Salemtowne

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Sep 12, 2024

  Based on observations and dietary staff interviews, the facility failed to maintain sanitary conditions in the central kitchen and in 1 of 4 satellite kitchens (Garden/Mill kitchen) by not ensuring staff covered their facial hair during food preparations, by not ensuring pots and pans were stacked clean on the storage rack, and by not ensuring pots, pans, and utensils were sanitized with a chemical sanitizing solution. These practices had the potential to affect food served to residents. Findings included: 1a. During a follow-up tour of the central kitchen on 9/11/24 at 10:43 a.m. […]

• No harm, potential for more than minimal, isolatedF760Mar 26, 2026

  Based on record review, and staff, Hospice Nurse, and Nurse Practitioner interviews, the facility failed to prevent a significant medication error when Medication Aide #1 (MA #1) administered Resident #1 Morphine 50 milligrams (mg) instead of the ordered 5 mg (Morphine is an opioid pain medication used in hospice care to relieve moderate-to-severe pain, anxiety, and severe breathlessness at the end of life). This deficient practice affected 1 of 3 residents reviewed for significant medication errors.The findings included: Resident #1 was admitted to the facility on [DATE] with history of multiple strokes and end of life care management. The Minimum Data Set (MDS) 5-day assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. […]

• No harm, potential for more than minimal, isolatedF761Dec 19, 2025

  Based on observation, record review, staff interviews, and manufacturer's recommendations, the facility failed to remove an expired insulin lispro kwikpen (an insulin pen) and failed to label the insulin lispro kwikpen with resident information for 1 of 5 medication carts reviewed for medication storage (Mill Place medication cart). The findings included:The manufacturer's 2023 storage recommendation for Insulin Lispro KwikPen stated that the pen should be discarded 28 days after opening.During an observation of the Mill Place medication cart on 12/10/25 at 11:45 a.m., Nurse #4 confirmed that a multidose Insulin Lispro KwikPen, opened on 10/16/25, remained in the cart for use. The pen was not labeled, and no information identified the resident's name or room number. […]

• No harm, potential for more than minimal, isolatedF880May 20, 2025

  Based on record review and interviews with staff and family member, the facility failed to follow their infection control policy regarding Clostridium difficile infection (C. difficile) [bacteria that can cause diarrhea and inflammation in the colon, can cause serious complications, and is highly contagious] for hand hygiene after resident care. Two nursing assistants used alcohol-based hand sanitizer and had not washed their hands with soap and water after caring for a resident with C. difficile. The deficient practice affected 3 of 5 staff members (Nursing Assistant (NA) #1, NA #2, and Medication Aide #1) interviewed for hand hygiene specific to C. difficile management (Resident #1). Findings included: The Infection Control Protocol for C. […]

• No harm, potential for more than minimal, isolatedF550Apr 20, 2023

  Based on record review, resident, staff interviews and student interviews, the facility failed to treat a resident in a dignified manner when a Nursing Assistant (NA) told a resident to use his brief when the resident requested assistance with toileting to the bathroom for 1 of 2 residents reviewed for dignity (Resident #69). Resident #69 stated the NA's statement and lack of assistance made him feel dirty. The findings included: Resident #69 was admitted to the facility 3/30/22 with diagnoses that included other sequelae (medical conditions resulting from stroke) of cerebral infarct, difficulty walking, other lack of coordination, muscle weakness, reduced mobility, and unspecified lack of coordination. […]