Salem Springlake Health & Rehabilitation Center

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to store, label and date food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interview and review of facility policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. for five (5) of fourteen (14) sampled residents(Resident #8, Resident #23, Resident #38, Resident #42 and Resident #203). Observation of a dinner meal in the dining room, on 12/04/2023, revealed Unit Manager #1 was standing over Resident #8 as she provided feeding assistance. Additionally, observations of Resident's #42, #23, #38, and #203, revealed staff failed to ensure the resident's bare bodies were not exposed to others.

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to revise the care plan following a significant weight change for four (4) of fourteen (14) sampled residents (Resident #22, Resident #42, Resident #18 and Resident #203). Review of Resident #22's, #42's, #28's, and #203's care plans revealed the care plans were not revised to include interventions for weight loss and supplements.

Inspectors wroteBased on observation, interviews, record review and review of facility policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible, for two (2) of fourteen (14) sampled residents (Resident #22 and Resident #42). 1. Review of Resident #42's weight beginning 09/04/2023, revealed an admission weight of 233.5 pounds (lbs). On 12/06/2023 at 10:30 AM, the Surveyor requested and observed staff obtain Resident #42's weight using a mechanical lift scale and weight was observed to be 187 lbs. This reflected a significant weight loss of 19.91% in ninety (90) days. 2. Review of recorded weights for Resident #22 revealed that on 06/14/2023, the resident weighed 131.4 lbs. [...]

Inspectors wroteBased on observation, interview, record review, and facility document review, it was determined the facility failed to ensure services were provided by sufficient competent staff, including but not limited to licensed nurses and nurse aides, on a 24-hour basis to provide nursing and related services to residents for four (4) of fourteen (14) sampled residents (Resident's #4, #6, #16, and #26). Interviews revealed nursing staff was slow to answer resident call lights.

Inspectors wroteBased on observation, interviews, record review, and review of facility policy, it was determined the facility failed to 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 for one (1) of fourteen (14) sampled residents (Resident #42). Observation on 12/06/2023 at 10:20 AM, revealed Certified Nursing Assistant (CNA) #3 failed to remove her soiled gloves prior to picking up and offering Resident #42 a glass of water.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, it was determined the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for one (1) of fourteen (14) sampled residents (Resident #42). Observation of Resident #42's bed on 12/07/2023, revealed there was a large gap between the side rails and bed mattress.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity, and care in a manner that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality, for two (2) of twelve (12) sampled residents (Residents #11 and #14). Staff failed to close the blinds/curtain when providing a skin assessment for Resident #11, leaving the resident's buttocks exposed to anyone who could have looked in the window. In addition, staff placed Resident #14's medication in his/her mouth with her bare hand and the resident stated it made him/her feel like a child.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for two (2) of twelve (12) sampled residents, (Residents #11 and #29), related to oxygen administration, and stoma/suctioning. Resident #11 was care planned for oxygen at 2 Liters per trach mask at 35% humidified oxygen air. However, observations on 03/30/2021 revealed Resident #11's oxygen humidification container was empty and the oxygen was not humidified at 35%, per the care plan. In addition, Resident #29 was admitted on oxygen; [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to update and revise the comprehensive nursing care plan for one (1) of (12) sampled residents (Resident #34) Resident #34 was readmitted to the facility on [DATE] with a new indwelling urinary catheter and was on oxygen therapy. However, review of Resident #34's Comprehensive Care Plan revealed the facility failed to revise the care plan to reflect the use and/or care of the indwelling urinary catheter and oxygen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined two (2) residents in the selected sample of twelve (12) were identified on the facility's Census and Condition to have a urinary catheters. The facility failed to have an effective system in place to ensure appropriate treatment and services was provided to one (1) of twelve (12) sampled residents (Resident #34). Resident #34 was readmitted to the facility on [DATE] with an indwelling urinary catheter in place. However, the facility failed to ensure the resident had a valid justification for use, a Physician's Order for the use of the catheter, interventions in place to address the care of the catheter, and appropriate care and services to prevent infections was provided.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure oxygen therapy was provided according to the Physician's Order and care plan for one (1) of twelve (12) sampled residents (Resident #11). Observations on 03/30/2021 at 10:08 AM, 11:30 AM, and 1:20 PM revealed Resident #11's oxygen humidification container was empty and not dated.

Inspectors wroteBased on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on 03/30/2021 revealed there were two (2) expired medications stored in the facility's medication refrigerator.

Inspectors wroteBased on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) and Prevention guidelines, it was determined the facility failed to ensure staff followed standard and transmission-based precautions to prevent the spread of infections; and, hand hygiene procedures when involved in direct resident contact. Resident #34 was on contact and droplet precautions due to being readmitted to the facility from hospital, however, observation revealed staff provided incontinent care to the resident without wearing a gown and shield. In addition, licensed staff placed Resident #14's medication in his/her mouth with her bare hand.