Salem Health & Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF803Jun 4, 2024

  Based on observations, interviews, and the review of documents, the facility staff failed to ensure menus were followed for two (2) of approximately 11 - 13 resident tray carts (each tray cart was used to transport multiple residents' trays to nursing units); this observation occurred for the lunch meal on 5/30/24. (The dietary staff members working on the food service line during the lunch meal on 5/30/24 indicated the last two (2) resident tray carts were the smallest carts to be sent out; the dietary staff members indicated each cart contained trays for approximately 20 residents.) The findings include: The facility staff failed to ensure all residents had the opportunity to receive the schedule menu items for the lunch meal on 5/30/24. […]

• No harm, potential for more than minimal, patternF924Jun 4, 2024

  Based on observation facility staff failed to ensure hand rails were intact on 4 of 4 nursing units. During initial tour and throughout the course of the facility, surveyors observed residents utilizing hand rails for stabilization while ambulating and as an anchor to pull themselves down the halls while in wheelchairs. On 6/3/24, the surveyor checked handrails throughout the building and found a number of missing handrail segments or end caps which left sharp edges exposed posing a risk of injury: On 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 hand rail was missing near the door to the unit manager's office. End caps were missing by rooms 14, 17, 23, 25, and 26. […]

• No harm, potential for more than minimal, patternF812Nov 2, 2022

  Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to properly sanitize items used for food preparation and serving, stacked wet pans together, and failed to discard an out of date food item. The findings included: The facility staff failed to properly prepare sanitizing rinse solution used following manual washing of items used to prepare and serve food on two separate occasions. The facility staff nested (stacked) wet pans together and failed to discard a container of apple cider vinegar with a best by date of 7/22/22. […]

• No harm, potential for more than minimal, isolatedF684May 6, 2026

  Based on staff interview and clinical record review, the facility staff failed to ensure residents receive treatment and care in accordance with a medical provider orders for (1) one of (3) three sampled residents, Resident #2. The findings included:For Resident #2, the facility staff failed to administer the medication Ertapenem for (7) seven days as ordered by a medical provider. Ertapenem is a potent antibiotic used to treat serious bacterial infections, including urinary tract infections. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to spina bifida, paraplegia, weakness, neuromuscular dysfunction of bladder, and type 2 diabetes mellitus. […]

• No harm, potential for more than minimal, isolatedF558Aug 28, 2025

  Based on observation, Resident interview, staff interview and facility document review the facility staff failed to ensure call bell was accessible for 1 of 7residents, Resident #5.The findings included:For Resident #5 the facility staff failed to ensure the resident's call bell was within reach.Resident #5's face sheet listed diagnoses which included but not limited to idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness.Resident #5's most recent minimum data set with an assessment reference date of 06/18/25 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Surveyor observed Resident #5 on 08/26/25 at 2:30 pm. […]