Salem Crossing

In the surveyor’s words

From the most serious findings on record at Salem Crossing, in the surveyor’s own words.

• Actual harm, isolatedF580Jun 29, 2022

  Based on observation, record review, and interview, the facility failed to ensure residents' physicians were notified related to a significant change in condition, which resulted in a continued decline and worsening of the resident's condition (Resident 67) for 2 of 24 residents reviewed for notification. (Residents 67 and 49) Findings include: 1. During an observation on 6/29/22 at 9:30 a.m., the resident was observed in the dining room during snack time. A staff member was assisting the resident with holding her cup and taking a drink. The clinical record for Resident 67 was reviewed on 6/28/22 at 12:38 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS (Minimum Data Set) assessment, dated 3/18/22, indicated the resident was severely cognitively impaired. […]

• No harm, potential for more than minimal, patternF727Jun 5, 2024

  Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 4 of 4 months reviewed. (March, April, May, and June, 2024). This had the potential to affect all 84 residents currently residing in the facility. Findings include: The review of the March to June 2024 licensed nursing schedule indicated the following days were short of 8 consecutive hours in a 24 hour day of RN coverage: March - On March 9 no RN coverage for 6a to 6p and 6p to 6a - On March 24 no RN coverage for 6a to 6p and 6p to 6a - On March 31 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a April - On April 27 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a - On April 28 no RN coverage for 6a to 6p and only 6 hours of RN coverage… […]

• No harm, potential for more than minimal, patternF761Jun 5, 2024

  Based on observation, record review, and interview, the facility failed to ensure appropriate pharmacy labeling for 4 of 13 insulin flexpens observed for medication storage. (Residents 19, 31, 85, and 42) Findings include: 1. During an observation of one of the two 100 Hall medication carts on 6/4/24 at 9:55 a.m., Resident 19's lispro flexpen was in a bag marked with her name and the flexpen's open date. There was no pharmacy label. The medication room refrigerator was reviewed with no other lispro flexpens with pharmacy labels for Resident 19. The record for Resident 19 was reviewed on 6/4/24 at 11:00 a.m. […]

• No harm, potential for more than minimal, patternF886Jun 29, 2022

  Based on record review and interview, the facility failed to ensure COVID-19 testing was completed for residents experiencing COVID-19 symptoms for 4 of 5 residents reviewed. (Resident 10, 233, 1 and 7) Findings include: 1. The clinical record for Resident 10 was reviewed on 6/29/22 at 9:02 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status MDS (Minimum Data Set) assessment, dated 6/16/22, indicated the resident was severely cognitively impaired. She was dependent on staff for care. The care plan, dated 6/9/22 and revised on 6/22/22 at 11:28 a.m., indicated the resident was at risk for impaired gas exchange related to sleep apnea. […]

• No harm, potential for more than minimal, patternF689Apr 26, 2021

  Based on observation, record review, and interview, the facility failed to ensure appropriate interventions to prevent accidents were implemented for 6 of 10 residents reviewed for accidents. (Residents 27, 44, 57, 53, 55, and 181) 1. The clinical record for Resident 27 was reviewed on 4/20/21 at 10:06 a.m. Diagnoses included, but were not limited to, weakness and dementia. The Quarterly MDS (Minimum Data Set) Assessment, dated 1/30/21, indicated the resident was moderately cognitively impaired, required extensive assistance of two plus staff members with transfers, and had two or more falls since the last assessment. During an observation, on 4/19/21 at 11:53 a.m., CNA (Certified Nursing Aide) 7 and CNA 8 went to assist Resident 27 from his bed to the wheelchair. […]