Salem Springlake Health & Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Nov 14, 2025

  Based on observation, interview and review of the facility policy, the facility failed to store, label and date food in accordance with professional standards for food service safety. The findings include: Review of the facility policy titled, Storage Procedures, revised 01/2025 revealed, refrigeration equipment was to be routinely cleaned and defrosted, foods should be covered and dated, leftovers were to be refrigerated immediately and used within five (5) days with a used by date clearly marked. Continued policy review revealed, Individual frozen supplements must be dated if being stored in refrigerators on designated nurses' stations kitchen refrigerator. […]

• No harm, potential for more than minimal, isolatedF550Dec 8, 2023

  Based on observation, interview and review of facility policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. for five (5) of fourteen (14) sampled residents(Resident #8, Resident #23, Resident #38, Resident #42 and Resident #203). Observation of a dinner meal in the dining room, on 12/04/2023, revealed Unit Manager #1 was standing over Resident #8 as she provided feeding assistance. Additionally, observations of Resident's #42, #23, #38, and #203, revealed staff failed to ensure the resident's bare bodies were not exposed to others. […]

• No harm, potential for more than minimal, isolatedF657Dec 8, 2023

  Based on observation, interview, record review and review of facility policy, it was determined the facility failed to revise the care plan following a significant weight change for four (4) of fourteen (14) sampled residents (Resident #22, Resident #42, Resident #18 and Resident #203). Review of Resident #22's, #42's, #28's, and #203's care plans revealed the care plans were not revised to include interventions for weight loss and supplements. The findings include: Review of the facility policy titled, Resident Assessment Comprehensive Care Plans, updated on 05/24/2022, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a residents medical, nursing and mental and… […]

• No harm, potential for more than minimal, isolatedF692Dec 8, 2023

  Based on observation, interviews, record review and review of facility policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible, for two (2) of fourteen (14) sampled residents (Resident #22 and Resident #42). 1. Review of Resident #42's weight beginning 09/04/2023, revealed an admission weight of 233.5 pounds (lbs). On 12/06/2023 at 10:30 AM, the Surveyor requested and observed staff obtain Resident #42's weight using a mechanical lift scale and weight was observed to be 187 lbs. This reflected a significant weight loss of 19.91% in ninety (90) days. 2. […]

• No harm, potential for more than minimal, isolatedF725Dec 8, 2023

  Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure services were provided by sufficient competent staff, including but not limited to licensed nurses and nurse aides, on a 24-hour basis to provide nursing and related services to residents for four (4) of fourteen (14) sampled residents (Resident's #4, #6, #16, and #26). Interviews revealed nursing staff was slow to answer resident call lights. The findings include: Review of the Facility Assessment Tool, revised 10/23/2023, revealed the facility staffing plan was based on resident population and their identified needs for care and support. […]