sampled resident was notified in a timely manner about a change in the resident's skin integrity, specifically a Stage II decubitus ulcer. Notification to the Health Care Surrogate occurred 32 days after the pressure area was first noted.

Complaint #2-2184 regarding failure to timely notify the legal representative of Resident #39 about a change in skin integrity. The Health Care Surrogate was first informed 32 days after the pressure area was initially noted.

The inspection was conducted as a comprehensive annual survey of Trinity Health Care of Logan to assess compliance with federal regulations regarding resident rights, quality of life, care planning, quality of care, dietary services, infection control, and physical environment.

The facility was found deficient in multiple areas including failure to report and investigate alleged misappropriation of resident property, failure to maintain resident dignity and respect, inadequate response to resident council grievances, failure to provide medically-related social services, incomplete care plans, failure to provide ordered treatments, poor hygiene and grooming, inadequate nutritional status maintenance, improper food handling and storage, infection control lapses, and failure of the emergency electrical system to operate as designed.

The inspection was conducted as a Life Safety Code survey under NFPA 101, 1981 Edition, to assess compliance with fire safety regulations.

The report includes a statement of deficiencies related to resident rights and notification requirements, with a focus on compliance with the Life Safety Code 1981 Edition.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing related to compliance with clinical record maintenance and other regulatory requirements.

The facility was found to be in compliance with physical environment provisions but failed to maintain complete nurses' notes for seven of twenty-one sampled residents, with incomplete documentation regarding impaction checks, stool consistency, and amounts removed or expelled.

The inspection was conducted to review compliance with the NFPA 101 Life Safety Code, 1981 (Existing) for the facility.

Based on review of facility documentation, staff interviews, observations, and performance testing, the facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1981.

The inspection was conducted based on a review of facility documentation, staff interview, observations, and performance testing to determine compliance with the provisions of 483.70 Physical Environment.

The facility was found to be in compliance with the provisions of 483.70 Physical Environment.

The inspection was conducted to assess compliance with the NFPA 101, Life Safety Code, 1981 (Existing) for the facility.

The facility was found to be without waivers and in compliance with 483.70(a) during the inspection conducted from January 3 to January 5, 2000.

The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to provide reasonable telephone access, dignity in dining, appropriate feeding assistance, proper gastrostomy tube medication administration, food preparation and sanitation, and timely pharmacist drug regimen reviews.