Salem Lutheran Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 28, 2021

  Based on observations, record review, staff and family interviews, the facility failed to provide adequate supervision and proper use of assistance devices to mitigate a resident's risk for elopement for 1 of 5 residents reviewed (Resident #1). On 8/31/21 at approximately 7:45 PM cognitively impaired Resident #1, with a history of wandering and elopement attempts, exited the building by following a visitor out the alarmed front door. Facility staff stated they assumed it was the visitor leaving and shut off the alarm. Staff stated they did not know the resident left the building. Approximately 20 minutes later, an off duty staff member observed the resident walking two and a half blocks south on Highway 173. […]

• Actual harm, isolatedF760May 22, 2026

  Based on clinical record review, staff interviews, facility document review, and policy review the facility failed to ensure that a resident was free of significant medication errors for 1 of 4 residents reviewed (Resident #1). On 4/1/26, staff failed to remove the plastic backing off of a Fentanyl (a powerful synthetic opioid) patch for which resulted in Resident #1 not receiving any medication through the patch and experiencing more pain and required an increase in the use of liquid morphine (a powerful, naturally occurring opioid analgesic derived from the opium poppy, primarily used to treat moderate to severe acute or chronic pain) medication until 4/3/26 when a new Fentanyl patch was replaced. […]

• Actual harm, isolatedF684Jun 6, 2023

  Based on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate a change in condition for three of three residents reviewed (Residents #22, #25, and #42). Two of the residents had a sudden increase of pain (Residents #22 and #25). Resident #22 walked independently in the facility and experienced a bout of dizziness causing her to fall on 5/13/23. At the time of the fall, Resident #22 denied pain but started to report pain later that evening and requested pain medication. Resident #22 did not use any as needed medication until after her fall on 5/13/23. Resident #22 received no evaluation by a provider until 5/17/23. During the hospital stay, the staff determined Resident #22 had multiple compression fractures in her back. […]

• Actual harm, isolatedF689Jun 6, 2023

  Based on interviews, emergency room , hospital and facility record review, the facility failed to provide adequate nursing supervision to prevent injuries for 3 of 4 residents reviewed (Residents #22, #25, and #33) for falls. In addition, the facility failed to complete neurological assessments for 1 of 4 residents (Resident #22) reviewed for falls. Despite the facility documenting that Resident #25 had difficulties with standing with her transfers using the mechanical standing lift, no one adjusted the transfer technique to ensure her safety with transfers. Due to the staff continuing to transfer Resident #25 with an unsafe technique, she fell out of the standing lift resulting in a compression fracture in her back. […]

• Actual harm, isolatedF684Sep 1, 2022

  Based on clinical record reviews, facility policy reviews, and staff interviews, the facility failed to provide an adequate assessment and timely intervention for a change in condition for 1 of 3 residents reviewed (Resident #3). Staff changed Resident #3's catheter due to it being plugged on 7/29/22. After 7/31/22 at 1:59 p.m. Resident #3's clinical record lacked documentation of urinary output. The staff failed to assess the lack of output. On 8/1/22, Certified Nursing Assistants (CNAs) reported that Resident #3 had blood in her incontinent pad. The nurse repositioned the catheter and thought it was okay, not knowing that Resident #3 did not have output recorded for the previous two shifts. She did not check the catheter the rest of her shift to assure it drained. […]