Salem Memorial District Hospital

Inspectors wroteBased on interview and record review, facility staff failed to provide documentation of monthly drug regimen reviews for five (Residents #1, #2, #4, #13 and #15) of five sampled residents. The facility census was 13.1. Review of the facility's policy titled Long Term Care Drug Regimen Review, dated 06/20/22, showed the drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/17/25, showed staff assessed the resident as: -Cognitively intact;-Diagnoses of Diabetes, urinary tract infection (UTI) and paraplegia, paralysis of the legs and lower body;-Received opioids; -Received anticoagulants; -Received antibiotics; [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 17.1. Review of the facility's job description titled Food Service Director dated 04/08/21, showed the purpose of the position is to provide supervision over all dietary functions and staff as directed/instructed, which included assisting in planning, organizing, developing, implementing, and directing the dietary services department, as well as its program and activities, in accordance with current rules, regulations, and guidelines that govern the facility. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow professional standards when physical therapy orders were not initiated for one resident (Resident #1). The facility census was 13.1. Review of the facility's policy titled Medication Management: Ordering and Transcribing, dated 03/01/14, showed all medication and treatment orders shall be written in the medical record or entered in the computerized order entry system of the resident and signed by the ordering licensed independent practitioner. All orders for treatment shall include the type of treatment, specific requirements of the treatment and frequency of the treatment.2. [...]

Inspectors wroteReviewed AT Based on observation, interview, and record review, facility staff failed to follow professional standards when staff prepared four medication cups with medications prior to the timed medication pass and left one resident (Resident #10) medication unattended on top of the medication cart. Facility staff failed to notify three resident's (Resident #5, #7, and #13) physician regarding medications not being administered on time. The facility census was 18. 1. Review of the Facility's Administration of Drugs policy, dated 01/24/14, showed medications may not be prepared in advance and must be administered within one hour of preparation. 2. Observation on 09/25/24 at 10:10 A.M., showed the medication cart contained: -One medication cup labeled with a first name contained one pill; -One medication cup labeled with a first name contained eight various pills; [...]

Inspectors wroteReviewed AT Based on observation, interview, and record review, facility staff failed to obtain informed consent from the resident and/or resident representative for the use of side rails for one resident (Resident #5) and failed to complete an entrapment risk assessment or obtain a physician's order for use of the bed rails for five residents (Resident #5, #8, #11, #12, and #13), out of five sampled residents. The facility census was 18. 1. Review of the facility's policies showed staff did not provide a policy for Entrapment Risk Assessments. Review of the facility's Bed Rails Policy, dated 03/14/2014, showed bed rails are considered a restraint, three rails may be raised at one time to enhance bed mobility of the patient, all four rails may not be raised at the same time. [...]

Inspectors wroteReviewed AT Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 25 opportunities observed, 15 errors occurred, resulting in a 60% error rate, which affected three residents (Resident #5, #7, and #13) out of seven sampled residents. The facility census was 18. 1. Review of the Facility's Medication Administration policy, dated 05/31/20, showed the individual administering a medication will be aware of the following information concerning each medication before administration: Appropriate timing of medication administration. 2. Review of Resident #5's Physician Order Sheet (POS), dated September 2024, showed staff is directed to administer medications at 8:00 A.M.: -Levothyroxine (treat low thyroid) 100 micrograms (mcg) daily on an empty stomach at 8:00 A.M.; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to reheat pureed food to prevent the growth of food-borne pathogens and potential for food-borne illness. Facility staff failed sanitize kitchen wares in a manner to prevent contamination. Facility staff failed to cover kitchen waste containers when not in actual use to deter the attraction of pests and rodents. These failures have the potential to affect all residents. The census was 18. 1. Review of the facility's Food Storage policy, revised [DATE], showed: -All food will have proper dates, labels and be properly covered when stored; -All prepared, ready-to-eat foods will be marked with a date of preparation and/or expiration date; -All food will be used by the expiration date. [...]

Inspectors wrotereviewed AT Based on interview and record review, the facility staff failed to implement an effective Quality Assurance (QA)/Quality Qssurance Preformance Improvemnt (QAPI) program when staff did not meet and discuss interventions to correct any on-going systemic issues that pertain to the Long Term Care (LTC). The facility census was 18. 1. Review of the facility's LTC QAPI Policy, revised 06/16/22, showed the following: -To identify and correct quality deficits along the areas for improvement within Long Term Care; -The multidisciplinary team will meet monthly to evaluate a current projects and identify areas that need improvement or included. The LTC Medical Director will be made aware of the findings of the LTC QAPI Committee Monthly, LTC Director will report to the Hospital QAPI Committee quarterly. [...]

Inspectors wroteBased on interview and record review, staff failed to provide residents with a written response to grievances. The facility census was 16. 1. Review of the facility's policy titled, Grievances, Investigating and Grievances and Complaints, revised 03/07/17, showed staff were directed to do the following: -It is the policy of this facility to investigate all grievances and complaints filed with the facility; -The Grievance/Complaint Investigation Report must be filed with the administrator within five (5) working days of the receipt of the grievance or complaint form; -The resident, or acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten (10) working days of the filing of the grievance or complaint; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate hair and nail care for three dependent sampled residents (Resident #3, #8, and #10). The facility census was 16. 1. Review of the facility's policy titled, Direct Resident Care, Hygiene and General Care, dated 01/24/23, showed staff were directed to do nail care every week and as needed (PRN). Review of the facility's policy titled, Resident Care Management, Scope of Care, dated 01/24/14, showed staff were directed to ensure each resident receives daily personal hygiene to assure cleanliness, good skin care, good grooming, and oral hygiene taking into account individual preferences. Review of the policies provided showed no policy in regard to facial hair management. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit Payroll Based Journal (PBJ) data (staffing information based on payroll data) for five quarters. The facility census was 16. 1. Review of the policies provided by the facility showed no PBJ policy. Review of the facility's PBJ Quarterly reports showed: -01/01/22 through 03/31/22, showed no data submitted for the quarter; -04/01/22 through 06/30/22, showed no data submitted for the quarter; -07/01/22 through 09/30/22, showed no data submitted for the quarter; -10/01/22 through 12/31/22, showed no data submitted for the quarter; -01/01/23 through 03/31/23, showed no data submitted for the quarter. During an interview on 08/22/23 at 8:31 A.M., the Long Term Care Director said he/she has worked for the facility for a week. He/She said PBJ data was not submitted for the last quarter, and it should be submitted quarterly. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 16. 1. Review of the facility's policy titled, Surveillence, Prevention, and Control of Infection, Renal Dosing of Selected Antimicrobials, dated 02/16/23, showed staff were directed to do the following: -All Medications administered at the facility will be of the appropriate dose, route and frequencey in consideration of the patient's condition, indications, and lab values; -The antimicrobial agents in this policy are considered to be of special interest to the Antimicrobials Stewardship Committee and require precautions and attention to ensure they are dosed appropriately. [...]