Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Logan during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen, where food was prepared and served for all residents receiving meal trays. Observations on multiple days showed a convection oven, stove, and areas under the steam and tray lines with food splatter, crumbs, and debris; walls behind equipment with dust, dirt, and dried food; a hanging electrical outlet and an air conditioning unit with built-up dust; and uncovered trash cans near the oven and in the dishwashing area. These conditions were confirmed with the dietary manager and did not comply with the facility’s policy requiring all equipment to be kept clean and sanitary.
A resident with a history of cerebral infarction and asthma was ordered Metoprolol Tartrate for HTN with instructions to hold the dose if SBP was below 110 or HR below 60, and to obtain and record vital signs to guide administration. Over an extended period, no SBP or HR values were documented on the MAR, and staff later confirmed that several doses should have been held but were not. This practice was inconsistent with the facility’s own medication administration policy requiring vital signs to be obtained and medications held when ordered parameters are not met, resulting in the resident receiving medication without adherence to prescribed hold parameters.
Surveyors found that the facility failed to maintain complete and accurate medical records for three residents, including inconsistent documentation of a leg wound’s location by a WNP compared with nursing notes and orders, missing documentation of an annual dental visit and treatment that existed only in email despite a care plan citing dental risk, and hospice records that were not uploaded into the EMR but kept in email after the medical records position was eliminated and no policy addressed record completeness.
A facility failed to document treatments for a resident's stage IV pressure ulcers, resulting in missed treatments over several days. The resident, who was cognitively intact, had treatment orders for cleansing and packing the ulcers, but the TAR showed multiple missed treatments. Interviews with the DON and an LPN confirmed the missed treatments, with the LPN noting the resident's occasional refusal and inability to document late entries.
The facility failed to notify the physician of new or worsening skin impairments for four residents, including red areas, blisters, scabs, bruises, and pressure ulcers. The DON confirmed that the wound provider saw one resident but did not document any assessment or findings.
The facility failed to maintain safe and sanitary conditions in resident rooms, affecting six residents. Issues included a burning out light bulb, chipped paint, cracked floor tiles, dust build-up, damaged walls, and a constantly running sink. Despite daily rounds, the Maintenance Director was unaware of these problems, and no work orders had been placed.
The facility failed to ensure accurate PASRR documentation for a resident, omitting a known diagnosis of delusional disorder. The social worker did not review the PASRR for accuracy, assuming it was correct from the transferring facility, potentially impacting the resident's care and services.
The facility failed to communicate significant mental health changes to the state mental health agency for a resident with multiple diagnoses, including delusional disorder, which was not marked on the PASRR Identification Screen. The social worker did not review the PASRR for accuracy, potentially delaying necessary services.
The facility failed to ensure skin and wound assessments were completed thoroughly, accurately, and timely for three residents. One resident had multiple instances of undocumented or improperly documented skin impairments, another had incomplete and inconsistent wound documentation despite having orders for wound care, and a third had issues with incomplete and inconsistent wound documentation for a scab and abscess on the left toes. Interviews with the DON confirmed ongoing issues with nursing assessment documentation.
The facility failed to properly document a newly identified pressure wound for a resident with severe cognitive impairment and required substantial assistance for bed mobility. Despite the presence of a stage two pressure ulcer, the physician was not notified immediately, and the skin assessment was delayed, leading to a deficiency in care.
A facility failed to ensure a resident receiving a prn narcotic pain medication had parameters ordered from the physician on when to administer it. The resident had diagnoses including dementia and a history of a fracture. The prn Norco was given without specifying the resident's pain level, and the Acetaminophen, which was effective, was not used in February. The DON confirmed the lack of parameters and acknowledged the issue.
The facility failed to ensure laboratory tests were completed as ordered for a resident with mood disorder, bipolar disorder, and major depressive disorder. The resident's Depakote levels were not drawn every six months as required, with the last recorded level collected in August 2022. An LPN confirmed the oversight, citing limitations in their laboratory system.
Unsanitary Kitchen Conditions During Food Preparation and Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to prepare and serve food under sanitary conditions for all 92 residents receiving trays from the kitchen. On 03/17/2026 at 10:33 A.M., observation of the kitchen revealed a convection oven with food splatter and crumbs, a container under the steam table with food debris, a wall behind the plate warmer with dust and dirt buildup, and a wall behind the toaster table with dried food splatter. On 03/18/2026 at 2:20 P.M., further observation with the Dietary Manager showed a hanging electrical outlet over the serving line and an air conditioning unit with built-up dust, uncovered trash cans beside the convection oven and in the dishwashing area, a stove with dried food debris and splatter, and a shelf under the tray line with crumbs and food debris. These conditions were verified with the Dietary Manager and were inconsistent with the facility’s Sanitary Conditions policy stating that all equipment will be maintained in a clean and sanitary fashion. The deficiency had the potential to affect all 92 residents who receive food from the kitchen and was investigated under Complaint Number 2696142. No specific residents, medical histories, or clinical conditions were described in the report beyond the census count and the fact that 92 residents receive trays from the kitchen.
Failure to Follow Ordered Vital Sign Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not following physician-ordered parameters for administration of Metoprolol Tartrate. The resident, admitted with diagnoses including cerebral infarction, unspecified and unspecified asthma, uncomplicated, had a physician order dated 01/30/26 for Metoprolol Tartrate 25 mg, 1.5 tablets by mouth twice daily for HTN, with instructions to hold the medication if systolic blood pressure (SBP) was below 110 or heart rate (HR) was below 60. Review of the medication administration record showed no documented SBP or HR from 01/30/26 through 02/26/26, despite the order requiring these parameters to determine whether the medication should be given or held. Pharmacy reiterated the same hold parameters on 02/26/26, yet vital signs were still not documented for the earlier period, and staff interviews confirmed that the medication should have been held for specific doses on 03/10/26 and 03/11/26 but was not. Review of the facility’s Medication Administration Policy dated 08/22/22 showed that staff were required to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs fell outside prescribed parameters, which was not followed in this case. This deficiency was identified for one resident out of five reviewed for unnecessary medications, with a facility census of 92, and was investigated under Complaint Number 2696141.
Incomplete and Inaccurate Medical Records for Wound, Dental, and Hospice Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for multiple residents. For one resident with severe cognitive impairment, multiple chronic conditions, and a documented skin tear to the left outer/lateral leg, the care plan and weekly non‑pressure skin grids consistently identified the wound on the left leg with specific measurements and drainage descriptions. However, a series of weekly Wound Nurse Practitioner progress notes from December through March inaccurately documented the wound as being on the right lateral leg, despite physician orders and nursing staff confirming the wound was on the left lower leg. An LPN verified during interview that the WNP documentation did not accurately reflect the actual wound location being treated. For another resident with multiple chronic diagnoses and no documented cognitive deficit, the comprehensive and quarterly MDS assessments indicated no issues with teeth, mouth or facial pain, or chewing difficulty. The care plan later identified the resident as being at risk for dental or chewing problems related to poor dental hygiene and included interventions such as arranging periodic dental consults and follow‑up dental visits. The medical record showed a refusal of dental services on one date and no documented evidence of a dental visit since admission. However, the facility’s contracted dental assistant had in fact seen the resident for an annual visit, performed a cleaning, and applied silver diamine fluoride to several teeth, with follow‑up dependent on insurance. During interview, the social worker acknowledged that this dental progress note was not in the resident’s medical record and was likely only available in email. A third resident, admitted with cerebral infarction and asthma and later enrolled in hospice, also had incomplete documentation in the medical record. Hospice documentation for this resident was not uploaded into the resident’s medical record and was instead maintained in email, as confirmed by facility staff. Further interview revealed that the medical records position had been eliminated, resulting in resident documents remaining in email and not being incorporated into the official medical record. Staff also confirmed that there was no medical records policy addressing the completeness of medical records, contributing to the absence of required hospice and dental documentation and the inaccurate wound location documentation in the residents’ charts.
Failure to Document Pressure Ulcer Treatments
Penalty
Summary
The facility failed to document treatments completed on two pressure ulcers for a resident, leading to a deficiency. The resident, who was cognitively intact and required assistance with certain activities, had two stage IV pressure ulcers on the left and right ischium. The treatment orders for these ulcers included cleansing, packing with collagen sheets or Mupirocin, and covering with gauze, to be performed twice a day and as needed. However, the Treatment Administration Record (TAR) revealed multiple missed treatments for both ulcers over several days in May and June 2024. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the missed treatments. The LPN, who was responsible for the resident's care on most weekdays, stated that treatments were performed when the resident allowed, but documentation was not possible for missed treatments due to the resident's occasional refusal and lack of confirmation for completed treatments. The facility's policy required treatment orders to be documented in the PCC and on the TAR, which was not adhered to in this case.
Failure to Notify Physician of Skin Impairments
Penalty
Summary
The facility failed to ensure the physician was notified after a change in condition of a new wound or the worsening of a current wound. This deficiency affected four residents (#3, #74, #89, and #93) of seven reviewed for skin impairments. The facility census was 98. The report details multiple instances where the facility did not have evidence of physician notification for new or worsening skin impairments, including red areas, blisters, scabs, bruises, and pressure ulcers. These findings were based on record reviews, staff interviews, and facility policy reviews. For Resident #89, the facility failed to notify the physician of multiple new skin impairments, including red areas on the left knee, scabs on the right hand and fingers, and bruising to the left knee. The facility also did not document the physician's notification for several other skin impairments identified in subsequent assessments. The Director of Nursing (DON) confirmed that the wound provider saw the resident but did not document any assessment or findings. Resident #3 had multiple instances of skin impairments, including bruising to the neck, redness to the back of the hands, and a surgical incision to the left iliac crest. The facility did not have evidence of physician notification for these impairments. Similarly, Resident #74 had new skin impairments, including scabs to the left toes and redness around the toenail bed, without evidence of physician notification. Resident #93 had a newly identified stage two pressure ulcer on the coccyx, but there was no evidence that the physician was notified immediately. The Charge Nurse confirmed that the wound physician was notified the following week but not immediately when the pressure wound was identified.
Facility Fails to Maintain Safe and Sanitary Resident Rooms
Penalty
Summary
The facility failed to ensure that residents' rooms were maintained in a safe, functional, and sanitary manner, affecting six residents. Observations revealed various issues such as a burning out light bulb, chipped paint, cracked floor tiles, dust build-up on vents and ceilings, damaged walls, and a constantly running sink. These deficiencies were noted during initial observations and remained unaddressed during follow-up visits. Maintenance Director #22 verified these findings but denied having received any work orders for the issues identified. Interviews with staff, including a State Tested Nursing Assistant (STNA) and the Maintenance Director, revealed that environmental concerns were supposed to be reported and entered into the computer system for repairs. However, the STNA denied reporting any issues, and the Maintenance Director confirmed that no work orders had been placed for the identified problems. Despite making daily rounds, the Maintenance Director was unaware of the environmental concerns in the 400 hall.
Failure to Ensure Accurate PASRR Documentation
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) documents for Resident #6 were accurate to her current conditions and diagnoses. Resident #6 was admitted with diagnoses including unspecified dementia with agitation/mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder. However, her PASRR Identification Screen did not include the diagnosis of delusional disorder, which was known upon admission. The social worker at the facility acknowledged that she did not review the PASRR for accuracy and assumed it had been completed correctly by the transferring facility. This oversight could have led to the resident not receiving timely services that might have been required through a Level II review if the PASRR had been accurate. The facility's policy on Resident Assessment- Coordination with PASARR Program, revised on 01/01/24, states that the social services director is responsible for ensuring the accuracy of PASRR screenings and coordinating assessments. Despite this policy, the social worker admitted to not verifying the PASRR documentation received from the transferring facility. This failure to review and ensure the accuracy of the PASRR documentation resulted in a deficiency, as the resident's delusional disorder was not included, potentially impacting the level of care and services provided to the resident.
Failure to Communicate Significant Mental Health Changes
Penalty
Summary
The facility failed to ensure all significant mental health changes were communicated to the state mental health agency, affecting one resident reviewed for PASRR documents. Resident #6, who was admitted with diagnoses including unspecified dementia with agitation/mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder, had an incomplete PASRR Identification Screen. The screen did not mark delusional disorder despite it being a known diagnosis upon admission. The facility sent a request for a Level of Care Review to the Central Ohio Area Agency on Aging, which did not require the inclusion of the resident's mental illness diagnoses, only instrumental activities of daily living. The Pre-Admission Screen Determination indicated no in-person assessment was required, and the resident was approved for transfer under a delayed exempt status. An interview with the facility's social worker revealed that she did not review the PASRR for accuracy upon the resident's admission, assuming it had been completed correctly by the transferring facility. She acknowledged that the resident's diagnosis of delusional disorder was not included in the PASRR and that this oversight could have triggered a Level II review, potentially delaying necessary services. The facility's policy on Resident Assessment-Coordination with PASARR Program mandates that any resident exhibiting new evidence of a serious mental disorder should be referred promptly to the state mental health authority for a Level II review, which was not done in this case.
Failure to Ensure Accurate and Timely Skin and Wound Assessments
Penalty
Summary
The facility failed to ensure skin and wound assessments were completed thoroughly, accurately, and timely for three residents. Resident #89, who was cognitively intact and had multiple diagnoses including heart failure and diabetes, had several instances where skin impairments such as scabs, blisters, and bruises were either not documented properly or not followed up on. The assessments often lacked details such as the size, location, and description of the wounds, and there were inconsistencies in the documentation regarding whether the wounds were new, unchanged, or healed. Despite having an order for a wound practitioner to evaluate and treat as necessary, there were no documented assessments or findings from the wound provider for Resident #89's various skin impairments. Resident #3, who was also cognitively intact and had multiple diagnoses including diabetes and heart failure, had similar issues with incomplete and inconsistent wound documentation. The resident had a pressure ulcer on the left knee amputation stump and other skin impairments such as bruising and redness that were not properly documented in the skin assessments. The assessments often did not include descriptions or measurements of the wounds, and there were gaps in the documentation of skin grid assessments. Despite having orders for wound care, the assessments did not consistently reflect the presence or status of the wounds. Resident #74, who was cognitively impaired and dependent for activities of daily living, also had issues with incomplete and inconsistent wound documentation. The resident had a scab and abscess on the left toes that were not properly documented in the skin assessments. The assessments often lacked details such as the size, location, and description of the wounds, and there were inconsistencies in the documentation regarding whether the wounds were new, unchanged, or healed. Despite having a plan of care that included interventions for skin impairments, the assessments did not consistently reflect the presence or status of the wounds. Interviews with the DON confirmed that the facility had issues with nursing assessment documentation not being accurate and detailed, and that these issues persisted even after completing education on the matter.
Failure to Document and Notify Physician of Pressure Wound
Penalty
Summary
The facility failed to properly document a newly identified pressure wound for Resident #93, who had severe cognitive impairment and required substantial assistance for bed mobility. Despite the resident's significant change in condition and the presence of a stage two pressure ulcer, the facility did not notify the physician immediately as required by their policy. The resident's medical record showed inconsistencies, with a weekly skin observation indicating no skin issues, while progress notes and skin assessments later identified a pressure wound. The wound was first noted on 01/14/24, but no skin assessment was completed until 01/24/24, and the physician was only notified the following week when onsite for other treatments. Interviews with the charge nurses confirmed the lack of immediate physician notification and the absence of a timely skin assessment. The facility's policies on notification of change and licensed nurse skin condition documentation were not followed, leading to a delay in appropriate care for the resident's pressure wound. The deficiency highlights a failure in the facility's documentation and communication processes, impacting the quality of care provided to Resident #93.
Lack of Parameters for PRN Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure a resident receiving a narcotic pain medication ordered on an as-needed basis (prn) had parameters ordered from the physician on when to administer the medication. This affected one resident reviewed for unnecessary medications. The resident had diagnoses including unspecified dementia, opioid use, and a history of a displaced fracture of the upper end of the left humerus. The resident's physician's orders included Norco 5-325 mg one half tablet by mouth twice a day on a scheduled basis and Norco 5-325 mg one half tablet every six hours as needed for pain, without specific parameters for administration. Additionally, the resident had an order for Acetaminophen 650 mg every six hours as needed for general discomfort, which was documented as effective when administered. However, the prn Norco was given without specifying the resident's pain level, and the Acetaminophen was not used at all in February despite being effective in the previous month. The resident's pain was monitored every shift, and she denied any pain for the majority of the assessments. An interview with the Director of Nursing (DON) confirmed that the physician's orders for the prn Norco did not include parameters for administration. The DON acknowledged that the resident had an order for Acetaminophen 650 mg for general discomfort, which was effective in managing the resident's pain when given. Despite this, the resident received four doses of prn Norco in February without the Acetaminophen being used. The pain assessments completed every shift in February indicated that the resident had no complaints of pain. The DON stated she would contact the physician to obtain further orders for parameters on when to use the prn Norco.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were completed as ordered by the physician for Resident #62, who was admitted with diagnoses including mood disorder, bipolar disorder, and major depressive disorder. The resident had an order to receive Depakote 500 milligrams twice a day for mood disorder, with a requirement to obtain a Depakote level every six months. However, the electronic medical record showed no evidence of the Depakote level being drawn every six months as ordered. The last recorded Depakote level was collected in August 2022, and this lapse was confirmed by an LPN who cited limitations in their laboratory system as the reason for the oversight.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Logan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of New Lexington | 15.1 mi | — | 3 | 0 |
| Buckeye Care And Rehabilitation | 15.1 mi | — | 21 | 0 |
| Main Street Terrace Care Center | 15.6 mi | — | 14 | 0 |
| Lanfair Center For Rehab & Nsg Care Inc | 16.7 mi | — | 0 | 0 |
| The Springs At Wyandot Trail | 17.2 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.