Every finding on record at Logan Regional Hospital Transitional Care Unit

Based on interview and record review it was determined, for 1 of 15 sampled residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident was not provided supervision during a transfer and sustained a fall. Resident identifiers: 18. Findings included: Resident 18 was admitted to the facility on [DATE] with diagnoses which included stage 4 chronic kidney disease and fracture of distal end of left femur. On 1/26/26 through 1/27/26, resident 18's medical records were reviewed. A physician order dated 6/3/25, restricted resident 18's lower left extremity to non weight-bearing status. A physician progress note dated 7/2/25 documented, Was notified . of a ground-level fall. Patient was seen and evaluated at bedside. She reports that she got up to use the bedside commode and was positioning her walker to be able to sit further back when she got tangled up causing her to fall forward landing on her face. The note continued, The superficial abrasion over her nose is not adequate for sutures. She is however on Eliquis therefore will get CT (Computed Tomography) head to rule out intracranial bleed and/or osseous injury. An addendum was added to the progress note stating CT (Computed Tomography) head negative for acute intracranial findings. There is mild soft tissue swelling over the anterior nasal bridge with a new minimally impacted anterior nasal bone fracture. Likely non operative, continue with supportive care. An incident note dated 7/2/25 revealed, Patient was transfering [sic] to a commode in the middle of the transfer I [Certified Nurses Assistant (CNA) 1] left[.] . two other call lights going off [CNA 1] felt the need to leave before the patient was sitting down. The patient has show [sic] improve [sic] strengh [sic] over the week. Nurse was at computer. The facility investigation dated 7/3/25 revealed [CNA 1] explained that while assisting the patient from the bed to the commode, she stepped away to answer call lights, believing the patient could complete the transfer independently. At that time, the patient's nurse was charting across the room. As [CNA 1] began leaving, the patient began to fall. [CNA 1] recognized she should not have left before the transfer was complete, as this placed the patient at risk. On 1/27/26 at 8:52 AM, an interview was conducted with the Administrator (ADM). The ADM stated because resident 18 had been improving in strength CNA 1 felt comfortable leaving resident 18 in the middle of a transfer. The ADM stated that at the time of the fall resident 18 was non weightbearing on her left leg, had oxygen tubing in place, and was utilizing a walker. The ADM stated that while they did not believe CNA 1 had any harmful intentions, corrective action was taken. The ADM stated that additional education about safe transfers was provided to CNA 1 and the facility staff. On 1/27/26 at 4:22 an interview was conducted with CNA 2. CNA 2 stated that a gait belt was used to assist resident 18 during transfers, and that resident 18 would use her walker and put weight on her right leg during transfers. CNA 2 stated that resident 18 should not have been left unattended during a transfer.

Based on interview and record review, it was determined, the facility did not ensure the resident's right to formulate an advanced directive. Specifically, for 1 out of 14 sampled residents, the resident's electronic medical record documented that the resident was a full code while the Physician Orders for Life-Sustaining Treatment (POLST) form documented the resident's wishes as Do not attempt or continue any resuscitation. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included hyponatremia, supraventricular tachycardia, hypertension, osteoporosis, fracture of radial neck, status post total knee replacement, and pain. On 1/3/23 at 10:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if the resident did not have an Advance Directive completed the resident would be a full code. On 1/3/23 at 10:46 AM, an observation was made of resident 1's electronic medical record dashboard that documented the code status as full code. On 4/7/22, resident 1's POLST form documented Do not attempt or continue any resuscitation (DNR) (Allow Natural Death) with comfort measures. On 12/16/22, resident 1's physician orders revealed an order for Do Not Resuscitate and Do Not Intubate. On 1/3/23 at 12:33 PM, an interview was conducted with LPN 1 and the Minimum Data Set (MDS) Coordinator. LPN 1 stated that resident 1's dashboard documented the code status as full code. LPN 1 stated that the nurse could not change the dashboard and that it populated through the orders. LPN 1 stated that he verified the POLST form and it documented that resident 1 was DNR. The MDS Coordinator stated that LPN 1 needed to put an order in for the Medical Director to sign with the updated code status, we need them to match. LPN 1 was observed to change the code status in the electronic medical record. The MDS Coordinator stated that it was the nurse's responsibility to update the code status when they received an order or POLST form from the physician. On 1/3/23 at 2:02 PM, an interview was conducted with the Unit Manager (UM). The UM stated that nursing staff were responsible to verify that the information on the dashboard reflected the POLST form directives.

A COVID-19 Focused Infection Control Survey was conducted on 11/9/20. Based on observations and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, residents were not placed on appropriate isolation precautions. Resident identifiers: 1 and 2. Findings include: 1. Resident 1 was admitted on [DATE] with [MEDICAL CONDITION] and a history of falls. On 11/9/20 at 5:10 PM, an observation of RN (Registered Nurse) 1 and Certified Nurse Aide (CNA) 1 was made as they entered resident 1's room. Neither RN 1 nor CNA 1 put on a gown to enter the room. In addition, CNA 1 did not have a face shield on. CNA 1 stated that resident 1 required assistance to get to the toilet. On 11/9/20 at 5:24 PM, two staff members entered resident 1's room and opened the door to the resident's restroom, where resident 1 was on the toilet. The two staff members spoke with the resident, and then left the resident's room. The staff members were wearing masks and a face shield but no gowns or gloves while in resident 1's room. On 11/9/20 at 5:32 PM, CNA 1 again entered resident 1's room while wearing a mask. She opened the bathroom door, and then placed a gown, face shield and gloves on before entering resident 1's bathroom to assist resident 1. Upon review of resident 1's medical record, the resident had been admitted on [DATE] and should have been on droplet and contact precautions until 11/20/20. 2. Resident 2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 11/9/20 at 5:17 PM, an observation was made of RN 2 and a new employee entering resident 2's room. The staff members were wearing masks, face shields and gloves, but no gown. Upon review of resident 2's medical record, the resident had been admitted on [DATE] and should have been on droplet and contact precautions until 11/16/20. On 11/9/20 at 5:15 PM, an interview was conducted with CNA 1. CNA 1 stated that there were currently four residents at the Transitional Care Unit (TCU), and none of the residents were on isolation precautions. CNA 1 stated that residents 1 and 2 did require hazardous medication precautions if staff were to be in contact with urine. CNA 1 stated that after admission, all staff were required to use a Powered Air-Purifying Respirator (PAPR) when interacting with residents until a resident had a negative covid test. CNA 1 stated that after a resident had a negative covid test, the resident was not on any isolation precautions even if the resident had been at the TCU for less than 14 days. On 11/9/20 at 5:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that all residents were tested for covid prior to admission to the TCU. LPN 1 stated that if residents tested positive, they were sent to a different area of the hospital. LPN 1 also stated that after a resident tested negative for covid, then the residents were not on any isolation precautions, even if the resident had been at the facility for less than 14 days. LPN 1 stated that resident 1 had a negative covid test on 11/3/20, so the only precautions for resident 1 were hazardous medication precautions. LPN 1 stated that if staff were going to be potentially in contact with resident 1's urine, they would put a gown, gloves, mask and face shield on. LPN 1 stated that resident 1 was not on any other precautions. LPN 1 stated that neither resident 1 nor resident 2 were on contact or droplet precautions. On 11/10/20 at 3:00 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated that if a resident was admitted from the hospital emergency room , a covid test was performed prior to admitting the resident to the TCU. The ADM stated that if the resident was admitted from another area of the hospital after having surgery, the resident would have had a covid test prior to having the surgery performed. The ADM stated that resident 1 had a negative test in the emergency roiagnom on [DATE], and that resident 2 had a negative test prior to surgery on 10/30/20. The ADM stated that the TCU was not putting residents on contact or droplet precautions for covid because the residents had already had a negative covid test. Per the Centers for Disease Control website dated 4/30/20, Considerations for new admissions or readmissions to the facility . managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE (personal protective equipment) should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE . (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) The Utah Department of Health (UDOH) issued a policy entitled Guidelines for Transferring Patients from Hospitals to Long Term Care Facilities During the COVID-19 Epidemic. The guidelines stated that long term care facilities receiving residents from a hospital should place the patient in an individual room and use Standard Contact and Droplet Precautions for 14 days even if the resident had a negative test.

Based on interview and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for safety. Specifically, refrigerated food items were not covered appropriately, floor tiles in the kitchen were missing, and floors and walls were soiled. Findings include: On 5/6/19 at approximately 2:00 PM, a tour was conducted of the facility kitchen. The following was observed: a) The grill freezer contained two bags of chicken tenders and one bag of cheese sticks which were observed to have been opened, but the bags had not been reclosed, which exposed the contents to air. b) There was a container of an unknown substance on the food preparation area by the pass through refrigerators. The container was not labeled or dated. c) The pass-through refrigerator had sticky handles. Inside the refrigerator, an opened bag of tortillas was observed and the contents were open to air. d) The cooks freezer had an opened bag of shrimp, with the contents open to air. e) In the salad refrigerator, containers of yellow peppers, bacon, pickles and sunflower seeds were not covered or labeled. f) In the catering refrigerator, two pans of cookies, 2 pans of raw chicken, 1 pan of fish, one pan of potatoes, and one pan of a zucchini mix were not covered, and the contents were open to air. g) In the specials refrigerator, one container of muffins was not covered, and the contents were open to air. h) The kitchen floor was observed to be sticky throughout. The kitchen floor was also observed to have debris throughout. The kitchen floor was also noted to have missing and/or broken tiles in multiple areas. There were also areas where the grout was in disrepair on the kitchen floor. i) The walls by the food preparation areas had splatters on them. j) A dietary staff member was observed to be rubbing her nose and then handling food items. On 5/6/19 at approximately 2:20 PM, an interview was conducted with the Assistant Dietary Manager (ADM). The ADM stated that he was aware of the broken tiles in the facility kitchen. The ADM confirmed that the uncovered items in the refrigerators should have been covered. The ADM also stated that he had conducted multiple trainings for dietary staff instructing them to completely close containers of food, so that the contents were not open to air.

Based on interview and record review it was determined that the facility did not develop and implement a comprehensive person-centered care plan for 1 of 7 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, activies of daily living function/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, and dehyrdration/fluid maintenance were not developed as required. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 2/1/18. Resident 1's Admission Minimum Data Set ((MDS) dated [DATE] revealed that activities of daily living function/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, and dehydration/fluid maintenance triggered in the Care Area Assessment (CAA) section. The MDS further revealed the areas triggered in the CAA section were care planned. Resident 1's care plans were reviewed and revealed there were no care plans developed for the activities of daily living function/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, and dehydration/fluid maintenance. On 2/1/18 at 7:45 AM, an interview was conducted with Administrator, who also functioned as the facility Director of Nursing. The Administrator confirmed that the care plans were not developed.

Based on interview and record review, it was determined the facility did not develop a baseline care plan for each residents that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of care for 2 of 7 sample residents. Specifically, the baseline care plan was not developed within 48 hours of the residents admission. Resident identifiers: 1 and 59. Findings include: 1. Resident 59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 59's medical record was reviewed on 2/1/18. A baseline care plan that included: a) Initial goals based on admission orders [REDACTED]. On 2/1/18 at approximately 9:30 AM, the facility Administrator, who also functioned as the Director of Nursing (DON) was interviewed. The Administrator confirmed that a baseline care plan had not been developed for resident 59 as required. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 2/1/18. A baseline care plan that included: a) Initial goals based on admission orders [REDACTED]. On 2/1/18 at 7:45 AM, an interview was conducted with Administrator, who also functioned as the DON. The Administrator confirmed that a baseline care plan had not been developed for resident 1 as required.

Based on observation, interview and record review it was determined the facility did not prepare food under sanitary conditions. Specifically, the sanitizing solution for counter tops did not have the required concentration of sanitizer. Findings include: According to the Serve Safe Course book, used by the facility as policy, sanitizing solution should be mixed "to the proper concentration since concentrations below those required. . . could fail to sanitize objects." Concentration is measured by using a sanitizer test kit and is expressed as parts per million. The sanitizing solution must be checked frequently since the sanitizer is depleted during use. On 4/24/12 at 8:45 AM, an inspection of the kitchen was made. Kitchen aid 1 was observed cutting vegetables on a counter top. After chopping the vegetables, the kitchen aid was observed cleaning the counter top. The surveyor asked that the sanitizing solution be checked for the proper concentration with a test strip. The kitchen aide left for about four minutes to find a test strip. The kitchen aide dipped the test strip into the solution. The test strip indicated that there was no solution in the water. The kitchen aide was asked where she obtained the solution. Kitchen aides 1 and 2 showed a closet in which the automatic dispenser was used to dispense solution was configured to come out in the correct parts per million with water. The container was almost empty. Kitchen aide 1 poured another bucket of cleaning solution and this was checked with another test strip. The test strip indicated that there was no solution in the water. Several different test strips were used and did not register in the solution. The Kitchen Aides (KA) attached a new bottle of chemical. Another bucket of solution was checked and did not register. KA 1 and 2 stated the automatic dispenser must be broken and the chemical provider would be called. KA 1 and 2 were asked how often they were required to check the solution. The KAs stated that the solution was checked every day. On 4/25/12 at 9:30 AM, the Director of Food Services (DFS) was interviewed. The DFS stated he did not know why the chemical did not register in the solution. The DFS stated the chemical company came every month to inspect the chemicals and the automatic dispenser. The DFS further stated the facility policy was the Serve Safe Course book.

Based on observation and interview, it was determined the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, (1) a facility staff member entered into a resident's room, without knocking, while a confidential interview was being conducted; and (2) a resident was ambulating in the hallway with a facility Occupational Therapist without the catheter bag being concealed. Resident identifiers: 46 and 51. Findings include: 1. Resident 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/24/12 at 10:33 AM, a confidential interview was conducted with resident 46. Resident 46 requested that the door to her room be closed, as she did not want the facility staff to know what she had to say. The door was closed by the State Surveyor. While the interview was being conducted, Licensed Practical Nurse (LPN) 1 entered resident 46's room without knocking. On 4/25/12 at 8:35 AM, Registered Nurse (RN) 1, who also functioned as a charge nurse, was interviewed. RN 1 stated that facility staff should always knock and wait for the resident to respond prior to entering the resident room. On 4/25/12 at 8:38 AM, LPN 1 was interviewed. LPN 1 stated that she did not knock on resident 46's door prior to entering her room on 4/24/12 at 10:33 AM. LPN 1 stated that she "could tell" that resident 46 was "uncomfortable" after she had entered the room. LPN 1 stated that she should have knocked on the door and announced herself prior to entering resident 46's room. 2. Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/24/12 at 11:06 AM, resident 51 was observed while ambulating with a facility Occupation Therapist in the main corridor by the nurses station. Resident 51 was observed to have a catheter bag hooked onto a metal bar on the front of the walker. Resident 51's catheter bag was not concealed and was observed to be approximately 1/2 way full with urine. On 4/24/12 at 11:20 AM, resident 51 was interviewed related to the catheter bag not being concealed. Resident 51 stated that it "would be nice if the bag was covered so that everyone (couldn't) see his 'pee'." On 4/25/12 at 8:35 AM, RN 1 was interviewed. RN 1 stated that the facility did not have privacy bags as most resident's didn't have catheters when they were admitted to the facility. RN 1 stated that she would conceal resident 51's catheter bag when he was ambulating in the corridors.

Based on observation and interview, it was determined the facility did not store drugs and biologicals in locked compartments which permitted only authorized personnel to have access. Specifically, three (3) over-the-counter bottles of medications were stored in an area of the facility that resident's and visitors had access too. Findings include: On 4/24/12 at 5:00 PM, the facility Common Room was observed. The Common Room was observed to have three (3) bottles of over-the-counter medications stored in two (2) employee mail slots. The over-the-counter medications included: (1) A bottle of allergy relief medication, (2) A bottle of Ibuprofen, and (3) A bottle of Acetaminophen. On 4/24/12 at 5:00 PM, Registered Nurse (RN) 2, who also functioned as a Unit Manager, was interviewed. RN 2 stated that the Common Room was used for any resident, family or staff that wanted to use the room. RN 2 stated that medications should be locked and secured at all times. RN 2 was asked about the over-the-counter medications identified as above. RN 2 stated that the medications "probably shouldn't have been stored there."

Based on interviews and record reviews, the facility did not report 1 of 1 allegations of abuse and neglect. The facility did not immediately report the allegation to the State Survey and Certification Agency and to Adult Protective Services or local law enforcement, as is required. In addition, the facility did not submit the findings of the facility's investigation to the State Survey and Certification Agency as required. Resident identifier 1. Findings include: On 2/24/09, in preparation for the investigation, the State Survey and Certification Agency's facility entity report log was reviewed. There was no evidence that the facility had reported any allegations of abuse or neglect to the State Survey and Certification Agency as per regulation. Resident 1, a [AGE] year old male, was admitted to the Transitional Care Unit on 1/2/09, with [DIAGNOSES REDACTED]. The Transitional Care Unit (TCU) Manager was interviewed on 2/25/09 at 9:15 AM. The TCU Manager was asked if there had been any allegations of abuse or neglect filed by a resident or family. The TCU Manager acknowledged that an allegation was filed by resident 1's family. The TCU Manager stated that he had informed Risk Management and Human Resources. When the TCU Manager was asked if the allegation was reported to the State survey and certification agency, the TCU Manager responded that he "did not know he needed to". The TCU Manager, the Risk Manager and the Human Resources Manager were interviewed on 2/25/09 at 11:00 AM. The TCU Manager stated that resident 1's family brought a letter to him at a meeting on 1/5/09 concerning an allegation of abuse and neglect. The letter from resident 1's family was reviewed on 2/25/09. The letter from the family stated . . . " Subject: Formal Complaint Concerning Patient Abuse and Neglect . . . January 2, 2009." The facility's computer generated incident report log was reviewed on 2/25/09. On 1/3/09 the facility had received a report that a resident (resident 1) fell trying to go to the bathroom and a complaint was "received from family stating staff was verbally abusive and neglectful." During an interview with the TCU Manager, Risk Manager, Human Resources Manager and Float Pool Manager on 2/25/09 at approximately 11:00 AM, the managers were asked about the reporting of the allegation. The managers all agreed that the allegations were not reported to the State Survey and Certification Agency as required. The managers provided the surveyors with the investigation of the incidents including staff interviews, meetings with the family of resident 1, staff reassignments and efforts to protect other residents. The facility managers also agreed that the investigation results were not reported to the State Survey and Certification Agency within 5 working days as required. After the receipt of allegations of abuse and neglect, the facility did not report the allegations or results of the investigation to the appropriate State agencies, including the State Survey and Certification Agency.