Salem West Healthcare Center

Inspectors wroteBased on observations, medical record review, policy review, and interview, the facility failed to ensure a nurse implemented professional standards of practice when he failed to ensure a medication's expiration/use by date and administered the medication to a resident. This affected one resident (#8) of six residents observed during medication administration.

Inspectors wroteBased on observation, review of physician orders, policy review and interview, the facility failed to implement physician orders related to monitoring a feeding tube for placement and flushing the tube. This affected one resident (#23) of six residents observed during medication administration.

Inspectors wroteBased on observation, review of physician orders, and interview, the facility failed to ensure medications were available for administration as ordered. This affected two residents (#23 and #26) of six residents observed for medication administration. The census was 67.

Inspectors wroteBased on observations, medical record review, policy review, and interview, the facility failed to ensure residents were free from significant medication errors in regard to expired insulin being used for administration. This affected one resident (#8) of six residents observed during medication administration.

Inspectors wroteBased on observation, review of physician orders, policy review, and interview, the facility failed to ensure medications were administered in accordance with physician orders. This resulted in three medication errors out of 26 opportunities resulting in an 11.1% medication error rate. This affected two (Residents #5 and #36) of five residents observed for medication administration. 1. On 04/28/26 at 8:42 A.M., Licensed Practical Nurse (LPN) #110 was observed administering medication to Resident #36. While preparing Resident #36's medication, LPN #110 indicated Resident #36 did not have some medications in the medication cart. The medications not available included nifedipine (calcium channel blocker). LPN #110 checked the pyxis medication dispensing machine and indicated nifedipine was not available. [...]

Inspectors wroteBased on observation, review of the facility floor plan, and interview, the facility failed to ensure a fire pull station was visible and accessible in the event of an emergency. This had the potential to affect all 70 residents in the facility. Findings Include:Review of the facility floor plan revealed they had 14 fire pull stations in the facility. On 09/28/25 at 4:45 P.M. an interview with Resident #22 revealed he was concerned about the shelving blocking the fire pull station behind the nurse ' s station. An observation 11/03/25 at 10:45 A.M. revealed the wheeled cart of resident charts was stored/parked in front of the fire pull station. An interview with Licensed Practical Nurse #215 at this time verified the fire pull station behind the nurse ' s station was not accessible due to being obscured by the rack of resident ' s charts. [...]

Inspectors wroteBased on review of the medical record, review of the Self-Reported Incident (SRI) Investigation, interview, and review of the facility policy, the facility failed to ensure submission of SRI investigations were complete to include suspected perpetrators (SP) for tracking purposes, to ensure the facility and the State agency had the ability to identify potentially similar occurrences and allegations related to the same staff member. This affected two residents (#21 and #46) out of three reviewed for abuse and had the potential to affect all 20 residents (#4, #13, #14, #15, #20, #21, #27, #28, #34, #36, #39, #42, #43, #45, #46, #58, #59, #61, #62, and #63) who resided on the secure unit. Findings Include:1. [...]

Inspectors wroteBased on review of the medical record, review of staff time punches, interviews, and review of facility policy, the facility failed to ensure Resident #28 was free from verbal abuse by a staff member. This affected one resident (Resident #28) of three residents reviewed for abuse. Findings Include:Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, diabetes, hypertension, diverticulitis, adult failure to thrive, schizoaffective disorder, anxiety disorder, and scoliosis. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #28 had moderately impaired cognition. Review of the Nursing Notes from 01/01/25 through 11/15/25 revealed no documentation of any incident of verbal abuse. Review of the hospice incident report for Resident #28 revealed on 11/10/25 at 11:14 A.M. [...]

Inspectors wroteBased on review of the medical record, review of staff time punches, review of facility self reported incidents (SRI), interviews, and review of facility policy, the facility failed to notify the State agency of an allegation of verbal abuse by a staff member. This affected one resident (Resident #28) of three residents reviewed for abuse. Findings Include:Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, diabetes, hypertension, diverticulitis, adult failure to thrive, schizoaffective disorder, anxiety disorder, and scoliosis. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #28 had moderately impaired cognition. Review of the Nursing Notes from 01/01/25 through 11/15/25 revealed no documentation of any incident of verbal abuse. [...]

Inspectors wroteBased on review of the medical record, review of staff time punches, review of facility self reported incidents (SRI), interviews, and review of facility policy, the facility failed to thoroughly investigate and take immediate action to protect a resident after an allegation of verbal abuse by a staff member. This affected one resident (Resident #28) of three residents reviewed for abuse and had the potential to affect all 20 residents who resided on the secure unit. Findings Include:Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, diabetes, hypertension, diverticulitis, adult failure to thrive, schizoaffective disorder, anxiety disorder, and scoliosis. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #28 had moderately impaired cognition. [...]

Inspectors wroteBased on medical record review, interview and policy review the facility failed to ensure complaints of new onset pain were addressed in a timely manner. This affected one (Resident #34) of three residents reviewed for injuries. The facility census was 81. Actual harm occurred beginning on 06/11/25 when Resident #34, who had a diagnosis of dementia and required assistance with care, complained of pain in the right thigh and lower extremity and demonstrated increased agitation during therapy that was not comprehensively assessed or treated. On 06/12/25, Resident #34 was unable to stand and had ongoing complaints of pain affecting therapy participation and mobility. Facility staff did not notify the resident's medical provider until 06/26/25 at 11:40 P.M. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure accuracy of medical records regarding bathing. This affected four (Residents #4, #5, #51 and #63) of six residents reviewed for provision of showers.

Inspectors wroteBased on medical record review and interview, the facility failed to honor a resident's documented code status. This affected one (Resident #73) of two residents reviewed for advance directives.

Inspectors wroteBased on observation, review of the medical record, and interview with staff, the facility failed to ensure a wound treatment order was obtained and transcribed in the medical record for Resident #35. This affected one resident (Resident #35) of three residents reviewed for wounds. Findings Include:Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included diabetes, dementia, bacteremia, chronic obstructive pulmonary disease, hypertension, anxiety disorder, depression, Alzheimer's disease, intermittent explosive disorder, dysphagia, and absence of part of the right foot. Review of the nurses note dated 10/16/25 at 6:45 P.M. revealed Resident #35 arrived with two emergency medical technicians (EMT) via an ambulance from the hospital. [...]

Inspectors wroteBased on observation, interview, record review, and review of the Payroll Based Journal (PBJ) and facility assessment, the facility failed to provide sufficient nursing staff to meet the total care needs of all residents for their highest practicable physical, mental and psychosocial well -being. This affected four residents (#21, #23, #38 and #42) of five residents reviewed for assistance with activity of daily living (ADL) needs and had the potential to affect all residents in the facility. The facility census was 64.

Inspectors wroteBased on observation, record review, job description review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 64 residents who resided in the facility.

Inspectors wroteBased on review of the facility assessment and staff interview, the facility failed to ensure a complete and accurate facility assessment was developed with active involvement of the required participants. This had the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, review of the facility policies, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to maintain infection control practices by not adhering to proper hand hygiene during care for two residents (#21 and #22). This afffected two residents (#21 and #22) of five residents reviewed for assistance with activity of daily living. Also, the facility failed to ensure a flow diagram and a written description to describe the facility's water system was included in the facility water management program (WMP) in order to minimize the growth and transmission of the bacterium Legionella. This had the potential to affect all residents residing at the facility. The facility census was 64. 1. [...]

Inspectors wroteBased on observation, record review, interview and review of facility policy, the facility failed to ensure call lights were within reach for Resident #50, #56 and #60, and failed to ensure Resident #20 was reasonably accommodated to meet his shower preference. This affected four residents (#20, #50, #56 and #60) of 22 residents reviewed for accomodation of needs/preferences. The facility census was 64.

Inspectors wroteBased on observation and interview the facility failed to ensure a clean environment was maintained for Resident #56 and Resident #267 and failed to maintain comfortable water temperatures and at the required water temperature for Resident #11, #15, #19, #27, #33, #34, #52 and #54. This affected 10 residents (#11, #15, #19, #27, #33, #34, #52, #54, #56 and #54) with the potential to affect an additional 13 residents (#7, #14, #22, #23, #28, #31, #37, #42, #43, #45 #46, #60 and #114) residing on the 100 hall. The facility census was 64.

Inspectors wroteBased on medical record review, interviews, review of care plan schedules, and review of facility policy, the facility failed to develop a comprehensive care plan as required for Resident #264, failed to ensure there was documented proof in the medical record that care plan meetings with required participants were being held for Residents #20 and #21, and failed to ensure fall interventions were timely updated in the care plan for Resident #38. This affected four residents (#20, #21, #38, #264) out of 22 residents reviewed for care plans. The facility census was 64.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #114 received staff assistance for showering, and failed to ensure timely incontinence care was provided for Resident #21, #23 and #42. This affected four residents (#114, #21, #23 and #42) of five residents reviewed for assistance with activity of daily living (ADL) needs. The facility census was 64.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure therapeutic activities as scheduled were being provided to residents on the secured unit. This had the potential to affect all 13 residents (#3, #8, #10. #18, #29, #30,#48, #55, #50, #56, #58, #59, #61) who resided on the secured unit. In addition, the facility failed to ensure Resident #20 was provided one-to-one activities of interest, and Resident #50 was provided routine therapeutic activities for socialization. This affected two residents (#20 and #50) of three residents reviewed for activities. The facility census was 64.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure smoking materials were in a secured area when not in use for Resident #26 and Resident #41, failed to ensure fall interventions were implemented after a fall for Resident #38, and failed to ensure water was at a safe temperature for Resident #36 and #267. This affected five residents (#26, #41, #38, #36, and #267) of seven residents reviewed for accidents/hazards. The facility census was 64.

Inspectors wroteBased on medical record reviews, interviews, review of signed arbitration agreements, and review of facility policy, the facility failed to ensure the arbitration agreements were explained in a way the residents understood prior to the residents signing the agreement. This affected five residents (#20, #21, #26, #51 and #214) out of five residents reviewed for arbitration agreements and had the potential to affect all 26 residents (#1, #11, #15, #16, #17, #20, #21, #26,#32, #34, #38, #39, #41, #42, #43, #44, #48, #50, #51, #52, #53, #54,#55,#57,#58, #214) the facility identified as having signed an arbitration agreement. The facility census was 64.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure all residents at all times on the secured unit were able to communicate their needs using a call system that would relay an audible sound directly to a staff member or to a centralized staff work area on the secured unit. This had the potential to affect all 13 residents (#3, #8, #10, #18, #29,#30, #49, #50, #55, #56, #57, #58, and #61) living on the secured unit. The facility census was 64.

Inspectors wroteBased on record review, observation, interview, and review of facility policy, the facility failed to provide a dignified dining experience for all residents. This affected one resident (#23) of five residents reviewed for food/nutrition. The facility census was 64.

Inspectors wroteBased on interviews and record review and review of facility policy, the facility failed to ensure privacy with mail correspondence for Resident #41. This affected one resident (#41) of one resident reviewed for privacy with mail. The facility census was 64.

Inspectors wroteBased on record review and interview, the facility failed to ensure the do not resuscitate (DNR) authorization form was completed in its entirety for Resident #51. This affected one resident (#51) of 22 residents reviewed for advanced directives. The facility census was 64.

Inspectors wroteBased on record review and interview the facility failed to ensure the Notice of Medicare Non-Coverage was acknowledged by the resident representative for residents with cognitive impairment. This affected two residents (#29 and #57) of five residents reviewed for beneficiary notices. The facility census was 64.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure admission paperwork was signed as required. This affected one resident (#214) of five residents reviewed for admission. The facility census was 64.

Inspectors wroteBased on record reviews, interviews, and review of facility policy, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the residents' status. This affected three residents (Residents #20, #21, and #38 ) out of 22 residents reviewed for accurate MDS assessments. The facility census was 64.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan to identify triggers and effective interventions related to a diagnosis of Post-Traumatic Stress Disorder (PTSD) for Resident #42. This affected one resident (#42) of 22 residents reviewed for care plans. The facility census was 64.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure indwelling urinary catheters were emptied in a timely manner to prevent back flow of urine for Resident #16. This affected one resident (#16) of three residents observed for catheters. The facility identified nine residents (#16, #51, #5, #2, #19, #45, #32, #53 and #31) as having indwelling urinary cathetars. The facility census was 64.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure weekly weights were being obtained as ordered by the physician to monitor nutrition status for Resident #38 and #42. This affected two residents (#38 and #42) out of four residents reviewed for nutrition. The facility census was 64.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #26 received proper and physician ordered care of a feeding tube site to prevent potential for skin irritation and infection. This affected one resident (#26) of two residents reviewed for feeding tubes. The facility census was 64.

Inspectors wroteBased on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure oxygen tubing was changed weekly. This affected three residents (#5, #20, and #21) out of three residents reviewed for respiratory care. The facility identified eleven residents (#5, #9, #17, #19, #20, #21, #23, #25, #27, #31, and #43) as having a physician order for oxygen. The facility census was 64.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from significant medication errors. This affected two residents (#35 and #37) of five residents reviewed for medication administration. The facility census was 64.

Inspectors wroteBased on interview and record review the facility failed to ensure lab work had been completed timely and according to physician order. This affected one resident (#15) of two residents reviewed for laboratory services. The facility census was 64.

Inspectors wroteBased on observation, interview, record review, review of the facility diet spread sheet, and review of facility policy, the facility failed to ensure Resident #42 received foods consistent with a dysphagia advanced diet to meet individual needs. This affected one resident (#42) out of four residents reviewed for nutrition. The facility identified six residents (#14, #27, #30, #42,#43, and #266) ordered a dysphagia advanced diet. The facility census was 64.

Inspectors wroteBased on interview and employee file reviews, the facility failed to conduct performance evaluations for Certified Nursing Assistants (CNA) as required. This had the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure Resident #13's pain was addressed in a timely and appropriate manner. Actual harm occurred on 08/17/24 when Resident #13, who had an open reduction and internal fixation (ORIF) surgery of a left femur fracture on 08/02/24, was admitted to the facility and the facility failed to develop and implement a comprehensive, individualized and adequate pain management program to provide effective and timely pain relief. Resident #13 displayed signs of pain on admission, during therapy evaluations on 08/19/24 with an increase in severity prior to direct care on 08/20/24 and received no pain interventions. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the self-reported incident (SRI) tracking number 250524, facility SRI investigation, medical record review, interviews, and facility policy review, the facility failed to prevent staff-to-resident physical abuse for Resident #34. This affected one resident (#34) of three residents reviewed for abuse. The facility census was 56.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure pharmacy services provided for timely ordering, dispensing, acquiring, and administering of medications to meet the needs of each resident. This affected two residents (Resident #45 and Former Resident #58) out of four residents who were reviewed for medication administration. The facility census was 56.

Inspectors wroteBased on observation, interview, medical record review, review of facility policy, and Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum summary, reference number QSO-24-08-NH review the facility failed to ensure proper infection control procedures were implemented and followed for Resident #13. This affected one resident (#13) of three residents reviewed for incontinence care. The facility census was 56.

Inspectors wroteBased on record review, observation and interviews the facility failed to ensure all staff were wearing the appropriate Personal Protective Equipment (PPE) to help prevent the spread of COVID-19 in the facility. This had the potential to affect 32 residents who were not COVID-19 positive (#2, #4, #7, #8, #9, #14, #15, #17, #19, #20, #21, #26, #28, #29, #30, #32, #34, #35, #36, #37, #40, #41, #42, #45, #46, #48, #50, #52, #54, #55, #57,and #58) and residing in the facility at the time of the survey. The facility census was 53.

Inspectors wroteBased on observation, record review, and interviews the facility did not ensure palatable food was served to all the residents eating meals from the kitchen. This had the potential to affect all residents in the facility, with the exception of Residents #4, #17 and #37 the facility identified as consuming nothing by mouth. The facility census was 58.

Inspectors wroteBased on medical record review, review of the infection control log/antibiotic stewardship program and interview the facility failed to implement a comprehensive antibiotic stewardship program. This affected three residents (#14, #57, and #222) of three residents reviewed for infections and had the potential to affect all 72 residents residing in the building.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice Form (SNF ABN) Form CMS-10055 was provided to Resident #14 and #71 as required. This affected two residents (#14 and #71) of three residents reviewed for liability notices. The facility census was 72.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASSAR) were accurate to contain diagnosis of serious mental disorders. This affected three resident (#10, #21 and #29) of five residents reviewed for PASSAR.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure residents who were dependent on staff for personal care received adequate and timely nail care. This affected three residents (#3, #43, and #172) of five residents reviewed for actives of daily living. The facility census was 72.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #14 received adequate and as ordered care for treatment related to a fracture. This affected one resident (#14) of one resident reviewed for injuries of unknown origin.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a splinting device was provided as planned for Resident #29 who had a left wrist/hand/finger contracture. This affected one resident (#29) of three residents reviewed for positioning.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure nebulizer treatments were maintained under sanitary conditions and oxygen humidification was provided for Resident #43. This affected one resident (#43) of four residents reviewed for respiratory care.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #26 received routine dental care. This affected one resident (#26) of two residents reviewed for dental care.