SALEM CENTER
For profit - Corporation
112 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
50/100
#87 of 122 in WV
Photo by Salem Center
Photo by Salem Center
Photo by Salem Center
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Salem Center has a Trust Grade of C, which means it is average and falls in the middle of the pack for nursing homes. It ranks #87 out of 122 facilities in West Virginia, placing it in the bottom half, and #5 out of 6 in Harrison County, indicating only one local option is better. The facility is improving, as the number of issues decreased from 12 in 2023 to 10 in 2025. Staffing is a weakness here, with a poor 1 out of 5 stars rating and a turnover rate of 46%, which is around the state average. However, there are no fines on record, which is a positive aspect. Several concerning incidents were noted during inspections, including a failure to provide a clean and safe environment, with broken toilets and peeling paint in resident rooms. Additionally, there were issues with infection control, such as improperly maintained equipment and inadequate protocols for transporting soiled linens. Staff also lacked training on the fire compression system in the kitchen, posing potential risks to all residents. Overall, while there are strengths in some areas, significant concerns remain that families should consider.
- Trust Score
- C
- In West Virginia
- #87/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 29%
No red flags
12 → 10 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 12 issues
2025: 10 issues
The Good
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5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below West Virginia average (2.7)
Below average - review inspection findings carefully
Staff Turnover: 46%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 37 deficiencies on record
Jun 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to ensure transfer/discharge notice was given prior to residents leaving the facility. THis was found true for 1 of 2 residents review...
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Based on record review and staff interview, the facility failed to ensure transfer/discharge notice was given prior to residents leaving the facility. THis was found true for 1 of 2 residents reviewed for closed record review regarding hospitalization and discharge. Resident identifier: #89 Facility Census: 89
Findings Include:
During a record review on 06/04/25 at 3:30 PM of Resident #89's record no transfer/discharge notice was found, documentation was requested from the Director of Nursing (DON)) and the Administrator.
On 06/05/25 at 9:14 AM, the Administrator stated we do not have the transfer/discharge for Resident #89, they went out for a procedure then went home and I guess they (facility staff) didn't think they needed to do it for some reason. Confirming no transfer/discharge paperwork was completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interviews, the facility failed to dispose of garbage and refuse properly. This had the potential to affect all residents in the facility. Facility Census 87
Findings ...
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Based on observation and staff interviews, the facility failed to dispose of garbage and refuse properly. This had the potential to affect all residents in the facility. Facility Census 87
Findings included:
a) Kitchen side sink counter:
On the initial vist to the kitchen on 06/02/25 at 11:45AM, it was observed that boxes and trash were in the floor next to a full trash cane beside the side sink counter and stacked containers of food left on the side sink counter in the kitchen during lunch prep.
b) Dumpster Area:
On 06/03/25, at approximately 1:40PM it was observed there were 3 dumpsters:
- The left dumpster was found with a broken tree branch protruding from the drainage pipe, blocking drainage.
- The middle dumpster was found with a garbage bag and used clear gloves scattered on the ground behind it.
- The right dumpster was found to have a plastic garbage bag with trash in it, protruding from the drainage pipe blocking drainage.
Staff interviews:
In an interview with the Kitchen Account Manager on 06/02/25 at 11:45AM, she stated the stacked containers were expired food that was to be disposed of but the trash can was already over flowing and that all of it should have been be taken out.
On 06/03/25 at 2:35PM, in an interview with the Kitchen Account Manager, she acknowleged the dumpster areas and issues and stated she did not know the dumpster drains were blocked and the trash littered on the ground was not from the kitchen. The kitchen does uses black gloves only.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
.
Based on observations and staff interviews the facility failed to ensure kitchen staff were provided education/training on how to use the fire compression system. This had the potential to affect al...
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Based on observations and staff interviews the facility failed to ensure kitchen staff were provided education/training on how to use the fire compression system. This had the potential to affect all residents in the facility. Facility Census 87
Findings included:
During a kitchen visit on 6/3/25 at 2:15 PM, It was observed there was not a manual pull chain for the fire system. When asked, the kitchen staff did not know how to manually activate the fire hood to extinguish a fire. Upon speaking with maintenance department, he showed the staff and survey team the button to activate the fire hood, until that moment, the kitchen staff did not know how to activate the fire
compression system .
On 06/03/25 at 2:24 PM, in an interview with the Maintenance Director, he verified there was a button staff can push to activate the fire compression system in case of a fire.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
.
Based on observations, staff and resident interviews, and record reviews, the facility failed to ensure food was palatable, visually appealing, and served in a manner consistent with residents' pref...
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Based on observations, staff and resident interviews, and record reviews, the facility failed to ensure food was palatable, visually appealing, and served in a manner consistent with residents' preferences. The facility was unable to incorporate individualized dietary preferences into the care planning process, was unable to deliver food met resident expectations for seasoning and appeal, and failed to ensure systemic measures were in place to verify meal quality through test trays. Environmental issues and kitchen disorganization further contributed to diminished quality of meal service. These failed practices had the potential to contribute to resident dissatisfaction, poor nutritional intake, and a decline in quality of life. This was true for Five (5) of five (5) residents reviewed for food satisfaction. Resident Identifiers: #31, #52. #66, #50 and #23. Facility census: 87.
Findings:
a) Resident #31
On 06/02/25 at 1:02 PM, Resident #31 was interviewed and stated meals were bland, sometimes cold, and sometimes served late. The resident stated individual preferences were not routinely accommodated and food options were generally not personalized.
On 06/03/25 at 1:12 PM, the surveyor observed the resident's lunch tray. It was an egg salad sandwich with a vegetable mash side. The food lacked seasoning and visual appeal. There were no garnishings or condiments provided to enhance the flavor or presentation of the meal.
A review of the care plan revealed no documentation of Resident #31's dietary preferences, food dislikes, or specific modifications related to cultural, personal, or medical food preferences. No interventions were listed to support resident satisfaction with meals.
On 06/04/25, during an interview with the dietary manager, she acknowledged resident food preferences were not gathered routinely except during her semiannual walk-through and at biannual food committee meetings. She stated staff, such as CNAs were expected to relay resident concerns during mealtimes if preferences changed. She further commented due to the dilapidated kitchen conditions, she was doing everything [she] can to meet requests.
Additionally, despite surveyor requests for test trays to assess food temperature, appearance, and taste due to resident complaints, no trays were provided on either 06/03/25 or 06/04/25. On 06/04/25 at 1:25 PM, the dietary manager stated she had placed the trays on the final meal cart but had not followed up to ensure delivery. She acknowledged , by time, food temperatures would not be accurate for evaluation. On 06/04/25 at approximately 1:15 PM, the facility administrator confirmed the survey team had not been notified when the trays were placed and had not received them.
Environmental observations in the kitchen on 06/02/25 and 06/03/25 showed poor sanitation, broken equipment (non-functioning oven, inadequate refrigeration, and no ventilation or air conditioning), and unsafe food storage conditions. These issues further compromised food quality and the ability to provide meals consistent with acceptable standards.
b) Resident #52
06/02/25 at 10:23 AM, Resident # 52 stated the food is cold and both over cooked and undercooked. The meat was tuff and potatoes were not done. The vegetables were mushy and overcooked.
c) Resident #66
On 06/02/25 at 9:49 PM, Resident #66 was interviewed. He stated the food is bad. He stated he pays so much to live there and can't get a decent meal and the vegetables were mushy from being overcooked. He stated he would love to have some fresh vegetables.
d) Resident #50
In an interview with Resident #50 on 06/02/25 at 09:30 AM She sated the food is terrible,
It has no seasoning and is often cold and the vegetables are mushy.
e) Resident #23
During an interview with Resident #23 on 06/02/25 at 10:04 AM, she stated the food is not good. The steak was cold and tough, but the potatoes were not done.
f) Based on resident complaints regarding the taste of the food, test trays were ordered from the kitchen on 06/03/25 and on 06/04/25. The kitchen did not deliver the two requested test trays on 06/03/25 and 06/04/25.
Staff interviews:
On 06/03/25 at 1:45PM, in an interview with The Kitchen Account Manager, she stated the test tray was forgotten and would send one the next day.
On 06/04/25 at 10:00AM in an interview with The Kitchen account Manager, she stated she would make sure a regular test tray and an optional test tray would be made for the survey team.
On 06/04/25 at 1:20PM, during an interview with The Kitchen Account Manager, she stated she had made the test trays herself and did not know why the survey team had not received them. She checked the food carts and the test trays were still on the cart confirming they were not delivered to the survey team.
On 06/04/25 at approximately 2:15 PM the facility administrator was asked about the Survey team not receiving a taste test tray, due to residents complaining about the taste of the food. Administrator stated I'm not sure why you all did not get a tray, they put it on the last cart going out, however the surveyors should have been notified by kitchen staff when the tray was sent to the hall. Confirming the surveyors did not get a tray to taste test on 06/03/25 or 06/04/25 was requested and made aware of by surveyors to the Dietary Manager.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review the facility failed to properly store food in accordance with professional sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantries. This had the potential to affect all residents in the facility. Facility census 87.
Findings Included:
a) On 06/02/25 at 11:35 am during the Initial Brief Tour of Kitchen, with the Kitchen Account Manager the following issues were found in the kitchen pantry, cooler, and utensil drawers :
Pantry:
- Spices in the cooking area left open and exposed.
- Corn muffins mix box was left open and exposed.
- Box of elbow noodles stored labeled with no opening date or expiration date.
- Spaghetti with an expiration date of 5/9/25 still in the pantry on 6/2/25.
b) Cooler:
- Staff personal drinks (An energy drink and a mountain dew) were found in the kitchen cooler
c) Cleanliness:
- Food spills in the floor at/near food prep area not cleaned up.
_ Metal basin pan left in the floor next to the wall and stove.
d) Utensil Drawers:
- The bottom utensil drawer had dried food spots on the inside top and sides. The utensils were not stored correctly, not facing all in the same direction.
e) Improper hair/beard covering:
- Chef with hair and beard not completely covered. He was wearing a hat with hair exposed at the neck.
Food Storage Policy:
On 06/03/25 at 1:00 PM a review facility policy labeled HCSG Policy 018, Food Storage: Dry Goods Procedures #5 stated All packaged and canned food items will be kept clean, dry and properly sealed and #6 stated Storage areas will be neat, arranged for easy identification, and date marked as appropriate.
Staff Interviews:
During a walkthrough and interview with the Kitchen Account Manager, she acknowleged the Spices left opened, Corn muffins box mix left open, elbow noodles stored incorrectly dated, and the spaghetti with an expired date. She also stated she was not aware of the staff personal drinks left in the kitchen cooler and removed them.
On 06/02/25 at 12:15PM, in an interview with The chef he acknowledged he was not wearing a beard or hairnet. He stated he did not know the cap/hat was not enough coverage and that his beard was too short to have to be covered.
During a Kitchen Visit on 6/3/25 at 2:15PM, the kitchen room tempertures were taken and the temperatures in the kitchen were 91 degrees as the AC was broken. The Cooler temperature was checked and found that the cooler was at 51 degrees due to excessive heat in the kitchen.
Staff interviews:
Kitchen Account Manager:
During an interview with the Kitchen Account Manager on 06/03/25 at 2:30PM, She acknowledged the high temperture in the kitchen and the cooler and stated the air conditioner had not been working and the cooler had trouble keeping the temperature correct for food storage.
Facility Administrator:
In an interview with the facility administrator on 06/2/25 at 4:00 PM she acknowledged the above Temperatures in the kitchen and in the cooler.
b) Nutrition room one:
- On 6/03/25 at 11:55AM, it was observed the refridgerater in the Nutrition Room One was at 44 degrees and a review of the refrigerator temp log, the tempertures on 06/03/2025 was 44 degrees, 6/02/25 was at 42 degrees, and 6/01/25 was at 44 degrees. The log stated the corrective action was ROOM HOT, and a bowl of oatmeal with the lid open and exposed was left from breakfast, sitting on the counter in Nutrition Room One, Not labeled.
Staff Interview:
- On 6/03/25 at 12:00PM, In an interview with Empolyee #26, she acknowledged the oatmeal on the counter and stated the Nutrition Room gets really hot due to the ice machine. When it is running, it causes the room to be really hot and the refrigerator can't keep up and once the ice machine stops making ice, the room cools down again.
c) Nutrition room [ROOM NUMBER]
On 06/03/25 at 12:35PM while checking Nutrition room [ROOM NUMBER], it was observed a tray of medicine pudding cups from food service was left in the refrigerator unlabeled without dates.
Staff Interview:
In an interview with The Nurse Infection Preventionist, she acknowledged the pudding cups in the fridge with out labels and dates. She stated these came from food service this way and said they should have been labeled and dated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0907
(Tag F0907)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to provide sufficient hallway space and equipment r/t resident wheel chairs lined up down both sides of the hallway on Hill Top Front Hall...
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Based on observation and staff interview, the facility failed to provide sufficient hallway space and equipment r/t resident wheel chairs lined up down both sides of the hallway on Hill Top Front Hall leaving no direct path. This was a random opportunity for discovery. Facility Census 87
Findings Included:
Observation:
On 06/03/25 at 3:30 PM, it was observed in the Hill Top Front Hallway, the resident wheel chairs were lined up on both sides of the hallway leaving all who walked through without a direct path.
Staff Interview:
In an Interview with The Facility Administrator on 6/4/25 at approx 2:50PM, she acknowledged the insufficient space/direct path for walking down the Hill Top Front Hallway.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation, inspection, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Location Identifiers: La...
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Based on observation, inspection, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Location Identifiers: Laundry rooms and Shower rooms. Facility Census:87.
Findings Include:
a) Laundry Rooms
On 06/03/25, at approximately 1:20 PM, an inspection of the laundry rooms was conducted, accompanied by the Regional Director of Maintenance (RDM) #90. During the inspection, it was noted the venting system in the dirty laundry room, which is responsible for maintaining negative pressure in the room, was not operational. Additionally, the air conditioning unit in the clean laundry room was also non-functional.
The failure to maintain the venting system's operational status created a potential risk of harm to residents, staff, and visitors at the facility. The venting system was designed to create negative pressure in the dirty laundry room, which helped prevent microorganisms from moving into the clean laundry room. However, the lack of negative pressure in the dirty laundry room could potentially allow microorganisms to transfer into the clean laundry room whenever the connecting door is opened.
During an interview with Housekeeping Staff (HS) #82, #84, and #87 on 06/04/25 at approximately 1:15 PM, they confirmed the venting system had not been operational for over one (1) month.
RDM #90, on 06/04/25 at 11:55 AM, confirmed the venting system was not operational. He stated he was working to get the venting system in the laundry room operational before the end of the day.
b) Shower Rooms:
On 06/03/25, at approximately 1:14 PM, an inspection of the two shower rooms was conducted, accompanied by Regional Maintenance Director (RMD) #90. It was observed the venting system was not operational. RMD #90 confirmed this and stated repairs were underway to restore the system as quickly as possible. The shower rooms had high humidity and a musty odor.
RDM #90 confirmed the shower rooms were warm, moist, and uncomfortable. He stated he was working to quickly get the ventilation system operational.
During an interview with Nursing Assistant (NA) #44 on 06/03/25 at approximately 2:00 PM, NA #44 confirmed the venting system in the shower rooms had not been operational for over a month.
The Administrator and DON were notified of the issues with the shower rooms on 06/03/25 at approximately 3:00 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
Based on observation and interviews, the facility failed to ensure there was adequate ventilation in the shower rooms and dirty laundry rooms. This failed practice had the potential to harm multiple r...
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Based on observation and interviews, the facility failed to ensure there was adequate ventilation in the shower rooms and dirty laundry rooms. This failed practice had the potential to harm multiple residents at the facility. Location Identifiers: Shower rooms and Dirty laundry room. Facility Census:87
Findings include:
a) Shower Rooms:
On 06/03/25, at approximately 1:14 PM, an inspection of the two shower rooms was conducted, accompanied by Regional Maintenance Director (RMD) #90. It was observed the venting system was not operational. RMD #90 confirmed repairs were underway to restore the venting system as quickly as possible. The shower rooms were humid and had a musty odor. Additionally, the shower stall walls had a black substance present on them, and several shower chairs had a brown substance on the underside of the seats and on the chair legs.
Warm, humid environments can increase the likelihood of mold growth on surfaces. Mold-related infections can impact the lungs, sinuses, skin, and in rare instances, other organs. These infections can be severe and potentially life-threatening.
During an interview with Nursing Assistant (NA) #44 on 06/03/25 at approximately 2:00 PM, NA #44 confirmed the venting system in the shower rooms had not been operational for over a month.
An interview with the Director of Nursing (DON) was conducted on 06/03/25 at approximately 1:45 PM. She was notified of the findings. DON verbalized her understanding and stated she would check on it.
b) Dirty Laundry Room
On 06/03/25, at approximately 1:20 PM, an inspection of the Dirty Laundry Room was conducted in the presence of the Regional Director of Maintenance (RDM) #90. During the inspection, it was found the venting system, which is crucial for maintaining negative pressure inside the room, was not operational.
The failure to maintain a negative pressure in the dirty laundry room potentially allowed the transfer of microorganisms from the dirty laundry room into the clean laundry room every time the connecting door was opened.
During an interview with Housekeeping Staff (HS) #82, #84, and #87 on 06/04/25 at approximately 1:15 PM, they confirmed the venting system had not been operational for over one (1) month.
RDM #90, on 06/04/25 at 11:55 AM, confirmed the venting system was not operational. He stated he was working to get the venting system in the laundry room operational before the end of the day.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident, and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident, and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in rooms 126, 127, 130, 162, and 163. This was also true for the kitchen and the Shower room, This was a random opportunity for discovery. Facility census: 87.
Findings included:
a) Upon survey entrance on 06/01/25 at 10:45 am , it was observed the following issues in these resident Rooms:
Resident room [ROOM NUMBER]:
- toilet seat broken and missing
- 1/2 inch size chips in the drywall in bathroom below the light switch
- scuff marks in drywall behind the head of resident B's bed
Residnet room [ROOM NUMBER]:
-Toilet tank lid missing, paint chipped above tissue holder, Scrapes in drywall below light switch
Resident room [ROOM NUMBER]:
- crack in chair rail behind bed A,
- paint peeling right wall below the light switch,
- unfinished drywall patch beside tissue paper holder,
- brownish stains on the floor at the base of the toilet,
- foot rail loose on resident A's bed, Bedside table drawer broken,
-black spots on the wall under the sink
Resident room [ROOM NUMBER]:
- bathroom wall drywall patch unfinished below the light switch
Resident room [ROOM NUMBER]:
- unfinished drywall patch beside tissue paper holder,
Resident room [ROOM NUMBER]:
- Black stains in the bottom of toilet bowl, unfinished drywall patch beside tissue paper holder,
During a walk through with the Administrator on 06/0/25 at 11:30AM , she acknowledged the unfinished drywall patches, broken, stained toilets, toilet tanks missing lids, loose footrail on bed and broken bedside table drawers in Resident Room #'s 126,127,130,136, and 162. She stated the facility recently hired a new maintenance director and she would make sure the room repairs would be placed on the TELS list.
b) During Kitchen visits on 06/02/25 at 11:50 AM and on 06/03/25 at 11:35AM, The following equipment/enviromental issues were observed:
- Exhaust fan above the stove and cooking area was not working
- Air Conditioning not working in the kitchen causing Temps to be over 91 degrees. Staff was observed with perspiration dripping off their faces during lunch prep on 6/03/25
-Top convection oven broken
- side line sink drain lever broken and being held up with a bucket stacked on boxes
- Upright freezer empty and not working
- spill left on the floor in front of the counter near the serving line area.
- the hand washing station trash receptacle foot pedal broken, the kitchen staff are not able to lift the lid after washing hands without contamination.
In an interview with the kitchen account manager, on 06/02/25 at 11:40 AM, she stated the exhaust fan had not been working for the past 7 months and the convection oven broke 6 months ago, the trash can in the hand washing station broke a few days ago, but she had not replaced it yet. She also stated the food spill was soup she had spilled earlier and would be cleaning it up after lunch was served. she did not know the staff had placed their drinks in the kitchen cooler but she felt they had put them there due to the heat. She stated it is so hot in the kitchen there hadn't been any air conditioning and there was no heat in the kitchen in the cooler months either and staff had to wear their coats while working last winter.
In an interview with the facility administrator on 06/2/25 at 4PM she acknowledged the exhaust fan not working, the broken convection oven, and the broken air conditioning issue with staff dripping sweat and provided verification the exhaust fan parts were ordered on 5/30/25 and then another part ordered on today's date 6/20/25 now awaiting arrival. She stated kitchen staff had 2 ovens they could use the one until the other was fixed and the freezer had been replaced by a chest freezer. She stated she was not aware the trash receptical in the hand washing station was broken.
c) Shower Rooms
During an inspection of the two shower rooms on 06/03/25, at approximately 1:14 PM, accompanied by the Regional Maintenance Director (RMD) #90. It was observed the ventilation system was not operational. RMD #90 confirmed the system was indeed inactive and repairs were underway to restore functionality as quickly as possible. The shower rooms were humid and had a musty odor. The walls of the shower stalls displayed a black substance, and multiple shower chairs had a brown substance on the undersides of the seats and on the legs.
During an interview with Nursing Assistant (NA) #44 on 06/03/25 at approximately 2:00 PM, NA #44 confirmed the venting system in the shower rooms had not been operational for over a month.
An interview with the Director of Nursing (DON) was conducted on 06/03/25 at approximately 1:45 PM. She was notified of the findings. DON verbalized her understanding and stated she would check on it.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain and ensure infection control standards were followed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain and ensure infection control standards were followed in several areas. Specifically, there were issues with the suction machine, and wheelchairs with tears in the cushions. The laundry room ' s ventilation system was inoperable, and appropriate infection control protocols were not implemented while using the facility ' s transport van to transport soiled linen to the laundromat over a span of 3 to 4 months. Additionally, there were deficiencies in infection control practices related to the cleaning and disinfection of reusable resident equipment.
In addition, the facility also failed to provide appropriate infection surveillance and did not implement measures for the surveillance and prevention of legionella and other opportunistic waterborne pathogens. This included a lack of control measures, such as flushing and draining dead legs and checking and flushing fixtures in unoccupied resident rooms, including unused showers and bedpan sprayers. Furthermore, soiled linen and trash were not removed from the shower rooms between uses.
These failed practices had the potential to cause serious injury, harm, impairment, and even death due to the potential risk of bacterial, viral, and fungal infections. Mold-related infections, in particular, can be severe and life-threatening, potentially affecting the lungs, sinuses, skin, and, in rare cases, other organs. Resident Identifier #80 Facility Census 89
Findings include:
a) Resident #80
On 06/04/25 an observation was made at 11:00 AM of resident #80's suctioning machine, the canister was about half full of clear/yellow thick substance and the cord was put over the machine, uncovered and exposed to the environment.
An interview on 06/04/25 at 12:00 PM with Registered Nurse (RN) #28 regarding Resident #80's suctioning machine not being covered/cleaned after being used, RN #28 stated i am sorry i have not used it or noticed it today i will get it taken care of right away, (we were in the room looking at the suctionsing machine when RN#28 confirmed it was not clean and was left uncovered.)
Based on observations and staff interviews, the facility failed to maintain and ensure infection control standards were followed in several areas. Specifically, there were issues with the suction machine, and wheelchairs with tears in the cushions. The laundry room ' s ventilation system was inoperable, and appropriate infection control protocols were not implemented while using the facility ' s transport van to transport soiled linen to the laundromat over a span of 3 to 4 months. Additionally, there were deficiencies in infection control practices related to the cleaning and disinfection of reusable resident equipment.
In addition, the facility also failed to provide appropriate infection surveillance and did not implement measures for the surveillance and prevention of legionella and other opportunistic waterborne pathogens. This included a lack of control measures, such as flushing and draining dead legs and checking and flushing fixtures in unoccupied resident rooms, including unused showers and bedpan sprayers. Furthermore, soiled linen and trash were not removed from the shower rooms between uses.
These failed practices had the potential to cause serious injury, harm, impairment, and even death due to the potential risk of bacterial, viral, and fungal infections. Mold-related infections, in particular, can be severe and life-threatening, potentially affecting the lungs, sinuses, skin, and, in rare cases, other organs. Resident Identifier #80 Facility Census 89
Findings include:
a) Resident #80
On 06/04/25 an observation was made at 11:00 AM of Resident #80's suctioning machine, the canister was about half full of clear/yellow thick substance and the cord was put over the machine, uncovered and exposed to the environment.
An interview on 06/04/25 at 12:00 PM with Registered Nurse (RN) #28 regarding Resident #80's suctioning machine not being covered/cleaned after being used, RN #28 stated I am sorry i have not used it or noticed it today I will get it taken care of right away, (we were in the room looking at the suctioning machine when RN#28 confirmed it was not clean and was left uncovered.)
B1) Dirty Laundry Room:
An inspection of the Laundry Room on 06/03/25, at approximately 1:20 PM, conducted alongside the Regional Director of Maintenance (RDM) #90, revealed the venting system in the dirty laundry room-which is essential for maintaining negative pressure-was not functioning. Additionally, the air conditioning unit in the clean laundry room was also inoperable.
The failure to keep the venting system in proper working condition potentially posed a risk to the health and safety of residents, staff, and visitors at the facility. The venting system was designed to create a negative pressure environment in the dirty laundry room, which helps prevent microorganisms from entering the clean laundry room. Without this negative pressure, microorganisms from the dirty laundry room might transfer to the clean laundry room each time the connecting door is opened.
During an interview with Housekeeping Staff (HS) #82, #84, and #87 on 06/04/25 at approximately 1:15 PM, they confirmed the venting system had not been operational for over one (1) month.
RDM #90, on 06/04/25 at 11:55 AM, confirmed the venting system was not operational. He stated he was working to get the venting system in the laundry room operational before the end of the day.
B2) Shower Rooms:
On 06/03/25, at approximately 1:14 PM, an inspection of the two shower rooms was conducted with RMD #90. During the inspection, it was observed soiled linen and trash had not been removed from the shower rooms. RMD #90 confirmed the trash should have been collected and the shower rooms should have been cleaned.
Additionally, the shower rooms were humid, had a musty smell, and displayed a black substance on the walls of the shower stalls.
RDM #90 confirmed the shower rooms were warm, moist, and humid. He also confirmed the shower walls needed to be cleaned.
B3) Laundry:
The facility failed to implement proper infection control protocols while using its transport van to take soiled linen to the laundromat weekly for three to four months.
During an interview on 06/04/25, at approximately 8:40 AM, Account Manager (AM) #85 mentioned she had been at the facility for about five months. She noted the washing machines have been frequently breaking down. When one or both of the machines are out of order, the laundry staff struggles to manage the daily volume of soiled linen. Since February, AM #85 has been taking loads of soiled linen to a laundromat in town at least once or twice a week. She last visited the laundromat on May 27, 2025, and stated, I can't go while you guys are here.
When asked about the process of transporting soiled linen to the laundromat, AM #85 explained she would coordinate the trip with the Activities Director. She mentioned the Activities staff would drive the laundry staff along with the soiled linen to the laundromat.
On 06/04/25, at approximately 10:00 AM, Activity Director (AD) #65 stated the following:
I try to schedule trips to the laundromat for soiled laundry between taking residents to their appointments. It can be a bit challenging, but we usually take the residents to their appointments first. After , we return to drop off the laundry staff with the soiled laundry at the laundromat. Once we've dropped them off, we go back and take the residents wherever they need to go. Later, we return to pick up the laundry staff.
The Administrator confirmed on 06/04/25 at 11:56 AM no arrangements had been made to ensure the van was cleaned and disinfected after transporting the soiled linen.
B4) Infection Prevention:
The facility failed to provide appropriate infection surveillance by not creating and implementing a plan to disinfect the van after transporting soiled laundry.
During an interview with Infection Preventionist (IP) #14 at approximately 12:55 PM on 06/04/25, she indicated she was not aware the transport van was being used to carry soiled laundry to the laundromat before transporting residents to their appointments. IP #14 expressed her commitment to ensuring infection prevention protocols are followed in the future when the van is used for transporting soiled linen.
The Administrator and Director of Nursing (DON) were notified of the lapse in infection prevention protocols on 06/04/25 at approximately 12:55 PM.
B5) Water Management:
On 06/04/25, at 2:55 PM, a review of the facility's records revealed the facility did not adequately implement surveillance and control measures. This included a lack of flushing, draining of dead legs, and maintenance of unused showers. While DM #11 provided water temperature monitoring logs and a maintenance service sheet for the ice machine, he was unable to supply logs documenting the flushing of dead ends or the actions taken when control limits were not met.
Record review also revealed two (2) resident rooms at the facility had been unoccupied for an extended period of time.
room [ROOM NUMBER] had been unoccupied from 05/10/25 to 05/24/25
room [ROOM NUMBER] had been unoccupied from 05/16/25 to 05/27/25
During an interview with DM #11 on 06/04/25 at approximately 11:25 AM, he stated he did not have any logs for the flushing of fixtures in the unoccupied rooms.
Senior Administrator (SA) #91 at 12:25 PM on 06/04/25 confirmed there were no flushing or maintenance logs or documentation available. SA #91 further stated she was immediately implementing a policy for logging the flushing and draining dead ends, showers, bed pan sprayers, and fixtures in rooms unoccupied for any length of time.
In addition, (SA) #91, on 06/04/25 at 1:35 PM, stated she had begun in-services and education for staff on following infection control protocols when using the van to transport soiled linen to the laundromat.
c) Resident wheelchairs in the Hill Top Back Hall
06/03/25 at 2:45 PM, During an observation of Hill Top Back hallway, it was observed resident assigned wheel chairs and one geri chair which were lined up outside the resident's room's had cracks and tears in the arm pads exposing the inner padding.
During a walk through and interview with facility Nurse Infection Preventionist, on 06/3/25 at approximately 2:50PM, she acknowledged the wheel chairs were assigned to residents in those rooms on hallway and agreed the wheel chairs and one geri-chair with cracked and torn areas on arm pads were an infection control issue and stated she would report them to the maintenance department for replacement arm pads.
c) Resident wheelchairs in the Hill Top Back Hall
06/03/25 at 2:45 PM, During an observation of Hill Top Back hallway, it was observed resident assigned wheel chairs and one geri chair were lined up outside the resident's room's had cracks and tears in the arm pads exposing the inner padding.
Staff Interview: 6/3/25 at 12:00 PM
During a walk through and interview with facility Nurse Infection Preventionist, on 06/3/25 at approximately 2:50PM, She acknowledged the wheel chairs were assigned to residents in those rooms on hallway and agreed the wheel chairs and one geri-chair with cracked and torn areas on arm pads were an infection control issue and stated she would report them to the maintenance department for replacement arm pads.
Oct 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, and staff interview, the facility failed to ensure personal privacy and confidentiality of personal and medical information contained in the electronic health record. This defici...
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Based on observation, and staff interview, the facility failed to ensure personal privacy and confidentiality of personal and medical information contained in the electronic health record. This deficient practice was based on a random opportunity for discovery for Resident #17, whose Medication Administration Record (MAR) was not secured but left open and visible for all who passed by the area to view. Resident identifier: Resident #17. Census: 84.
Findings included:
a) Resident #17
A review of Policy 0PS209 Privacy Rights :Patient, dated 11/28/16. noted the patient has a right to personal privacy and confidentiality of there personal and medical records.
An observation of medication administration, on 10/24/23 at 08:25 AM, revealed Registered Nurse (RN) #74 prepared the medications and entered Resident #17's room to administer the medications. RN #74 failed to secure the computer screen before leaving the cart, leaving the medical and personal information of Resident #17 available to view by any passerby. The information that was in plain view, included the resident's name and room number, diagnoses of the resident and medications the resident was being prescribed.
An interview was conducted, with RN #74, when the nurse returned to the medication cart on 10/24/23 at 08:33 AM, RN #74 confirmed the Medication Administration Record for Resident #17 was left visible while administering the medications to the resident, remained visible when the nurse returned, and there were individuals present in the hallway that was not privileged to the personal and medical information of Resident #17. RN #74 stated my bad, I know to close that screen and failed to do so.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to identify a psychiatric diagnosis of depression for Resident #78. This was true for one (1) of five (5) residents reviewed under the c...
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Based on record review and staff interview, the facility failed to identify a psychiatric diagnosis of depression for Resident #78. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #78. Facility Census: 84.
Findings Included:
a) Resident #78
On 10/24/23 at 9:43 AM, a record review was completed for Resident #78. The review found the resident was prescribed Cymbalta (antidepressant) 30mg (milligram) daily for depression with a start date of 09/22/23.
The Minimum Data Set (MDS) with the assessment reference date (ARD) of 09/27/23 was reviewed and section I (psychiatric/mood disorder) found a no which indicates the resident did not have a diagnosis of depression.
On 10/25/23 at 11:04 AM, an interview was held with the Director of Nursing (DON). The DON stated, there is no documented diagnosis of depression listed on the MDS.
No further information was obtained during the long-term survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflecte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #77. Census 84.
Findings Included:
a) Resident #77
On 10/16/23, a record review of the resident's electronic medical record (EMR), found the resident's admission PASARR, dated 06/09/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None.
A continued record also revealed the resident received a psych diagnosis of schizoaffective disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed.
On 10/24/23 at 1:24 PM, an interview with the Administrator confirmed the admission PAS presented to the surveyor did not indicate a diagnosis of schizoaffective disorder and a new PAS was not completed for schizoaffective disorder upon Admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, record review, resident interview and staff interview, the facility failed to develop and/or implement a care plan regarding refusal of care for Resident #82 and the use of a rig...
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Based on observation, record review, resident interview and staff interview, the facility failed to develop and/or implement a care plan regarding refusal of care for Resident #82 and the use of a right hand splint for Resident #76. This was true for two (2) of 18 residents reviewed during the survey process. Resident Identifiers: #82 and #76. Facility Census: 84.
Findings Included:
a) Resident #82
On 10/23/23 at 11:15 AM, the resident was observed and appeared to be somewhat disheveled. A record review was completed on 10/23/23 at 12:16 PM. The review found multiple refusals of showers and bed baths documented. The resident had only two (2) showers documented in September, 2023 and one (1) shower and two (2) bed baths documented in October, 2023. The following dates of refusals are as follows:
--09/18/23
--09/21/23
--09/27/23
--09/29/23
--09/30/23
--10/02/23
--10/03/23
--10/06/23
--10/09/23
--10/11/23
--10/16/23
--10/18/23
The care plan indicates the resident needs extensive assistance of one (1) staff member for bathing. However, the care plan does not list refusals of care under a behavior monitoring focus.
On 10/24/23 at 1:10 PM, the Administrator was notified and confirmed a focus area of refusals of care had not been developed on the care plan.
No further information was obtained during the long-term survey process.
b) Resident #76
On 10/23/23 at 11:46 AM, an initial observation found a right hand splint laying on the night stand by Resident #76's bed. The resident was asked, when do you wear your splint? The resident responded,
I haven't worn it since I've been out of therapy.
On 10/24/23 at 12:18 PM, an additional observation was made of the right hand splint laying on the night stand. The resident was again asked, have you worn your hand splint? The resident responded, nope .they haven't put it on me.
On 10/24/23 at 12:42 PM, a physician's order dated 09/06/23 was found. The physician's order stated, Patient to donn R (right) hand splint for up to 6 (six) hr/day (hours per day) or as patient tolerates to prevent contractures with skin checks prn (as needed).
A record review on 10/24/23 at 1:00 PM, discovered physical therapy (PT) had been discontinued on 09/01/23 and occupational therapy (OT) was discontinued on 09/06/23.
The care plan does not identify the use of a hand splint or prevention of contractures.
On 10/25/23 at 9:30 AM, the Director of Nursing (DON) stated, there is no documentation of the splints being applied .therapy put the order in .and they are not allowed to put in orders.
No further information was obtained during the long-term survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview, the facility failed to revise a care plan for one (1) of 18 sampled residents, when an assessment was made with additional information obtained...
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Based on observation, record review and staff interview, the facility failed to revise a care plan for one (1) of 18 sampled residents, when an assessment was made with additional information obtained regarding resident's care and or behavior. Resident #47 was known by staff to adjust/alter oxygen flow rates but this behavior was not included in the resident's care plan revision. Resident identifier: Resident #47. Census: 84.
Findings included:
a) Resident #47
An observation, on 10/22/23 at 12:22 PM, showed oxygen was being administered to Resident #47 at a rate of 4.5 liters/minute (L/min). During the observation, the resident's spouse revealed, Resident #47 would adjust the flow rate depending on how he was feeling. Resident #47 confirmed this.
A record review revealed Resident #47 was to receive oxygen at 3.0 L/min via nasal cannula continuously as resident will allow every day and night shift.
A review of the current comprehensive resident centered care plan, last review of 08/11/23, showed the resident was diagnosed with Chronic Obstructive Pulmonary Disease, and was to be administered oxygen therapy in accordance with the physician's orders. There was no evidence the resident altered the flow rate and an intervention to ensure effective and correct implementation of the physician's orders.
An observation, made with Registered Nurse (RN) #71, on 10/24/23 at 1:30 PM, revealed oxygen was being administered to Resident #47 at a rate of four (4) L/min. RN #71 confirmed the flow rate of 4 L/min.
A review of the medical record by RN #71 and RN #74 on 10/24/23 at 1:38 PM, verified the physician's order was for Resident #47 to receive oxygen therapy with a flow rate of 3 L/min. RN #71 stated , at this time, Resident #74 must have turned it up.
An additional interview with RN #74, on 10/24/23 at 1:45 PM, revealed Resident #47 was known to make adjustments to the oxygen flow rate and had been spoken to about the importance of not self adjusting the oxygen.
A review of the care plan did not show any evidence Resident #47 made adjustments to the oxygen flow rate, or any goal or approaches to monitor the resident altering the treatment ordered by the physician.
An interview, with the DON at 10/24/23 2:12 PM, verified the resident adjusting the oxygen incorrectly should have been care planned and the care plan had the current care plan not been revised to reflect the residents behavior of self adjusting the oxygen and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, resident interview and staff interview, the facility failed to follow a physician's order regarding right hand splint application for Resident #76 and complete neu...
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Based on observation, record review, resident interview and staff interview, the facility failed to follow a physician's order regarding right hand splint application for Resident #76 and complete neurological (neuro) checks after a fall for Resident #17. This was true for two (2) of 18 residents reviewed during the long-term survey process. Resident Identifiers: #76 and #17. Facility Census: 84.
Findings Included:
a) Resident #76
On 10/23/23 at 11:46 AM, an initial observation found a right hand splint laying on the night stand by Resident #76's bed. The resident was asked, when do you wear your splint? The resident responded,
I haven't worn it since I've been out of therapy.
On 10/24/23 at 12:18 PM, an additional observation was made of the right hand splint laying on night stand. The resident was again asked, have you worn your hand splint? The resident responded, nope .they haven't put it on me.
On 10/24/23 at 12:42 PM, a physician's order dated 09/06/23 was found. The physician's order stated, Patient to donn R (right) hand splint for up to 6 (six) hr/day (hours per day) or as patient tolerates to prevent contractures with skin checks prn (as needed).
A record review on 10/24/23 at 1:00 PM, discovered physical therapy (PT) had been discontinued on 09/01/23 and occupational therapy (OT) was discontinued on 09/06/23.
On 10/25/23 at 9:30 AM, the Director of Nursing (DON) stated, there is no documentation of the splints being applied .therapy put the order in .and they are not allowed to put in orders.
No further information was obtained during the long-term survey process.
b) Resident #17
1) A review of the Policy and Procedure, NSG204 Neurological Evaluation, with a revision date of 06/01/21, showed the Neurological evaluations would be performed when a resident sustained an injury to the face. The policy showed the neurological evaluation would be performed every 15 minutes for two (2) hours then every 30 minutes for two hours then every 60 minutes for four hours then every eight (8) hours until at least 72 hours had elapsed or as ordered by the physician.
An observation, on 10/23/24, at 12:05 PM, revealed Resident #17 had bruising about the face. Resident #17 stated at this time, she had sustained a fall in the bathroom hitting her head.
A record review on 10/24/23, revealed the resident had sustained a fall which involved hitting her head/face on 10/11/23. Further review of the documentation showed evidence of a neurological evaluation being completed at 11:30 AM with no evidence of another neurological evaluation for 10/11/23 at 11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 01:00 PM, 01:15 PM, 01:45 PM, 02:15 PM, 02:45 PM, 03:15 PM.
Additionally, there was no evidence of a neurological evaluation being completed on 10/12/23 for 07:15 PM and no evidence of a neurological evaluation being completed on 10/14/23 for the time frame of 11:15 AM or 07:15 PM.
An interview, with the Director of Nursing (DON) on 10/24/23 at 03:15 PM, revealed a neurological evaluation was expected to be completed on the times designated based on the policy and procedure. It was stated by the DON, there was no evidence the staff completed the neurological evaluation for the designated time frames required and for 72 hours after the incident occurred and should have been.
No further evidence was provided at the time of exit on 10/25/23.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, record review, resident and staff interview, the facility failed to ensure each resident received care consistent with professional standards of practice following physician's or...
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Based on observation, record review, resident and staff interview, the facility failed to ensure each resident received care consistent with professional standards of practice following physician's orders to treat pressure sores. This was true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Protocol for the care area of pressure ulcers. Resident #17 was not provided the treatment in accordance with physician's orders. Resident identifier: Resident #17. Census: 84.
Findings included:
An interview, with Resident #17, on 10/23/23 at 1:27 PM, revealed the resident was receiving cream to an area on the back and buttocks due to having had problems with pressure ulcer development.
An observation of the treatment , performed by Registered Nurse (RN) #74 on 10/24/23 at 12:30 PM, revealed RN #74, cleansed the area on Resident #17's back and buttocks with Wound cleanser and applied and Optifoam dressing to both areas.
A record review , of the treatment orders, did not include an order for wound cleanser and an Optifoam dressing. for the area treated on the back and buttocks of Resident #17.
An interview, with the Director of Nursing (DON) on 10/24/23 at 2:06 PM, revealed there was no current physician's order for the treatment performed by RN #74 and stated further she had reviewed the record and contacted the Nurse Practitioner for clarification. The DON explained after reviewing the medical record and discussion with Nurse Practitioner, there was no order for the resident to receive the treatment observed and the resident should not have received the Optifoam dressing to the two areas performed by RN #74 .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to complete an annual performance review for Nurse Aide (NA) #66. This was true for one (1) of five (5) employees reviewed under the car...
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Based on record review and staff interview, the facility failed to complete an annual performance review for Nurse Aide (NA) #66. This was true for one (1) of five (5) employees reviewed under the care area of sufficient and competent staffing. Facility Census: 84.
Findings Included:
a) Nurse Aide (NA) #66
A review of nursing aide requirements was completed on 10/24/23 at 1:00 PM. The review found NA #66 did not have a current performance evaluation. The last documented performance evaluation was completed in 2019.
An interview with the Director of Nursing (DON) on 10/24/23 at 1:50 PM was completed. The DON stated, NA #66 has not had a performance evaluation since 2019 .she worked infrequently while going to nursing school and she was prn (as needed), now she is back.
On 10/24/23 at 2:00 PM, the Administrator confirmed a performance evaluation should have been completed.
No further information was obtained during the long-term survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review, staff and resident interview, the facility failed to ensure a resident was not administered a psychotropic drug unless, based on a comprehensive assessment of the resident, the...
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Based on record review, staff and resident interview, the facility failed to ensure a resident was not administered a psychotropic drug unless, based on a comprehensive assessment of the resident, the drug was medically necessary to treat a specific condition with behaviors monitored to ensure effectiveness of the medication prescribed. Resident #6 and Resident #78 were receiving an anti-psychotic medication, however, behavior monitoring did not contain a documented specific behavior to be observed and monitored. This failed practice was identified in two (2) of five (5) residents reviewed for unnecessary medications during the LTCSP. Resident identifier: Resident #6 and #78. Census: 84
Findings included:
a) Resident #6
A record review was completed for Resident #80 on 10/25/23 at 9:54 AM. The review found the resident was taking an anti-psychotic medication (Abilify) for Schizo-affective disorder. The Medication Administration Record (MAR) was reviewed and found a physician's order for Abilify (Aripiprazole) 0.5 mg. Give 0.5 tablet by mouth one time per day for Schizoaffective. The physician's order included a question regarding behavior, Yes or No. However, the physician's order did not include any specific behaviors to monitor.
On 10/25/23 at 11:04 AM, the Director of Nursing (DON) was notified of the finding and confirmed there was no specific behaviors documented for staff to monitor. The DON further stated, there should have been behaviors listed for staff to observe for in order to document the presence or absence of a documented behavior.
b) Resident #78
On 10/12/23 at 10:00 AM, a record review was completed for Resident #78 The review found the resident was taking an antidepressant (Cymbalta) for depression. The Medication Administration Record (MAR) dated October, 2023, was reviewed and found a physician's order for Cymbalta 30mg (milligram) daily for depression dated 09/22/23. The physician's order included a question regarding behavior, Yes or No. However, the physician's order did not include any specific behaviors to monitor.
On 10/25/23 at 11:04 AM, the Director of Nursing (DON) was notified and confirmed there was no documentation of specific behaviors listed to monitor.
No further information was obtained during the survey process.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
.
Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, a grievance that was reported. This practice affected one (1) ...
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.
Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, a grievance that was reported. This practice affected one (1) of one (1), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #72. Facility census: # 84.
Findings Included:
a) Resident #72
On 10/23/23 at 12:52 PM during an interview with Resident #72 she stated, she made a complaint about another Resident peering in her room, a month ago. Resident #72 stated that nothing was ever done about the issue.
10/23/23 a record review of the grievances log revealed no issues were documented for Resident #72.
A continued record review of Resident #72's Quarterly 09/07/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #72 has capacity.
10/25/23 at 9:29 AM during an Interview the Social Worker (SW) #67 stated she was aware of the concern, and she stated she educated the male resident #11 and followed up with resident #72 at the time of grievance. She was asked to provide documentation from the issue.
On 10/25/23, at 12:25 pm SW #67 provided social services notes for Resident #72 with the effective date 09/28/23 at 11:28 AM late entry with the created date today, 10/25/23 at 11:28 AM for the grievance noted. She also provided two (2) Social service notes, one dated 08/28/23 for Resident #11 revealing he was educated that he cannot sit outside female resident rooms. Second note with the effective date 09/28/23 at 2:00 PM late entry with the created date today, 10/25/23 at 11:51 AM with education about sitting outside female resident rooms particularly when they were sleeping.
On 10/25/22 at 12:48 PM during an interview the Administrator confirmed, there was no documentation for Resident #72's grievance and she advised the SW #67 to complete progress notes on this date about the 09/28/23 grievance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for ...
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Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for 0ne (1) of one (1) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #72. Facility census: 84.
Findings Included:
a) Policy review
Record review of the facility's policy titled, grievance /concern, showed:
-Upon receipt of the grievance / concern, the grievance / concern form will be initiated by staff member receiving the concern.
-Upon receipt of the grievance /concern form, the Administrator or designee will document the grievance / concern on the grievance / concern log.
- Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated.
-Notify the person filing the grievance of resolution in a timely manner.
b) Resident #72
On 10/23/23 at 12:52 PM during an interview with Resident #72 she stated that she made a complaint about another Resident peering in her room, a month ago. Resident #72 stated that nothing was ever done about the issue.
10/23/23 a record review of the grievances log revealed no issues were documented for Resident #72.
A continued record review of Resident #72's Quarterly 09/07/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #72 has capacity.
10/25/23 at 9:29 AM during an Interview the Social Worker (SW) #67, stated she was aware of the concern, and she stated she educated the male resident #11 and followed up with resident #72 at the time of grievance. She was asked to provide documentation from the issue.
On 10/25/23, at 12:25 pm SW #67 provided social services notes for Resident #72 with the effective date of 09/28/23 at 11:28 AM late entry with the created date today, 10/25/23 at 11:28 AM for the grievance noted. She also provided two (2) Social service notes, one dated 08/28/23 for Resident #11 revealing he was educated that he cannot sit outside female resident rooms. Second note with the effective date 09/28/23 at 2:00 PM late entry with the created date today, 10/25/23 at 11:51 AM with education about sitting outside female resident rooms particularly when they were sleeping.
On 10/25/22 at 12:48 PM, an interview with the Administrator confirmed, there was no documentation for Resident #72's grievance and she advised the SW #67 to complete progress notes on this date about the 09/28/23 grievance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to have cans with uncompromised seals, dishware stored inverted or covered, supplies stored off the floor, and clean sanitized mobile utili...
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Based on observation and staff interview the facility failed to have cans with uncompromised seals, dishware stored inverted or covered, supplies stored off the floor, and clean sanitized mobile utility food carts. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census. 84.
Findings included:
a) Kitchen tour
During Initial tour on 10/23/23 at 10:44 AM found:
1- two (2) food #10 cans with dented compromised seals.
2- two (2) mobile utility carts with food on them, having old food and other debris on all three (3) shelves.
3-dish stored inverted with dust and debris in bowls and cups.
4- Items such as open paper towels in the dry storage, stored on the floor.
An Interview with the Dietary Manager during initial tour verified all issues noted. She stated that she was unaware of the issues, and she would fix the issues.
May 2022
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure one (1) of 27 residents reviewed during the long-term care survey process had advance directives completed as recognized by ...
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Based on record review and staff interview, the facility failed to ensure one (1) of 27 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident #49 did not have a Physician Orders for Scope of Treatment (POST) form signed by the individual making decisions on behalf of the resident. Resident identifier: #49. Census: 82.
Findings included:
a) Resident #49
A record review showed a POST form, dated 01/14/2022. The form contained verbal consent by Resident #49's decision maker. No other update with the resident representative's signature was found.
An interview, with Social Services employee #3, (SS#3) on 05/17/22 at 11:45 AM, revealed the facility had no signed POST form for Resident #49. SS #3 stated the facility felt it was adequate to obtain verbal consent and no other signature was required.
An interview with the Director of Nursing (DON), on 05/18/22 at 11:57 AM, verified only verbal consent was obtained for Resident #49's POST form. It was stated further by the DON, the facility would use verbal consent when representatives were not able to visit the facility in person and did not pursue having families sign if the facility had verbal consent.
A review of the visitation log, maintained by the facility, showed two (2) occasions when Resident #49's resident representative had visited the facility in person. The dates included 04/24/22 and 05/1/22. There was no evidence the facility attempted to get a signature on the POST form during either of visits in which the resident's representative was present in the facility.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
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Based on random observation and interview, the facility failed to ensure a Resident's medical information was secured in a manner that protected personal, medical and health information. This was a ...
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Based on random observation and interview, the facility failed to ensure a Resident's medical information was secured in a manner that protected personal, medical and health information. This was a random opportunity for discovery. Resident identifier #73. Facility census: 82.
Findings Included:
A review of the facility's policy titled privacy rights: Patients. Effective date 06/01/96 with revisions 11/28/16 revealed the following:
--The patient has a right to personal privacy and confidentiality of his/her personal and medical records.
a) Resident #73
On 05/19/22 at 10:40 AM, an observation of the computer monitor displaying an electronic medical record for Resident #73. The medication cart was left unattended, on top of the Hilltop-hall. The cart was in a place easily accessible to residents, visitors, or other unauthorized persons.
On 05/19/22 at 10:42 AM, during an interview with the Assistant Director of Nursing (ADON), it was confirmand the information was in view. The ADON stated that resident information should never be in view of guests or visitors. She closed and locked out the Resident Information on the medication cart monitor screen.
No further information was provided prior to the end of the survey on 05/19/22 at 3:30 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
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Based on resident interview, facility documentation review and staff interview the facility failed to make efforts to resolve a resident's grievance as indicated by the actions taken to investigate ...
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Based on resident interview, facility documentation review and staff interview the facility failed to make efforts to resolve a resident's grievance as indicated by the actions taken to investigate the concern on the grievance form. This was a random opportunity for discovery. The failed practice was true for one (1) of one (1) grievance forms reviewed. Resident identifier: #34. Facility census: 82.
Findings included:
a) Resident #34
During an interview on 05/16/22 at 2:45 PM, Resident #34 stated that currently there was a grievance made against Nurse Aide (NA) #45. Resident #34 stated a grievance form was completed because NA #45 documented assistance was given to Resident #34 for a shower however Resident #34 was adamant that NA #45 did not assist with showering on two (2) separate occasions. Resident #34 stated that information on the results of grievance was wanted. Resident #34 stated the only knowledge available was Residents are only allowed two (2) showers per week.
Review of the facility's grievance logs verified a grievance form dated 04/27/22. The grievance form completed by Resident #34 stated, I still want to file a grievance on NA #45 for not giving me a shower on my shower day but documenting that it was done when it wasn't .I haven't had a shower since Saturday. The actions taken to investigate and resolve the grievance were as followed: Talk to aides about showers, Shower schedules- Two (2) times a week not three (3) and the Director of Nursing (DON) will investigate and educate. Showers were to be scheduled for Resident #34 on Saturday day shifts and Wednesday evening shifts. The grievance form dated 04/27/22 had a resolved date of 04/30/22.
During an Interview on 05/17/22 at 3:45 PM, Director of Nursing (DON) stated that there was no evidence available to show where an investigation or education was provided related to the grievance dated 04/27/22. There was no evidence available to show the actions taken to investigate and resolve the grievance was completed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, facility documentation review and staff interview the facility failed to provide a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, facility documentation review and staff interview the facility failed to provide a resident with Activities of Daily Living (ADL) care in the form of a shower. This was true for one (1) of four (4) Residents review for ADL care. Resident identifier: # 34. Facility census: 82.
Findings included:
a) Resident # 34
During an interview on 05/16/22 at 2:45 PM, Resident #34 stated that currently there was a grievance made against Nurse Aide (NA) #45. Resident #34 stated a grievance form was completed because NA #45 documented assistance was given to Resident #34 for a shower however Resident #34 was adamant that NA #45 did not assist with showering on two (2) separate occasions. Resident #34 stated that information on the results of grievance was wanted. Resident #34 stated the only knowledge available was Residents are only allowed two (2) showers per week.
Review of the facility's grievance logs verified a grievance form dated 04/27/22. The grievance form completed by Resident #34 stated, I still want to file a grievance on NA #45 for not giving me a shower on my shower day but documenting that it was done when it wasn't .I haven't had a shower since Saturday. The actions taken to investigate and resolve the grievance were as followed: Talk to aides about showers, Shower schedules- Two (2) times a week not three (3) and the Director of Nursing (DON) will investigate and educate. Showers were to be scheduled for Resident #34 on Saturday day shifts and Wednesday evening shifts. The grievance form dated 04/27/22 had a resolved date of 04/30/22.
Review of the Woodside Shower List on 05/18/22 showed Resident #34's room [ROOM NUMBER] was scheduled for showers on Saturday day shifts and Wednesday evening shifts.
A review of Resident #34's medical record showed Resident was provided shower assistance on the following dates:
05/04/22- Wednesday evening shift
05/07/22- Saturday morning shift
05/14/22- Saturday morning shift
Resident #34's medical record was marked Not Applicable for a shower on Wednesday 05/11/22 per shower schedule.
During an Interview on 05/17/22 at 3:45 PM, Director of Nursing (DON) stated that a scheduled Wednesday bath for Resident #34 was missed on 05/11/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to follow physicians orders in accordance with professional st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to follow physicians orders in accordance with professional standards of practice. Resident identifiers: #67 and #49. Facility Census: 82
Resident #67
a) Resident #67 has a current order for HYDROcodone-Acetaminophen Tablet 7.5-325 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 related to PAIN, UNSPECIFIED (R52) For pain 6-10, using pain scale 0-10.
According to the Medication Administration Report (MAR) he was administered the HYDROcodone-Acetaminophen Tablet 7.5-325 MG twenty one (21) times in April 2022 and May 2022 for a pain level less than six (6). This was confirmed with the Director of Nursing during an interview on 5/18/22 at 12:30 PM
b) Resident #49
A record review for Resident #49 showed the resident was admitted to the facility on [DATE] with a diagnosis of Idiopathic constipation. Physician's orders included the following protocol to administer in case of Resident #49 not having bowel movement (BM) on a regular basis.
The protocol was ordered as follows:
-Milk of Magnesia Suspension 400 milligrams (mg) per 5 milliliters (ml) Give 30 ml by mouth as needed for constipation. Give at bedtime if no BM in three (3) days.
- Dulcolax Suppository 10 mg. Insert 1 suppository rectally as needed for constipation if no result from Milk of Magnesia.
-Fleet Enema 7-19 Gram (GM)/ 118 ml- Insert 1 dose rectally as needed for constipation if no result from Dulcolax within two (2) hours and if no result from Fleet Enema, call MD/advanced provider for further orders.
A record review showed progress notes indicating a Fleets enema had been administered and was effective on 05/03/22. An additional review of the bowel movement records for May 2022 noted a BM on 05/05/22 as the last BM recorded for Resident #49 until 05/11/22. There was no evidence the Bowel Protocol ordered by the physician had been administered as ordered.
An interview, with the Director of Nursing (DON), on 05/17/22 at 03:42 PM , revealed Resident #49 should have received the bowel protocol on 05/08/22 because of not having a BM for 3 days but confirmed the bowel protocol was not given as ordered by the physician.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on observation policy review and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opp...
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Based on observation policy review and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of a medication cart unlocked and unattended. Facility Census: 82.
Findings Included:
A review of the facility's policy titled Storage and Expiration Dating of Medication, Biologicals. Effective date 12/01/07 with revisions 01/01/22 revealed the following:
--Facility should ensure that all medications and biologicals are stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.
a) Hilltop Hall Medication Cart
On 05/19/22 at 10:40 AM, An observation of an unlocked, unattended medication cart on the Hilltop Hall. The cart was in a place easily accessible allowing access to these medication by residents, unauthorized persons, or visitors.
On 05/19/22 at 10:42 AM, during an interview with the Assistant Director of Nursing (ADON), it was confirmand the Medication cart was unlocked. The ADON verified that the medication cart should not be unlocked when unattended. She closed and locked the medication cart at this time.
No further information was provided prior to the end of the survey on 05/19/22 at 3:30 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight ran...
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Based on record review and staff interview, the facility failed to ensure each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this not possible or resident preferences indicate otherwise for 1 of 3 residents reviewed during the Long-Term Care Survey Process (LTCSP) for the area of nutrition. Resident identifiers: #49 and #9. Census: 82
Findings included:
a.) Resident #49
A record review for Resident #49 showed the weight for Resident #49 on 01/13/22 to be 189.3 lbs and the resident's weight to be 170.3 lbs on 04/13/22, indicative of a 10.4 percent weight loss. The resident also had a weight of 175.5 lbs on 04/05/22 and a weight of 164.6 lbs recorded on 05/05/22 indicating a significant weight loss of 6.21 percent in one (1) month.
Further review of the medical record showed a nutritional assessment noting the resident required increased nutritional needs and the facility would offer alternate food choices if less than 50% consumed at mealtime as a mechanism to prevent further weight loss.
Meal consumption records from 04/01/22 -05/18/22 were reviewed:
--For 70 of the 82 meals reviewed for 04/01/22 through 04/30/22, showed Resident #49 refusing or not eating greater than 50 percent of the meal, yet there was no evidence Resident #49 was offered an alternative to the meal to assist in the prevention of further weight loss.
--For 36 of the 47 meals reviewed for 05/01/22 though 05/18/22 showed Resident #49 refusing or not eating greater than 50 percent of the meal yet there was no evidence Resident #49 was offered an alternative to the meal to assist in the prevention of further weight loss.
An interview, with the DON, on 5/18/22 at 11:04 AM, revealed there was no evidence to show the staff had offered an alternate when the resident consumed less than 50 percent of the meal. The DON stated further, there was no place to document that information even though it was an approach the staff were supposed to be utilizing to prevent further weight loss for Resident #49.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure that nursing assistants (NA's) received 12 annual hours of training a year including dementia training and abuse prevention....
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Based on record review and staff interview, the facility failed to ensure that nursing assistants (NA's) received 12 annual hours of training a year including dementia training and abuse prevention. This was true for two (2) of five (5) employee files that were reviewed. Employee Identifiers: #26 and #57. Facility census: 82.
Findings include:
a) Employee #26
On 05/19/22 during a review of Employee #26, nursing assistant (NA), personnel record found she was hired 08/26/14. Further review of her personnel record found her list of trainings for the past 12 months found no dementia training or abuse prevention training.
On 05/19/22 at 10:04 AM, during an interview with the Director of Nursing (DON), was asked if all employee training were contained within their employee file. The DON Verified that NA #26 did not have the required trainings for dementia or abuse.
b) Employee #57
On 05/19/22 during a review of Employee #57, nursing assistant (NA), personnel record found he was hired 12/01/12. Further review of her personnel record found his list of trainings for the past 12 months found no dementia training.
On 05/19/22 at 10:04 AM, during an interview with the Director of Nursing (DON), was asked if all employee training were contained within their employee file. The DON Verified that NA #57 did not have the required trainings for dementia.
No further information was provided prior to the end of the survey on 05/19/22 at 3:30 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on observation, interview and policy review, the facility failed to ensure medications and biologicals used in the facility were stored in accordance with currently accepted professional princ...
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Based on observation, interview and policy review, the facility failed to ensure medications and biologicals used in the facility were stored in accordance with currently accepted professional principles. The Hilltop medication room refrigerator and medication cart was not locked and unattended. This is true for one (1) of two (2) units. Facility Census 82.
Findings included:
A review of the facility's policy titled Storage and Expiration Dating of Medication, Biologicals. Effective date 12/01/07 with revisions 01/01/22 revealed the following:
-- Facility should ensure that all medications and biologicals are stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.
-- Controlled Substances stored in the refrigerator must be in a separate container and double locked.
a) Hilltop Hall Medication Cart
On 05/19/22 at 10:40 AM, An observation of an unlocked, unattended medication cart on the Hilltop Hall. The cart was in a place easily accessible allowing access to these medication by residents, unauthorized persons, or visitors.
On 05/19/22 at 10:42 AM, during an interview with the Assistant Director of Nursing (ADON), it was confirmand the Medication cart was unlocked. The ADON verified that the medication cart should not be unlocked when unattended. She closed and locked the medication cart at this time.
b) Hilltop Medication Room Refrigerator
On 05/19/22 at 10:45 AM, An observation of an unlocked, unattended Medication Room Refrigerator on the Hilltop Hall. The refrigerator had an unlocked pad lock hanging in the lock slot. Continued observation found controlled substances in the refrigerator in a separate container.
On 05/19/22 at 10:46 AM, during an interview with the Assistant Director of Nursing (ADON), it was confirmand the Medication Room Refrigerator was unlocked with Controlled substances in the refrigerator. The ADON verified that the medication room refrigerator should be locked at all times to protect all medications including the controlled substances when unattended. The ADON tried to lock the Pad lock on the medication refrigerator at this time but was unable to get it to lock. The ADON stated that she would have to get the maintenance personnel to fix the lock or provide a new one.
No further information was provided prior to the end of the survey on 05/19/22 at 3:30 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview and resident interview the facility failed to provide food preferences in a timely manner. This failed practice has the potential to affect all residents who re...
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Based on observation, staff interview and resident interview the facility failed to provide food preferences in a timely manner. This failed practice has the potential to affect all residents who receive nutrients from the kitchen. resident identifier #12. Facility Census 82
Findings included;
a) Resident #12 food preferences
On 05/16/22 at 11:20 AM interview with Resident #12 revealed the menu is not always correct and they do not always get what is on their ticket. Resident also stated they were suppose to receive tomato soup with lunch and did not receive any soup. They further stated their dislikes and likes are not on the ticket.
On 05/16/22 at 11:40 AM, interview with Regional Dietary Manger (RDM) asking to see preference sheet for Resident #12 and RDM stated after looking, there is not a preference sheet for the resident. Asked when preference sheets are obtained once admitted and how often are the preference sheets updated. RDM stated, within 5 (five) days of admission and then after every 6 (six) months at the minimum. The goal is to try and update quarterly. Resident was admitted in 2016 and no preference sheets were initiated or updated.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
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Based on resident interview and staff interview, Resident Council grievances were not addressed timely. This is true for five of 27 reviewed. Resident identifiers #77, #63, #42, #44 and #64. Facilit...
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Based on resident interview and staff interview, Resident Council grievances were not addressed timely. This is true for five of 27 reviewed. Resident identifiers #77, #63, #42, #44 and #64. Facility Census 82
Findings included;
a) Resident Council
On 05/17/22 02:00 PM, residents #77, #63, #42, #44 and #64 voiced that meeting after meeting
the issues brought up from previous meetings are the same issues that are never addressed or resolved. Resident Council President #77 stated, for example snacks not always provided, showers not give on days assigned, foods not always hot, beds not always made timely or sheets changed after showers, water not always passed and shower rooms only has a couple showers that actually work.
On 5/19/22 at 12:45 PM, interview with Activity Director (AD) concerning resident council meeting for 5/10/22 meetings under administration stated, don't feel issues get resolved timely, or they come back again later in time. AD stated, yes the residents who attended resident council on 5/10/22 meeting did voice concerns about issues not getting resolved when brought to administration.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
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b) Resident #26
Resident #26 was observed to have a left eye that is drooping, very red and watering. Per the Physicians note on 05/04/22, it stated continued eversion of the left lower eye lid. Upo...
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b) Resident #26
Resident #26 was observed to have a left eye that is drooping, very red and watering. Per the Physicians note on 05/04/22, it stated continued eversion of the left lower eye lid. Upon review the facility failed to implement this on the care plan. This was confirmed with the Director of Nursing (DON) on 05/17/22 at 1:13 PM.
Medical record review revealed an original observation on 05/16/22 at 1:19 PM that Resident #26's left eye very red and watering and swollen.
According to record review drainage from the left eye was cultured on 04/21/21 with no growth present. She sees a local optometrist. She has a history of Cerebrovascular Accident (CVA) with left sided weakness
Interview on 05/07/22 at 1:13 PM the DON verified her left eye does not close completely while sleeping, dries out and gets irritated. The DON confirmed artificial tears had been ordered previously with no treatment currently ordered.
According to the care plan there is no mention of her left eye lid eversion, only states she wears glasses and sees an Optometrist.
c) Resident #41
Upon record review it was found that Resident #41 is on Eliquis 5 milligrams twice a day for a thrombosis. According to review of her diagnosis history, thrombosis is not documented as a current or historical diagnosis.
Interview on 05/19/22 at 9:34 AM the DON stated the Resident is on Eliquis for A-Fib with a coronary angioplasty implant and graft and does not have a diagnosis for a thrombosis.
The care plan initiated for the cardiovascular symptom does not have A Fib, the presence of a coronary angioplasty implant and graft or a thrombosis on the care plan.
Based on record review and staff interview the facility failed to implement a care plan to address residents' medical needs for pressure ulcer care, eye eversion and the use of an anticoagulant. This was true for three (3) of 27 care plans reviewed. Resident identifiers #50, #41 and #26. Facility census: 82.
Findings included:
a) Resident #50
A review of Resident #50's medical record showed a diagnosis of Pressure Ulcer of right buttock, stage two (2). A physician order dated 04/01/22 stated, Cleanse stage 2 pressure ulcer of right upper buttock with wound cleanser. Pat dry. Apply thin layer of Chamosyn cream. Complete at least 2 times daily and as needed during turning and repositioning. Skin Check assessments dated 04/16/22 through 05/13/22 stated Resident had a stage 2 right upper buttocks. The care plan was reviewed with no pressure ulcer care or treatment addressed.
During an Interview on 05/18/22 at 10:30 AM, Center Reimbursement Coordinator (CRC) #49 stated the pressure ulcer was not addressed on the current care plan as it appeared to have been resolved by accident on 04/22/22.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
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Based on resident interview and record review the facility failed to ensure all resident are offered an evening snack. This failed practice has the potential to affect all residents who receive snac...
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Based on resident interview and record review the facility failed to ensure all resident are offered an evening snack. This failed practice has the potential to affect all residents who receive snacks from the kitchen. resident identifiers #77, #63, #42, #44 and #64. Facility Census 82
Findings included;
a) Snacks
On 05/17/22 2:00 PM resident council meeting concerning snacks not always being offered or being available. Resident Council President #77 stated, for example, one evening there were no snacks at all in the pantries and the kitchen was locked up so, no snacks could be obtained.
There are usually no snacks for diabetics to consume. Resident Council #77 stated, around the first week of May 2022 there we no snacks available and the nursing staff put their money together to go purchase snacks at the local grocery store and spend $145.00 worth of snacks so residents could have snacks. Residents #63, #42, #44 and #64 all agreed.
On 05/18/22 at 9:00 AM, interview with Dietary Manager (DM) regarding snacks and how many snacks are taken to pantry on units and how often. DM stated, a copy of how much is taken to pantries and nursing has to sign off on sheets of snacks taken to pantries.
When asked if snacks are every not taken to unit pantries. DM stated, yes and explained situation and that a dietary aide #300 did not take snacks one evening after dietary aide #300 stated snacks were completed and were not. This dietary aide #300 was terminated. DM showed documentation that dietary aide #300 was no longer employed at facility.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview and policy review the facility failed to properly label and date food items stored in the refrigerators in accordance with the professional standards for food s...
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Based on observation, staff interview and policy review the facility failed to properly label and date food items stored in the refrigerators in accordance with the professional standards for food service safety. The facility failed to complete daily temperature checks for the kitchen area reach-in refrigerator. The failed practice had the potential to affect more than a limited number of residents. Facility census: 82.
Findings included:
A record review of the facility's policy titled Food and Nutrition Services Policies and Procedures revised date 06/15/18 stated, All foods are labeled with name of product and the date received and use by date once opened. Food and nutrition services employees observe and record equipment temperatures daily according to the Refrigerator/Freezer Temperature Standards.
a) Walk-in Refrigerator
An observation of the walk-in refrigerator, on 05/16/22 at 11:10 AM, showed food items that were opened or pre-made with no labels or dates. The food items were as followed:
- One (1) opened container of Beef Base with no receive or use by date
- One (1) metal container of diced onions with foil over the top with no label or date
- Two (2) three (3) quart containers of diced potatoes with no label or date
During an interview on 05/16/22 at 11:10 AM, Dietary Manager (DM) stated the items should have been labeled and dated when opened and stored.
b) Reach-In Refrigerator
An observation of the reach-in refrigerator on 05/16/22 at 11:15 AM, showed food items that were pre-made with no labels or dates. The food items were as followed:
- Three (3) individual plastic containers of pureed orange substance not labeled or dated
During an interview on 05/16/22 at 11:15 AM, DM did not know what the orange substance was and stated the items should have been labeled and dated. DM stated the three (3) individual containers of orange substance would be discarded immediately.
An additional observation on 05/16/22 at 11:17 AM showed the reach-in refrigerator temperature log was missing temperature checks for the date of 05/15/22.
During an interview on 05/16/22 at 11:17 AM, DM stated the reach-in refrigerator temperature log was incomplete and missing temperatures checks for the date of 05/15/22.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on observation, record review, and interview, the facility failed to keep an accurate antibiotic line listing and failed to discard biohazard materials appropriately. This failed practice had ...
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Based on observation, record review, and interview, the facility failed to keep an accurate antibiotic line listing and failed to discard biohazard materials appropriately. This failed practice had the potential to more than a limited number of residents. Resident identifiers: #11, #49, and #50. Facility Census: 82
Findings included:
a) Resident #11 and #49
Based on record review the antibiotic line listing was not completed in its entirety. This was confirmed with Registered Nurse (RN) #32 on 05/19/22 at 2:25 PM.
On the March Line List and the 2022 Running list there are two Residents that are currently on antibiotics that are not on the line listing. They are Resident #11 and #49. Both orders are prophylactic. Resident #11 had Augmentin started on 01/10/22 with no stop date and Resident #49 had Macrobid started on 01/13/22 with no stop date.
b) Resident #50
An observation on 05/16/22 at 12:52 PM showed a clear bag of brown substance laying on the floor by Resident #50's bathroom door.
During an interview on 05/16/22 at 12:52 PM, Resident #50 stated that the bag was trash. Resident #50 stated, that is trash that is where they changed my stoma.
During an interview on 05/16/22 at 12:54 PM, Infection Preventionist (IP) verified the bag of feces was not discarded appropriately for infection control practices. IP stated that he could identify the inappropriate discard of biohazard material as an infection control issue. IP continued to disclose that new Nurse Aides had not been disposing of items appropriately lately so immediate education and teaching moments would have been implemented as infection control issues occur.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Salem Center's CMS Rating?
CMS assigns SALEM CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Salem Center Staffed?
CMS rates SALEM CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 46%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Salem Center?
State health inspectors documented 37 deficiencies at SALEM CENTER during 2022 to 2025. These included: 37 with potential for harm.
Who Owns and Operates Salem Center?
SALEM CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 112 certified beds and approximately 85 residents (about 76% occupancy), it is a mid-sized facility located in SALEM, West Virginia.
How Does Salem Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, SALEM CENTER's overall rating (2 stars) is below the state average of 2.7, staff turnover (46%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Salem Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Salem Center Safe?
Based on CMS inspection data, SALEM CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Salem Center Stick Around?
SALEM CENTER has a staff turnover rate of 46%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Salem Center Ever Fined?
SALEM CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Salem Center on Any Federal Watch List?
SALEM CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.