A list of the most recent deficiencies for Embassy of Logan. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-28 | 2023-08-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-28 | 2023-08-17 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-20 | 2023-08-17 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-06-20 | 2023-08-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-20 | 2023-08-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-20 | 2023-08-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-20 | 2023-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-20 | 2023-08-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-20 | 2023-08-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-15 | 2023-08-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-15 | 2023-08-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-15 | 2023-08-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-24 | 2023-05-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-04 | 2023-01-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-04 | 2023-01-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-03 | 2022-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-22 | 2021-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-22 | 2021-12-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-22 | 2021-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-26 | 2021-06-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-26 | 2021-06-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-26 | 2021-06-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-26 | 2021-06-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-26 | 2021-06-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-26 | 2021-06-17 | N |
| Provide appropriate foot care. | Health | 2021-05-26 | 2021-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-26 | 2021-06-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-26 | 2021-06-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-26 | 2021-06-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-26 | 2021-06-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-26 | 2021-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-26 | 2021-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-06-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-26 | 2021-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-25 | 2021-06-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-25 | 2021-06-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-10 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-10 | 2019-12-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-10 | 2019-12-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-10 | 2019-12-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-10 | 2019-12-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-10 | 2019-12-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-10-10 | 2019-12-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-10 | 2019-12-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-10 | 2019-12-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-10 | 2019-12-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-10 | 2019-12-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-10 | 2019-12-11 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-10-10 | 2019-12-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-10 | 2019-12-11 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-10 | 2019-12-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-10 | 2019-12-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-10 | 2019-12-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-10-10 | 2019-12-11 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-10-10 | 2019-12-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-10 | 2019-12-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-10 | 2019-12-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-10 | 2019-12-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-10 | 2019-12-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-10 | 2019-12-11 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-10-10 | 2019-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-10 | 2019-12-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-12-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-03 | 2019-12-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-03 | 2019-12-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-03 | 2019-12-10 | N |
