Salem Center

Inspectors wroteBased on observation, resident, and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in rooms 126, 127, 130, 162, and 163. This was also true for the kitchen and the Shower room, This was a random opportunity for discovery. Facility census: 87.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain and ensure infection control standards were followed in several areas. Specifically, there were issues with the suction machine, and wheelchairs with tears in the cushions. The laundry room ' s ventilation system was inoperable, and appropriate infection control protocols were not implemented while using the facility ' s transport van to transport soiled linen to the laundromat over a span of 3 to 4 months. Additionally, there were deficiencies in infection control practices related to the cleaning and disinfection of reusable resident equipment. In addition, the facility also failed to provide appropriate infection surveillance and did not implement measures for the surveillance and prevention of legionella and other opportunistic waterborne pathogens. [...]

Inspectors wroteBased on observations and staff interviews the facility failed to ensure kitchen staff were provided education/training on how to use the fire compression system. This had the potential to affect all residents in the facility.

Inspectors wroteBased on observations, staff and resident interviews, and record reviews, the facility failed to ensure food was palatable, visually appealing, and served in a manner consistent with residents' preferences. The facility was unable to incorporate individualized dietary preferences into the care planning process, was unable to deliver food met resident expectations for seasoning and appeal, and failed to ensure systemic measures were in place to verify meal quality through test trays. Environmental issues and kitchen disorganization further contributed to diminished quality of meal service. These failed practices had the potential to contribute to resident dissatisfaction, poor nutritional intake, and a decline in quality of life. This was true for Five (5) of five (5) residents reviewed for food satisfaction. Resident Identifiers: #31, #52. #66, #50 and #23. Facility census: 87.

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantries. This had the potential to affect all residents in the facility. Facility census 87. Findings Included: a) On 06/02/25 at 11:35 am during the Initial Brief Tour of Kitchen, with the Kitchen Account Manager the following issues were found in the kitchen pantry, cooler, and utensil drawers : Pantry: - Spices in the cooking area left open and exposed. - Corn muffins mix box was left open and exposed. - Box of elbow noodles stored labeled with no opening date or expiration date. - Spaghetti with an expiration date of 5/9/25 still in the pantry on 6/2/25. b) Cooler: - Staff personal drinks (An energy drink and a mountain dew) were found in the kitchen cooler c) Cleanliness: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide sufficient hallway space and equipment r/t resident wheel chairs lined up down both sides of the hallway on Hill Top Front Hall leaving no direct path. This was a random opportunity for discovery. Facility Census 87 Findings Included: Observation: On 06/03/25 at 3:30 PM, it was observed in the Hill Top Front Hallway, the resident wheel chairs were lined up on both sides of the hallway leaving all who walked through without a direct path. Staff Interview: In an Interview with The Facility Administrator on 6/4/25 at approx 2:50PM, she acknowledged the insufficient space/direct path for walking down the Hill Top Front Hallway.

Inspectors wroteBased on observation, inspection, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Location Identifiers: Laundry rooms and Shower rooms. Facility Census:87. Findings Include: a) Laundry Rooms On 06/03/25, at approximately 1:20 PM, an inspection of the laundry rooms was conducted, accompanied by the Regional Director of Maintenance (RDM) #90. During the inspection, it was noted the venting system in the dirty laundry room, which is responsible for maintaining negative pressure in the room, was not operational. Additionally, the air conditioning unit in the clean laundry room was also non-functional. The failure to maintain the venting system's operational status created a potential risk of harm to residents, staff, and visitors at the facility. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure there was adequate ventilation in the shower rooms and dirty laundry rooms. This failed practice had the potential to harm multiple residents at the facility. Location Identifiers: Shower rooms and Dirty laundry room.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure transfer/discharge notice was given prior to residents leaving the facility. THis was found true for 1 of 2 residents reviewed for closed record review regarding hospitalization and discharge. Resident identifier: #89 Facility Census: 89 Findings Include: During a record review on 06/04/25 at 3:30 PM of Resident #89's record no transfer/discharge notice was found, documentation was requested from the Director of Nursing (DON)) and the Administrator. On 06/05/25 at 9:14 AM, the Administrator stated we do not have the transfer/discharge for Resident #89, they went out for a procedure then went home and I guess they (facility staff) didn't think they needed to do it for some reason. Confirming no transfer/discharge paperwork was completed.

Inspectors wroteBased on observation and staff interviews, the facility failed to dispose of garbage and refuse properly. This had the potential to affect all residents in the facility.

Inspectors wroteBased on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for 0ne (1) of one (1) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #72. Facility census: 84. Findings Included: a) Policy review Record review of the facility's policy titled, grievance /concern, showed: -Upon receipt of the grievance / concern, the grievance / concern form will be initiated by staff member receiving the concern. -Upon receipt of the grievance /concern form, the Administrator or designee will document the grievance / concern on the grievance / concern log. - Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated. [...]

Inspectors wroteBased on observation and staff interview the facility failed to have cans with uncompromised seals, dishware stored inverted or covered, supplies stored off the floor, and clean sanitized mobile utility food carts. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census. 84.

Inspectors wroteBased on observation, and staff interview, the facility failed to ensure personal privacy and confidentiality of personal and medical information contained in the electronic health record. This deficient practice was based on a random opportunity for discovery for Resident #17, whose Medication Administration Record (MAR) was not secured but left open and visible for all who passed by the area to view. Resident identifier: Resident #17. Census: 84.

Inspectors wroteBased on record review and staff interview, the facility failed to identify a psychiatric diagnosis of depression for Resident #78. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #78. Facility Census: 84. Findings Included: a) Resident #78 On 10/24/23 at 9:43 AM, a record review was completed for Resident #78. The review found the resident was prescribed Cymbalta (antidepressant) 30mg (milligram) daily for depression with a start date of 09/22/23. The Minimum Data Set (MDS) with the assessment reference date (ARD) of 09/27/23 was reviewed and section I (psychiatric/mood disorder) found a no which indicates the resident did not have a diagnosis of depression. On 10/25/23 at 11:04 AM, an interview was held with the Director of Nursing (DON). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #77. Census 84. Findings Included: a) Resident #77 On 10/16/23, a record review of the resident's electronic medical record (EMR), found the resident's admission PASARR, dated 06/09/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record also revealed the resident received a psych diagnosis of schizoaffective disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. [...]

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to develop and/or implement a care plan regarding refusal of care for Resident #82 and the use of a right hand splint for Resident #76. This was true for two (2) of 18 residents reviewed during the survey process. Resident Identifiers: #82 and #76. Facility Census: 84. Findings Included: a) Resident #82 On 10/23/23 at 11:15 AM, the resident was observed and appeared to be somewhat disheveled. A record review was completed on 10/23/23 at 12:16 PM. The review found multiple refusals of showers and bed baths documented. The resident had only two (2) showers documented in September, 2023 and one (1) shower and two (2) bed baths documented in October, 2023. The following dates of refusals are as follows: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to revise a care plan for one (1) of 18 sampled residents, when an assessment was made with additional information obtained regarding resident's care and or behavior. Resident #47 was known by staff to adjust/alter oxygen flow rates but this behavior was not included in the resident's care plan revision. Resident identifier: Resident #47. Census: 84.

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to follow a physician's order regarding right hand splint application for Resident #76 and complete neurological (neuro) checks after a fall for Resident #17. This was true for two (2) of 18 residents reviewed during the long-term survey process. Resident Identifiers: #76 and #17. Facility Census: 84. Findings Included: a) Resident #76 On 10/23/23 at 11:46 AM, an initial observation found a right hand splint laying on the night stand by Resident #76's bed. The resident was asked, when do you wear your splint? The resident responded, I haven't worn it since I've been out of therapy. On 10/24/23 at 12:18 PM, an additional observation was made of the right hand splint laying on night stand. [...]

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to ensure each resident received care consistent with professional standards of practice following physician's orders to treat pressure sores. This was true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Protocol for the care area of pressure ulcers. Resident #17 was not provided the treatment in accordance with physician's orders. Resident identifier: Resident #17. Census: 84.

Inspectors wroteBased on record review and staff interview, the facility failed to complete an annual performance review for Nurse Aide (NA) #66. This was true for one (1) of five (5) employees reviewed under the care area of sufficient and competent staffing. Facility Census: 84. Findings Included: a) Nurse Aide (NA) #66 A review of nursing aide requirements was completed on 10/24/23 at 1:00 PM. The review found NA #66 did not have a current performance evaluation. The last documented performance evaluation was completed in 2019. An interview with the Director of Nursing (DON) on 10/24/23 at 1:50 PM was completed. The DON stated, NA #66 has not had a performance evaluation since 2019 .she worked infrequently while going to nursing school and she was prn (as needed), now she is back. On 10/24/23 at 2:00 PM, the Administrator confirmed a performance evaluation should have been completed. [...]

Inspectors wroteBased on record review, staff and resident interview, the facility failed to ensure a resident was not administered a psychotropic drug unless, based on a comprehensive assessment of the resident, the drug was medically necessary to treat a specific condition with behaviors monitored to ensure effectiveness of the medication prescribed. Resident #6 and Resident #78 were receiving an anti-psychotic medication, however, behavior monitoring did not contain a documented specific behavior to be observed and monitored. This failed practice was identified in two (2) of five (5) residents reviewed for unnecessary medications during the LTCSP. Resident identifier: Resident #6 and #78. Census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, a grievance that was reported. This practice affected one (1) of one (1), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #72. Facility census: # 84. Findings Included: a) Resident #72 On 10/23/23 at 12:52 PM during an interview with Resident #72 she stated, she made a complaint about another Resident peering in her room, a month ago. Resident #72 stated that nothing was ever done about the issue. 10/23/23 a record review of the grievances log revealed no issues were documented for Resident #72. A continued record review of Resident #72's Quarterly 09/07/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #72 has capacity. [...]

Inspectors wroteBased on resident interview and staff interview, Resident Council grievances were not addressed timely. This is true for five of 27 reviewed. Resident identifiers #77, #63, #42, #44 and #64.

Inspectors wroteBased on record review and staff interview the facility failed to implement a care plan to address residents' medical needs for pressure ulcer care, eye eversion and the use of an anticoagulant. This was true for three (3) of 27 care plans reviewed. Resident identifiers #50, #41 and #26. Facility census: 82.

Inspectors wroteBased on resident interview and record review the facility failed to ensure all resident are offered an evening snack. This failed practice has the potential to affect all residents who receive snacks from the kitchen. resident identifiers #77, #63, #42, #44 and #64.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to properly label and date food items stored in the refrigerators in accordance with the professional standards for food service safety. The facility failed to complete daily temperature checks for the kitchen area reach-in refrigerator. The failed practice had the potential to affect more than a limited number of residents. Facility census: 82.

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep an accurate antibiotic line listing and failed to discard biohazard materials appropriately. This failed practice had the potential to more than a limited number of residents. Resident identifiers: #11, #49, and #50. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (1) of 27 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident #49 did not have a Physician Orders for Scope of Treatment (POST) form signed by the individual making decisions on behalf of the resident. Resident identifier: #49. Census: 82.

Inspectors wroteBased on random observation and interview, the facility failed to ensure a Resident's medical information was secured in a manner that protected personal, medical and health information. This was a random opportunity for discovery. Resident identifier #73. Facility census: 82. Findings Included: A review of the facility's policy titled privacy rights: Patients. Effective date 06/01/96 with revisions 11/28/16 revealed the following: --The patient has a right to personal privacy and confidentiality of his/her personal and medical records. a) Resident #73 On 05/19/22 at 10:40 AM, an observation of the computer monitor displaying an electronic medical record for Resident #73. The medication cart was left unattended, on top of the Hilltop-hall. The cart was in a place easily accessible to residents, visitors, or other unauthorized persons. [...]

Inspectors wroteBased on resident interview, facility documentation review and staff interview the facility failed to make efforts to resolve a resident's grievance as indicated by the actions taken to investigate the concern on the grievance form. This was a random opportunity for discovery. The failed practice was true for one (1) of one (1) grievance forms reviewed. Resident identifier: #34. Facility census: 82.

Inspectors wroteBased on resident interview, record review, facility documentation review and staff interview the facility failed to provide a resident with Activities of Daily Living (ADL) care in the form of a shower. This was true for one (1) of four (4) Residents review for ADL care. Resident identifier: # 34. Facility census: 82.

Inspectors wroteBased on record review and staff interview, the facility failed to follow physicians orders in accordance with professional standards of practice. Resident identifiers: #67 and #49. Facility Census: 82 Resident #67 a) Resident #67 has a current order for HYDROcodone-Acetaminophen Tablet 7.5-325 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 related to PAIN, UNSPECIFIED (R52) For pain 6-10, using pain scale 0-10. According to the Medication Administration Report (MAR) he was administered the HYDROcodone-Acetaminophen Tablet 7.5-325 MG twenty one (21) times in April 2022 and May 2022 for a pain level less than six (6). [...]

Inspectors wroteBased on observation policy review and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of a medication cart unlocked and unattended. Facility Census: 82. Findings Included: A review of the facility's policy titled Storage and Expiration Dating of Medication, Biologicals. Effective date 12/01/07 with revisions 01/01/22 revealed the following: --Facility should ensure that all medications and biologicals are stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. a) Hilltop Hall Medication Cart On 05/19/22 at 10:40 AM, An observation of an unlocked, unattended medication cart on the Hilltop Hall. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this not possible or resident preferences indicate otherwise for 1 of 3 residents reviewed during the Long-Term Care Survey Process (LTCSP) for the area of nutrition. Resident identifiers: #49 and #9. Census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that nursing assistants (NA's) received 12 annual hours of training a year including dementia training and abuse prevention. This was true for two (2) of five (5) employee files that were reviewed. Employee Identifiers: #26 and #57. Facility census: 82.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure medications and biologicals used in the facility were stored in accordance with currently accepted professional principles. The Hilltop medication room refrigerator and medication cart was not locked and unattended. This is true for one (1) of two (2) units. Facility Census 82.

Inspectors wroteBased on observation, staff interview and resident interview the facility failed to provide food preferences in a timely manner. This failed practice has the potential to affect all residents who receive nutrients from the kitchen. resident identifier #12.