Salem Memorial District Hospital

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF756Oct 16, 2025

  Based on interview and record review, facility staff failed to provide documentation of monthly drug regimen reviews for five (Residents #1, #2, #4, #13 and #15) of five sampled residents. The facility census was 13.1. Review of the facility's policy titled Long Term Care Drug Regimen Review, dated 06/20/22, showed the drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart.2. […]

• No harm, potential for more than minimal, widespreadF801Oct 16, 2025

  Based on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 17.1. Review of the facility's job description titled Food Service Director dated 04/08/21, showed the purpose of the position is to provide supervision over all dietary functions and staff as directed/instructed, which included assisting in planning, organizing, developing, implementing, and directing the dietary services department, as well as its program and activities, in accordance with current rules, regulations, and… […]

• No harm, potential for more than minimal, patternF658Sep 27, 2024

  Reviewed AT Based on observation, interview, and record review, facility staff failed to follow professional standards when staff prepared four medication cups with medications prior to the timed medication pass and left one resident (Resident #10) medication unattended on top of the medication cart. Facility staff failed to notify three resident's (Resident #5, #7, and #13) physician regarding medications not being administered on time. The facility census was 18. 1. Review of the Facility's Administration of Drugs policy, dated 01/24/14, showed medications may not be prepared in advance and must be administered within one hour of preparation. 2. […]

• No harm, potential for more than minimal, patternF700Sep 27, 2024

  Reviewed AT Based on observation, interview, and record review, facility staff failed to obtain informed consent from the resident and/or resident representative for the use of side rails for one resident (Resident #5) and failed to complete an entrapment risk assessment or obtain a physician's order for use of the bed rails for five residents (Resident #5, #8, #11, #12, and #13), out of five sampled residents. The facility census was 18. 1. Review of the facility's policies showed staff did not provide a policy for Entrapment Risk Assessments. Review of the facility's Bed Rails Policy, dated 03/14/2014, showed bed rails are considered a restraint, three rails may be raised at one time to enhance bed mobility of the patient, all four rails may not be raised at the same time. […]

• No harm, potential for more than minimal, patternF759Sep 27, 2024

  Reviewed AT Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 25 opportunities observed, 15 errors occurred, resulting in a 60% error rate, which affected three residents (Resident #5, #7, and #13) out of seven sampled residents. The facility census was 18. 1. Review of the Facility's Medication Administration policy, dated 05/31/20, showed the individual administering a medication will be aware of the following information concerning each medication before administration: Appropriate timing of medication administration. 2. […]