Salem Transitional Care

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 15, 2025

  Based on interview and record review it was determined the facility failed to ensure a heat pack was safely applied for 1 of 1 sampled resident (#76) reviewed for accidents. Resident 76 sustained burns. Findings include: On 11/23/24 the Past Noncompliance was corrected when the facility initiated an investigation, identified the root cause of the incident, and provided CNA and nurse in-service training on the use of heat packs. The training included: 1. A nurse was to approve a heat pack prior to use for each resident, 2. A barrier was to be applied between the heat source and the resident's skin, and 3. A heat pack was only to be left on for a maximum of 20 minutes. Resident 76 was admitted to the facility in 10/2024 with a diagnosis of kidney disease. […]

• Actual harm, isolatedF686Feb 16, 2024

  Based on interview and record review it was determined the facility failed to accurately assess, monitor, and prevent worsening of pressure ulcers for 1 of 3 residents (#1) reviewed for pressure ulcers. This failure resulted in the resident developing bilateral (both sides) Stage 4 pressure ulcers to the buttocks which required hospitalization , surgical intervention and placed other residents at risk for worsening pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel defined the following pressure injury stages: Stage 2 pressure ulcers: partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. […]

• Actual harm, isolatedF686Sep 1, 2022

  Based on interview and record review it was determined the facility failed to provide immediate interventions, ongoing assessments and monitoring for identified skin impairment for 1 of 1 sampled resident (#1) reviewed for a pressure ulcer. This resulted in Resident 1 developing an unstageable pressure ulcer. Findings include: CMS Appendix PP S483.25(b) Skin Integrity and S483.25(b)(1) Pressure ulcers, defined the following: - Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. […]

• No harm, potential for more than minimal, patternF584Jul 24, 2026

  Based on observation, interview, and record review it was determined the facility failed to provide a homelike dining environment for 1 of 1 dining rooms reviewed for resident council. This placed residents at risk for an institutional dining experience and lower quality of life. Findings include: A review of the 6/2026 Resident Council Meeting Minutes revealed the residents liked having tablecloths on the tables in the dining room. The dietary department responded stating, labor cuts have eliminated linens on tables. […]

• No harm, potential for more than minimal, patternF880Jul 24, 2026

  Based on observation, interview and record review it was determined the facility failed to implement appropriate contact precautions for 3 of 3 sampled residents (#s 8, 23 and 125) reviewed for contact precautions. This placed residents at risk for the spread of infection. Findings include: The facility's Contact Precautions policy, dated 9/10/25, indicated to don appropriate PPE before or upon entry into the environment (e.g., room) of resident on contact precautions. 1. Resident 8 was admitted to the facility in 8/2026 with diagnoses including vascular dementia and a stroke. […]