Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Salem Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to Administer Ordered Antibiotic Course: A resident with spina bifida, paraplegia, bladder dysfunction, diabetes, and moderate cognitive impairment did not receive a full ordered course of IM ertapenem for a UTI. The MAR showed missed doses and a refusal, the record lacked a note explaining one missed dose, and only 5 of 7 ordered doses were given despite the provider order for daily therapy.
A resident with moderate cognitive impairment and physical limitations was repeatedly observed with their call bell out of reach, both while in bed and in a wheelchair. Despite facility policy and staff acknowledgment that call bells should always be accessible, the device was found on the floor or on the opposite side of the bed, making it difficult for the resident to access assistance when needed.
Facility staff did not provide written notification to a resident before moving them to a different room for medical management, despite the resident being cognitively intact and the facility's policy requiring such notification. Only verbal notification was given, and documentation was incorrectly completed by a social worker.
A resident with diabetes, neuropathy, and muscle weakness, who was moderately cognitively impaired and dependent on staff for ADLs, did not receive necessary nail care. The resident reported discomfort and stated they had requested nail trimming multiple times without results, leading them to chew their own nails. Observations confirmed the resident's nails were long and unclean, and staff interviews showed inconsistent provision of nail care despite facility policy assigning this responsibility to CNAs and nurses.
A resident with Type 2 Diabetes Mellitus did not receive ordered blood glucose checks or Novolog insulin administration on multiple occasions, with no documentation to indicate the medication was given, refused, or held. The DON could not provide evidence explaining the omissions, and facility policy required such checks and documentation prior to medication administration.
A resident with multiple pressure ulcers and complex medical conditions did not receive proper wound care when a nurse and an LPN failed to follow infection control procedures, including not cleaning scissors before use and not performing hand hygiene between glove changes and wound care steps, contrary to facility policy and standard clinical guidelines.
Staff failed to accurately document a wound's location for one resident, recording it on the wrong foot in clinical records, and did not document scheduled oxycodone administration on the MAR for another resident, despite recording it on the NARC log. Both residents had complex medical histories, and these documentation errors were confirmed by facility leadership.
Staff failed to adhere to infection control protocols during wound care for two residents, including not cleaning scissors between uses, not performing hand hygiene between glove changes, and improper handling of a multiuse Dakins Solution bottle by an LPN, which was placed on unclean surfaces and returned to the treatment cart without sanitization.
Facility staff did not ensure that three resident rooms were kept clean, safe, and functional, as evidenced by persistent dust and debris in air conditioning units, missing or soiled bathroom fixtures, uncleaned furniture, broken overbed tables, and a toilet bowl with a large smear of feces that remained unaddressed over multiple days.
Facility staff did not provide required written notifications of transfer or discharge reasons to two residents, their representatives, and the ombudsman, as mandated by facility policy. One resident, who was cognitively intact and had multiple chronic conditions, did not receive proper notification for one hospital transfer, and the ombudsman was not notified for any of the resident's transfers. Another resident with severe cognitive impairment also lacked ombudsman notification for a hospital transfer. Staff interviews and record reviews confirmed these omissions.
A resident with multiple chronic conditions was given Vitamin D3 10 mcg instead of the provider-ordered Vitamin D 50 mcg during a medication pass. The LPN administering medications was interrupted twice, and the correct medication was not available in the cart. Facility policy requires the five rights of medication administration and minimizing interruptions, but these were not followed, resulting in the resident not receiving the correct medication.
A nurse dropped an oral medication tablet onto the medication cart and then administered it to a resident without following proper infection control procedures. The incident was observed during a medication pass and discussed with facility leadership, but no further information was provided to the survey team.
The facility failed to provide scheduled menu items to all residents during a lunch service, running out of pork loin and roasted potatoes. The shortage was due to insufficient preparation, with only four pork loins cooked instead of six and one too few bags of potatoes. Substitutions were made after the deficiency was noted, with dietitian approval for mashed potatoes and pulled pork.
Surveyors observed that handrails were not intact on all four nursing units, with missing segments and end caps leaving sharp edges exposed. Residents were seen using these handrails for stabilization and mobility. The deficiency was noted in various locations, including the front hallway, Unit 1, Unit 2, and Unit 3. Facility leadership was informed, but no further information was provided to surveyors.
A resident with a severe cognitive impairment and a pressure ulcer did not receive treatment as ordered by the Wound Nurse Practitioner (WNP). Despite the WNP's recommendations to use medical grade honey fiber, the facility staff used 0.25% Dakin's solution instead. The resident's Treatment Administration Record (TAR) consistently showed the incorrect treatment, and the facility's policy to treat wounds as ordered was not followed.
The facility failed to document detailed pain assessments for a resident after a fall and during as-needed pain medication administration. Another resident experienced late administration of prescribed pain medications, affecting their pain management. The DON attributed delays to computer issues, but documentation did not support this claim.
Two residents experienced delays in receiving timely radiology services at the facility. One resident's x-rays for a left leg and hip injury were delayed by three days, while another resident's x-rays for a suspected fracture were delayed by two days. The delays were due to communication and staffing issues with the contracted radiology company, contrary to the facility's policies and service agreement.
A facility failed to conduct a Level I PASARR screening for a resident with multiple serious diagnoses, including mental disorders, prior to admission. The resident was assessed as cognitively intact, but the required screening documentation was missing. Efforts to retrieve the PASARR from the previous hospital were unsuccessful, leading to the completion of a new PASARR during the survey. The facility's policy mandates collaboration to ensure PASARR completion before admission, which was not adhered to in this case.
The facility staff failed to follow provider orders for two residents, leading to deficiencies in care. One resident did not receive recommended compression stockings for swelling, despite complaints and a request for a diuretic. Another resident's blood pressure and heart rate were not checked before administering hypertension medications, contrary to orders. These issues were discussed with facility management, but no additional information was provided before the exit conference.
A resident dependent on enteral feeding did not receive the provider-ordered water flushes on seven occasions, leading to potential dehydration. The resident, with multiple health conditions and moderate cognitive impairment, expressed feeling hungry and craving water. The facility's policy required routine irrigation, but this was not adhered to, as noted in the Medication Administration Record.
A resident with severe medical conditions was not provided enteral feeding as per medical orders, receiving continuous feeding instead of the prescribed bolus method. The facility staff did not follow the specified feeding schedule, leading to a deficiency noted by surveyors.
A resident with multiple health conditions was observed receiving oxygen at a rate of 3 l/m instead of the ordered 2 l/m. This discrepancy was confirmed by an LPN and the Unit Manager, who adjusted the setting. The facility's policy required adherence to provider orders, which was not followed in this case.
The facility failed to provide timely laboratory services for two residents. One resident with respiratory failure and vascular dementia did not receive a STAT CBC and BMP as ordered, and flu and COVID-19 tests were delayed. Another resident with a history of urinary tract infections experienced a delay in CBC and BMP testing, despite symptoms indicating urgency. The facility's policy requires timely testing, but these deficiencies were noted by surveyors.
Facility staff failed to document medication administration for a resident on two occasions, despite administering the medications. Additionally, two residents were receiving treatments without documented provider orders: one with an indwelling urinary catheter and another receiving supplemental oxygen. These documentation lapses were discussed with facility leadership, but no further information was provided to address the concerns.
A resident on transmission-based precautions for ESBL in the urine was not properly protected due to a CNA's failure to don required PPE before entering the room. The CNA mistakenly believed the resident was not on isolation, despite clear signage and orders indicating otherwise. This incident reflects a breakdown in communication and adherence to infection control protocols.
A resident was not offered a pneumococcal vaccine upon admission, despite having a history of receiving previous doses and being eligible according to CDC guidelines. The resident, who had chronic health conditions and was cognitively intact, was only offered the vaccine after a surveyor's inquiry, which they declined. The facility's policy requires vaccine tracking, but no evidence of compliance was found.
Failure to Administer Ordered Antibiotic Course
Penalty
Summary
The facility failed to ensure Resident #2 received treatment and care in accordance with a medical provider order when ordered ertapenem was not administered for the full 7-day course. Resident #2 had diagnoses including spina bifida, paraplegia, weakness, neuromuscular dysfunction of the bladder, and type 2 diabetes mellitus, and the most recent MDS indicated a BIMS score of 10 out of 15, showing moderate cognitive impairment. The April 2026 order directed ertapenem sodium injection 1 gram intramuscularly once daily for a urinary tract infection for 7 days, with the first dose to be given immediately and the order ending on 4/26/26. The MAR showed the medication was not administered on 4/19/26, was refused on 4/20/26, was administered on 4/21/26 through 4/25/26, and was not administered on 4/26/26, resulting in only 5 doses being given. The clinical record did not contain a progress note explaining why ertapenem was not administered on 4/19/26. A provider note on 4/20/26 documented that the resident had refused the IM antibiotic, stated he did not want a shot, and then agreed to receive daily IM ertapenem for 7 days after education. The DON acknowledged that only 5 doses were received and stated an order should have been obtained to extend the medication administration.
Call Bell Not Accessible to Resident with Cognitive and Physical Impairments
Penalty
Summary
Facility staff failed to ensure that a resident's call bell was accessible, as observed on multiple occasions. The resident, who has diagnoses including idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness, was found with the call bell on the floor or out of reach while in bed or seated in a wheelchair. The resident's most recent assessment indicated moderate cognitive impairment. During interviews, the resident acknowledged difficulty accessing the call bell, stating they could reach it only with effort if necessary. The DON confirmed that call bells are required to be within reach of residents at all times, regardless of their location in bed or in a chair. Facility documentation, including Mosby's Textbook for Long-Term Care Assistants, also specifies that call lights must always be kept within the person's reach. Despite these requirements, repeated observations showed the call bell was not accessible to the resident, and no additional information was provided by facility leadership prior to the survey exit.
Failure to Provide Written Notification of Room Change
Penalty
Summary
Facility staff failed to provide written notification of a room change to a resident prior to moving the resident to another room. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including malignant neoplasm of the frontal lobe and cervical spondylosis with radiculopathy, was moved to a different room for medical management. The clinical record showed that the resident's Power of Attorney was notified and gave consent for the change on the same day the move occurred, but there was no evidence that the resident received written notification prior to the move. A Room Change Notification form was completed by a social worker, who later admitted to marking that the resident and responsible party received a copy of the notification in error. The facility's policy required proper documentation and timely notification for internal room transfers, but in this instance, only verbal notification was provided. The deficiency was confirmed through staff interviews, clinical record review, and facility document review, with no additional information provided to the survey team before the exit conference.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) care, specifically nail care, to a dependent resident diagnosed with idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness. The resident was assessed as moderately cognitively impaired and required assistance with ADLs according to their care plan. During multiple interviews, the resident reported that their long, jagged fingernails with brownish debris underneath were bothersome and stated that they had asked staff to trim their nails but this was not done. The resident indicated they resorted to chewing their nails due to lack of assistance. Observations confirmed the resident's nails were untrimmed, and staff interviews revealed inconsistencies regarding who was responsible for providing nail care and the frequency with which it was performed. While CNAs and nurses were identified as responsible for nail care, staff who worked with the resident that week had not provided the service. Facility policy required nursing staff to provide care according to current standards, but documentation and interviews indicated this standard was not met for the resident in question.
Failure to Administer Insulin and Document Blood Glucose Checks as Ordered
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for one resident diagnosed with multiple conditions, including Type 2 Diabetes Mellitus. The resident had medical provider orders for Novolog insulin to be administered subcutaneously before meals and at bedtime, with specific dosing instructions based on a sliding scale and blood glucose checks. Review of the medication administration record (MAR) for August revealed that there was no documentation of blood glucose checks or administration, refusal, or holding of Novolog on several specified dates and times. The resident's care plan included interventions to administer medications as ordered and to monitor for signs and symptoms of hypoglycemia. During an interview, the DON was unable to provide evidence explaining the lack of documentation or administration of Novolog on the identified dates. The facility's policy required staff to check the MAR for orders and ensure any necessary tests, such as vital signs or blood glucose checks, were completed prior to medication administration. No further information or documentation was provided to the survey team to account for the missed treatments prior to the survey exit.
Failure to Follow Infection Control Procedures During Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide appropriate care and treatment to promote healing of pressure ulcers for one resident with multiple complex medical conditions, including type 2 diabetes mellitus, gangrene, and acute osteomyelitis. The resident was assessed as moderately cognitively impaired and had one stage 1 pressure ulcer and three unstageable pressure ulcers. During a wound care and dressing change, a registered nurse, assisted by an LPN, did not follow proper infection control procedures. Specifically, the nurse used bandage scissors that were not cleaned prior to use, failed to perform hand hygiene between glove changes, and did not change gloves or perform hand hygiene between cleaning the wound and applying the treatment dressing. Facility policies and standard clinical references provided clear instructions for hand hygiene before and after glove use, after contact with potentially contaminated materials, and before and after dressing changes. The infection preventionist confirmed that the observed practices did not meet facility expectations or policy requirements. The failure to adhere to infection control protocols during wound care was observed and discussed with facility leadership.
Incomplete and Inaccurate Clinical Record Documentation for Two Residents
Penalty
Summary
Facility staff failed to ensure complete and accurate clinical records for two of ten sampled residents. For one resident, staff incorrectly documented the location of a foot wound, recording it as being on the left foot in the skin assessment, treatment administration record, and wound assessment report, when the wound was actually on the right foot. Medical provider notes and orders referenced both feet inconsistently, but the wound nurse and DON later confirmed the documentation error. The facility was unable to provide a policy for accurate documentation when requested by surveyors. For another resident, staff failed to document the administration of scheduled oxycodone on the medication administration record (MAR) for multiple dates and times, despite the medication being administered and recorded on the controlled drug administration record (NARC log). The resident had multiple diagnoses, including chronic pain and moderate cognitive impairment. The facility's policy required documentation of medication administration on the MAR, but this was not followed for the identified dates.
Failure to Follow Infection Control Procedures During Wound Care and Medication Handling
Penalty
Summary
Facility staff failed to follow established infection control procedures for two residents during wound care and medication handling. For one resident with multiple pressure ulcers, diabetes, gangrene, and osteomyelitis, a registered nurse did not clean scissors before use during a dressing change and failed to perform hand hygiene between glove changes and before applying wound treatments, despite facility policy requiring hand hygiene before and after glove use and after contact with potentially contaminated materials. The infection preventionist confirmed that scissors should be cleaned after each use and hand hygiene should be performed with each glove change, which was not done during the observed dressing change. In a separate incident, another staff member did not maintain infection control measures when handling a multiuse bottle of Dakins Solution. The LPN placed the bottle directly on an unclean overbed table and later on a fabric chair cushion in a resident's room without sanitizing the bottle before returning it to the treatment cart. The infection preventionist stated that the solution should have been stored in a zip lock bag in the treatment cart, and the observed handling did not meet infection control expectations.
Failure to Maintain Sanitary and Safe Resident Rooms
Penalty
Summary
Facility staff failed to maintain a safe, functional, sanitary, and comfortable environment in three sampled resident rooms. In one room, the air conditioning/heating wall unit (p-tac) contained a large amount of thick dust and debris, including torn paper or wrapper, and the bathroom ceiling light cover was missing, leaving the bulb exposed. The bathroom vent was rusted and covered in dust, the bathroom door was soiled around the doorknob and edges, and a nightstand had multiple areas of a dried, light-brown substance. These conditions remained unchanged upon re-inspection the following day. In another room, the p-tac unit was observed with thick dust, debris, food crumbs, and two dead bugs in the grates. The window curtains had fallen down in the middle, with several sharp-ended curtain hooks left in the windowsill, and the curtains had multiple dark stains. The overbed table's leg supports were soiled with a white substance, and two broken overbed tables were in use, one of which could not be raised or lowered and had non-functional wheels, while the other had an unstable tabletop. The p-tac unit remained uncleaned upon follow-up, though the curtains had been re-hung. In a third room, the bathroom toilet bowl had a large, brown smear of feces on the outside, approximately the size of an average woman's hand. This unsanitary condition was observed repeatedly over two days, with no change despite multiple observations and staff being made aware. Facility policy required daily cleaning and spot cleaning of all necessary areas, but staff interviews revealed that rooms were not cleaned every day, and the observed deficiencies persisted throughout the survey period.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
Facility staff failed to provide timely and proper written notification of transfer or discharge to residents, their representatives, and the Office of the State Long-Term Care Ombudsman for two of seven sampled residents. For one resident with multiple chronic conditions and a cognitively intact status, written notification of the reason for transfer/discharge was missing for one of three hospital transfers, and there was no evidence that the ombudsman was notified for any of the resident's transfers. The facility's policy required advance written notification to the resident, representative, and ombudsman, as well as documentation in the medical record and a progress note confirming the notifications, but these steps were not followed for the specified events. For another resident with severe cognitive impairment and multiple serious diagnoses, staff could not provide evidence that the ombudsman was notified of the resident's transfer to the hospital. Interviews with facility staff confirmed the absence of required documentation and notifications. The survey team reviewed facility policy and found that it outlined the necessary steps for notification, but these procedures were not adhered to in the cases reviewed.
Failure to Administer Correct Medication Dose as Ordered
Penalty
Summary
Facility staff failed to follow the medical provider's orders for one resident by administering Vitamin D3 10 mcg instead of the ordered Vitamin D 50 mcg. The resident, who had diagnoses including osteoarthritis, congestive heart failure, and moderate protein-calorie malnutrition, was observed during medication administration to receive the incorrect vitamin supplement. The resident's medical record did not contain an order for Vitamin D3, and the correct Vitamin D was not available in the medication cart at the time of administration. During the medication pass, the LPN responsible for administering medications was interrupted twice by other staff members delivering medications and narcotic count records. Facility policy requires adherence to the five rights of medication administration and specifies that medications should be administered without unnecessary interruptions. Despite these guidelines, the resident did not receive the correct medication as ordered by the provider.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
Facility staff failed to maintain an infection prevention and control program when a nurse dropped an oral medication tablet onto the top of the medication cart and subsequently administered the tablet to a resident. During a medication pass observation, the nurse removed a Finasteride 5 mg tablet from a blister pack, which inadvertently landed on the medication cart. The nurse then donned a glove, picked up the tablet from the cart, placed it in the medication cup with the resident's other medications, and administered all medications to the resident. This incident was observed by the surveyor and discussed with facility leadership, but no additional information regarding the concern was provided before the exit conference.
Menu Item Shortage During Lunch Service
Penalty
Summary
The facility staff failed to ensure that the scheduled menu items were available for all residents during the lunch meal on May 30, 2024. Observations revealed that the facility ran out of two menu items, pork loin with garlic and fresh herbs, and roasted red potatoes, before all residents received their meals. The dietary staff indicated that the last two resident tray carts, which were the smallest and contained trays for approximately 20 residents each, did not have the scheduled menu items. The Dietary Manager was observed cooking additional pork loin and preparing more roasted potatoes after the shortage was identified. The issue arose because the dietary staff had initially prepared an insufficient quantity of pork loin and potatoes. The cook reported that the wrong size pork loin was cooked, and one too few bags of potatoes were prepared. The facility's Region Director of Operations confirmed that only four pork loins were cooked instead of the required six. To address the shortage, the facility obtained dietitian approval to substitute mashed potatoes for roasted potatoes and pulled pork for pork loin. However, these substitutions were made after the deficiency was noted.
Handrail Deficiency in Facility
Penalty
Summary
Facility staff failed to ensure that handrails were intact on all four nursing units, as observed by surveyors. During the initial tour and throughout the facility, surveyors noted that residents were using handrails for stabilization while walking and as an anchor to pull themselves along in wheelchairs. On June 3, 2024, surveyors found several missing handrail segments or end caps, which left sharp edges exposed, posing a risk of injury. Specifically, in the front hallway, there were no end caps between the elevator and dining room, and no end cap or corner segment by the ladies' restroom. On Unit 1, a segment of the handrail was missing near the unit manager's office door, and end caps were missing by rooms 14, 17, 23, 25, and 26. On Unit 2, the rail by the pantry was missing an end cap, and on Unit 3, end caps were missing by the MDS office and a room. The administrator, director of nursing, MDS corporate consultant, regional nurse consultant, and a consulting administrator were informed of these concerns during a summary meeting on June 3, 2024. No additional information was provided to the surveyors before their exit.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility staff failed to provide treatment in accordance with the provider orders for a resident with a pressure ulcer. The resident, who was severely cognitively impaired, was admitted with an unstageable pressure ulcer to the mid back. The Wound Nurse Practitioner (WNP) initially recommended cleansing the wound with a wound cleanser and applying medical grade honey fiber, but the facility staff instead used 0.25% Dakin's solution, contrary to the WNP's orders. Despite the WNP's repeated recommendations to use medical grade honey fiber, the facility staff continued to use Dakin's solution. The WNP noted improvements in the wound's condition over time, but the treatment orders were not followed as directed. The resident's Treatment Administration Record (TAR) consistently showed the use of Dakin's solution instead of the recommended treatment. The surveyor attempted to interview the WNP and the facility wound nurse, but they were no longer employed at the facility. The Director of Nursing (DON) was informed of the treatment error but did not provide additional information. The facility's policy stated that wounds should be treated as ordered, but this was not adhered to in the case of the resident's pressure ulcer.
Deficiencies in Pain Management and Medication Administration
Penalty
Summary
The facility staff failed to document detailed assessments for Resident #185 following a fall and during the administration of as-needed pain medications. On 10/27/23, Resident #185 experienced a fall that led to a medical provider ordering x-rays for the left leg and hip. However, there was no documentation indicating the change in the resident's condition that prompted these orders. Additionally, when pain medications were administered on an as-needed basis, the staff did not complete or document detailed pain assessments, including pain characteristics, impact on quality of life, factors affecting pain, and a physical description of the pain location. For Resident #123, the facility staff did not administer pain medications timely according to the resident's preferences, which affected the maintenance of an acceptable pain level. Despite being prescribed Oxycodone, Baclofen, and Gabapentin at specific times, the medications were frequently administered late, sometimes over two hours past the scheduled time. The resident expressed that their pain was not controlled satisfactorily due to the inconsistent timing of medication administration, although the clinical record did not show any missed doses. The Director of Nursing (DON) attributed the late administration of medications to computer issues with the medication cart, but this was not substantiated by the documentation provided. The surveyor's review of the Medication Administration Record (MAR) confirmed the late administration of medications, contradicting the DON's explanation. The facility's policy on medication administration emphasizes the importance of administering medications at the right time, which was not adhered to in these cases.
Delayed Radiology Services for Residents
Penalty
Summary
The facility failed to provide timely radiology services for two residents, resulting in deficiencies identified during a survey. Resident #185 experienced a delay in obtaining x-rays for a left leg and hip injury. The x-rays were ordered on 10/27/23 following a fall, but were not completed until 10/30/23. The facility's medical director indicated that radiology reports should ideally be available within 24 hours, and decisions would be made if reports were not available within 48 hours. However, the delay was attributed to a lack of documentation and communication between the facility and the contracted radiology company. Resident #167 also experienced a delay in receiving x-rays for a suspected fracture. The x-rays were ordered on 4/7/24 after the resident was found with a large bruise and swelling on the left thigh. Despite the order, the x-rays were not completed until 4/9/24, resulting in a diagnosis of a comminuted intertrochanteric fracture. The delay was partly due to the resident being combative, as reported by the facility, but the mobile imaging company stated they were unable to send someone due to staffing issues and a backlog. The survey revealed that the facility's contracted radiology services were not meeting the needs of the residents, as evidenced by the delays in obtaining necessary x-rays. The facility's policies and the service agreement with the mobile imaging company required timely delivery of radiology services, which was not adhered to in these cases. The lack of communication and documentation between the facility and the radiology company contributed to the deficiencies identified during the survey.
Failure to Conduct PASARR Screening Prior to Admission
Penalty
Summary
The facility staff failed to conduct a Level I PASARR screening for a resident prior to their admission, which is a requirement to determine if the resident has or may have a mental disorder, intellectual disability, or related condition. The resident in question had a diagnosis list that included multiple serious conditions such as Multiple Sclerosis, Legal Blindness, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Parkinson's Disease. Despite these diagnoses, the resident was assessed as cognitively intact with a BIMS score of 15 out of 15. However, during a clinical record review, the surveyor could not locate the PASARR documentation for this resident. The Discharge Planning Director acknowledged the absence of the PASARR and mentioned efforts to retrieve it from the hospital where the resident was previously located. Despite these efforts, the PASARR was not found, prompting the facility to complete a new PASARR on the date of the surveyor's inquiry. The facility's policy requires collaboration among the Social Worker, Discharge Planner, and Admissions Director to ensure the completion of the Level I PASARR prior to admission, but this process was not followed in this instance. The issue was discussed with the facility's administrative team, but no further information was provided before the exit conference.
Failure to Follow Provider Orders for Two Residents
Penalty
Summary
The facility staff failed to adhere to medical provider orders for two residents, leading to deficiencies in care. For one resident, the staff did not follow the orthopedic specialist's recommendation to provide compression stockings, which were advised on a follow-up appointment. Despite the resident's complaints of swelling and pain, and their request for a diuretic, there was no documentation of these issues or the provision of compression stockings until much later. The resident's clinical record showed a delay in entering the provider order for compression stockings, which was only done after the surveyor's inquiry. For another resident, the facility staff did not follow the provider orders for administering medications for hypertension. The orders required checking the resident's blood pressure and heart rate before administering Amlodipine Besylate and Metoprolol Tartrate, respectively. However, the clinical record lacked evidence of these checks being performed. This oversight was contrary to the facility's medication administration policy, which mandates adherence to prescriber orders. The survey team discussed these concerns with the facility's management, but no further information was provided before the exit conference.
Failure to Provide Ordered Hydration for Enteral Feeding
Penalty
Summary
The facility staff failed to ensure a resident who is fed by enteral means received the appropriate provider-ordered hydration. This deficiency was identified for one of four sampled residents dependent on enteral feeding. The resident, who had multiple diagnoses including respiratory failure, vascular dementia, and dysphagia, was moderately cognitively impaired and had a feeding tube. The resident's care plan included administering tube feedings and flushes per order, but the facility staff did not provide the required water flushes on seven separate occasions in May 2024. The resident expressed feeling hungry and craving water, and was observed with dry lips and a white coating, indicating possible dehydration. The provider orders required flushing the feeding tube with 200 cc of water every four hours, but the Medication Administration Record showed omissions on specific dates and times. The facility's policy on enteral feeding tubes required routine irrigation per provider order, but this was not followed. The issue was discussed with the facility's administration, but no further information was provided before the survey exit conference.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility staff failed to ensure that a resident receiving enteral feeding was provided with the appropriate treatment as per the medical provider's orders. The resident, who had a range of serious medical conditions including respiratory failure, malignant neoplasms, and dysphagia, was observed receiving continuous feeding via a pump at a rate of 55 ml/hour. However, the medical provider's orders specified that the resident should receive Osmolite 1.5 at 250 ml via bolus five times a day at specific times. The discrepancy between the ordered bolus feeding and the continuous feeding observed was discussed with the facility's administration and nursing staff. The Registered Dietitian later explained that the feeding method was changed to bolus due to a medication the resident was taking, which required the feeding to be held during administration. Despite this explanation, the facility did not provide further information to the survey team before the exit conference.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility staff failed to administer supplemental oxygen as ordered by the provider for a resident diagnosed with chronic respiratory failure, asthma, chronic kidney disease stage 3, heart failure, paroxysmal atrial fibrillation, and a displaced bicondylar fracture of the left tibia. The resident's comprehensive person-centered care plan included an intervention to administer oxygen as ordered, but observations on two separate occasions revealed that the resident was receiving oxygen at a delivery rate of 3 liters per minute, contrary to the provider's order of 2 liters per minute. The discrepancy was confirmed by a Licensed Practical Nurse and the Unit Manager, who acknowledged the incorrect setting and adjusted it to the correct rate. The facility's policy on respiratory care and oxygen equipment stated that oxygen therapy should be administered per the provider's order, which was not adhered to in this instance. The issue was discussed with the facility's administration, but no further information was provided to the survey team before the exit conference.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility staff failed to provide timely laboratory services for Resident #160, who had multiple diagnoses including respiratory failure and vascular dementia. A telehealth evaluation on 4/14/24 noted a temperature of 100.4°F and low oxygen saturation, leading to a STAT order for a CBC and BMP due to suspected aspiration pneumonia. However, the surveyor could not find evidence that these tests were conducted. Additionally, on 5/21/24, the resident exhibited symptoms warranting flu and COVID-19 testing, but the tests were delayed, with the COVID test completed the next day and the flu test two days later. Another deficiency was identified for Resident #123, who had a history of major depressive disorder and recurrent urinary tract infections. On 5/4/24, a CBC and BMP were ordered due to symptoms of dysuria, with the expectation that the tests would be conducted promptly. However, the tests were not performed until 5/8/24, three days after the order. The delay in testing was acknowledged by the Director of Nursing, who indicated that such tests should be done the same day or the next, depending on the situation. The facility's policy on laboratory and diagnostic testing, effective 1/29/24, requires that a licensed nurse obtain and monitor tests as ordered by the provider. Despite this policy, the survey revealed that the facility failed to ensure timely completion of laboratory tests for two residents, leading to a deficiency finding. The survey team discussed these concerns with the facility's administration, but no further information was provided before the exit conference.
Documentation Deficiencies in Medication and Treatment Orders
Penalty
Summary
The facility staff failed to accurately document medication administration for Resident #31 on two occasions. On 05/12/24 and 05/17/24, the medication administration record (MAR) lacked documentation for the 9:00 p.m. doses of seven medications, including Atorvastatin, Gabapentin, Melatonin, Mirtazapine, Carvedilol, Mycophenolate, and Hydroxyzine. Interviews with RN #6 and LPN #5 revealed that both nurses administered the medications but forgot to document the administration in the MAR, citing oversight and distraction as reasons for the lapse. The facility's medication administration policy requires documentation immediately after administration, which was not adhered to in these instances. For Resident #384, the facility staff failed to document a medical provider order for an indwelling urinary catheter. The resident, who was coded for the presence of an indwelling catheter due to a neurogenic bladder, was observed with the catheter in place. However, the clinical record did not contain a corresponding medical provider order. The absence of this documentation was discussed with the facility's administrative and nursing leadership, but no additional information was provided to address the concern. Resident #160 was observed receiving supplemental oxygen without a current provider order. The resident's previous order for oxygen was discontinued, and no new order was documented despite the ongoing administration of oxygen at 3 liters per minute. The survey team discussed this issue with the facility's leadership, highlighting the lack of documentation for the continued use of supplemental oxygen. Again, no further information was provided to resolve the deficiency before the exit conference.
Failure to Follow Infection Control Protocols for Resident on Isolation
Penalty
Summary
The facility staff failed to maintain an effective infection prevention and control program, as evidenced by the incident involving a resident who was on transmission-based precautions due to ESBL in the urine. Despite the presence of a contact precautions sign and a caddy of PPE supplies outside the resident's room, a certified nursing assistant (CNA) entered the room without donning the required gown and gloves. The CNA then took the resident's disposable cup into the hall to refill it with ice, indicating a lack of adherence to the necessary precautions. The CNA mistakenly believed that the resident was not on isolation, attributing the contact precautions sign to a previous resident. Upon further investigation, it was confirmed that the resident was indeed on contact precautions as per medical provider orders dated prior to the incident. The resident's care plan also specified the need for contact isolation and appropriate PPE usage. The facility's policy on transmission-based precautions was not followed, leading to the deficiency noted by the surveyor. The incident highlights a lapse in communication and adherence to infection control protocols among the facility staff.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility staff failed to offer a pneumococcal immunization to a resident, identified as Resident #90, in accordance with nationally recognized standards. Upon review, it was found that Resident #90, who was over the age of 65 and had a history of receiving a PPSV23 vaccine in 2007 and a Prevnar 13 vaccine in 2018, was not offered a PCV20 or PPSV23 following their admission to the facility. The resident's medical history included Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Asthma, and they were cognitively intact with a BIMS score of 14 out of 15. During an interview, the Infection Preventionist (IP) admitted to not having evidence of offering the pneumococcal vaccine to Resident #90 after admission and could not recall if the resident was asked about it. The IP subsequently offered the vaccine on the day of the interview, which the resident declined. The facility's policy on pneumococcal vaccination, which aligns with CDC guidelines, requires screening for eligibility and maintaining vaccine tracking in the electronic medical records. However, the surveyor could not find evidence of compliance with this policy for Resident #90 prior to the exit conference.
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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 Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Davis And Mcdaniel Veterans Care Center | 0.5 mi | ★★★★★ | 3 | 0 |
| Brandon Oaks Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Snyder Nursing Home | 2.3 mi | ★★★★★ | 5 | 0 |
| Raleigh Court Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| South Roanoke Nursing And Rehabilitation | 4.1 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.