Embassy of Logan

In the surveyor’s words

From the most serious findings on record at Embassy of Logan, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 20, 2023

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

• Actual harm, isolatedF676May 26, 2021

  Based on record review, staff interview and policy review the facility failed to implement a comprehensive and individualized restorative nursing ambulation program to ensure Resident #40 received the assistance needed for ambulation to maintain the resident's highest level of functioning ability. Actual Harm occurred for Resident #40 when the resident experienced a decline in functional ability, from only requiring minimum staff assist with the ability to ambulate 50 feet to requiring maximum staff assist with the ability to only ambulate five feet four months after her physical therapy ended and she was referred to a restorative maintenance program for ambulation that was not implemented. This affected one resident (#40) of five residents reviewed for restorative nursing services. […]

• Actual harm, isolatedF684Mar 2, 2021

  Based on record review, review of a self reporting incident (SRI), staff interview and policy review, the facility failed to ensure a resident received timely care and services following a change in condition. This affected one (Resident #100) of four residents reviewed in three separate SRI's. Actual Harm occurred for Resident #100 when she complained of extreme pain in her left hip and was noted to have swelling the morning of 02/06/21. The physician was not notified until approximately eight hours later and x-rays were not obtained until later that evening showing she had a dislocated hip. Resident #100 required treatment at the hospital for a [MEDICAL CONDITION]. Findings include: A review of Resident #100's medical record revealed she was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Mar 19, 2026

  Based on observation, staff interview, and facility policy and procedure, the facility failed to prepare and serve food under sanitary conditions. This had the potential to affect the 92 of 92 residents who receive trays from the kitchen. The census was 92. Findings include: On 03/17/2026 at 10:33 A.M. Observation of the kitchen revealed the confection oven with food splatter and food crumbs. A container under the steam table with food debris, the wall behind the plate warmer with dust and dirt build up. The wall behind the table with the toaster with dried food splatter. 03/18/2026 at 2:20 P.M. observation of the kitchen with Dietary Manager #109 revealed the hanging electrical outlet over the serving line had a built up of dust hanging on it, and on the air conditioning unit. […]

• No harm, potential for more than minimal, widespreadF921Apr 24, 2023

  Based on observation and staff interview the facility failed to provide a safe, sanitary, and comfortable environment. This had the potential to affect all the residents living in the facility. The facility census was 93. Findings include: Observation on 04/17/23 at 9:11 A.M. revealed the 400 hall in need of repair. There was missing drywall and chipped paint on the walls, doors and door frames. The 400 shower room had the toilet loose at the base, missing and broken tiles, mold in the shower stall, rusted door frame and walls and door with areas of chipped/missing paint. Observation on 04/17/23 at 9:30 A.M. revealed the 700 hall shower room with broken and missing tiles and the door frame needed painted. Observation on 04/17/23 at 9:38 A.M. […]