Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to update the
plan of care with changes in the resident’s needs for four residents (Resident # 11, 19,
27, and 35). The facility census was 44.
1. Review of the facility’s Minimum Data Set (MDS) policy, a federally mandated assessment
tool completed by facility staff, undated, and Care Planning Policy, undated, showed the
policies directed staff to complete the following:
-Physical as well as psychosocial needs will be addressed on the plan of care with
interventions specific to each individual resident;
-Care plan changes should be added as the resident changes occur and updates added as
warranted;
-Care should be individualized for the unique needs of the resident.
2. Review of Resident #11’s Annual Minimum Data Set (MDS), a federally mandated assessment
tool completed by facility staff, dated 6/6/18, showed the staff assessed the resident as
follows:
-Severe Cognitive Impairment;
-Requires total dependence on two staff members for bed mobility, transfers, and
toileting;
-[DIAGNOSES REDACTED]. in the blood).
-At risk for developing pressure ulcers;
-No pressure ulcers present on admission, or at time of assessment;
-Bilateral Upper and Lower Extremity Impairments;
-physician’s orders [REDACTED].>-And Utilizes a pressure reducing device to his/her
chair and bed, and has a turning/reposition program in place.
Review of the resident’s plan of care, dated 7/29/18, showed it did not contain direction
for the staff in regards to a red area on his/her coccyx.
Review of resident’s skin assessment dated [DATE] showed a red area to coccyx.
Review of the resident’s physician’s orders [REDACTED].
Observation on 8/22/18 at 2:09 P.M., showed the resident with a red area to his/her
coccyx.
3. Review of Resident #19’s comprehensive MDS, dated [DATE], showed staff assessed the
resident as follows:
-Moderate Cognitive Impairment;
-Requires extensive assistance of two staff members for bed mobility, and dressing;
-Requires total dependence on two staff members for transfers, and toileting;
-[DIAGNOSES REDACTED].), depression, and [MEDICAL CONDITION] (an insufficiency of veins in
the body);
-At risk for developing pressure ulcers;
-No pressure ulcers present on admission, or at time of assessment;
-And Utilizes a pressure reducing device to his/her chair and bed, and has a
turning/reposition program in place.
Review of the resident’s progress notes, dated 7/19/18, showed that an unidentified staff
member documented the resident had a two centimeter by four centimeter fluid filled area
to heel, skin blanchable, heels floated. Further review of the progress notes showed they
did not contain further documentation in regards to the blister to the resident’s heel.
Review of the resident’s plan of care, dated 7/29/18, showed it did not contain direction
for staff related to the blister on the resident’s heel.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
During an interview on 8/22/18 at 3:15 P.M., Licensed Practical Nurse (LPN) I said if a
resident has a wound or other skin issue, the care plan should be updated immediately.
He/she said if the care plan can not be updated immediately it should be done at some
point during the shift. He/she said it’s the responsibility of the charge nurse to update
the care plan.
During an interview on 8/22/18 at 3:30 P.M., the Director of Nursing (DON) said that all
wounds should be on the care plan. He/she said it is the responsibility of the charge
nurse’s to add the interventions to the care plan and he/she does not know why the
residents wound was not on the care plan.
4. Review of Resident #27’s plan of care, dated 12/28/17, showed it did not contain
direction for staff in regards to non-compliance with oxygen use, direction to educate the
resident about the possible outcomes of not using his/her oxygen, and interventions to
encourage the resident to use his/her oxygen as ordered.
Review of the resident’s quarterly MDS , dated 7/18/18, showed staff assessed the resident
as follows:
-Cognitively Intact;
-Independent with bed mobility, eating, and toileting;
-Requires supervision of one staff for dressing and transfers;
-[DIAGNOSES REDACTED].
-And uses oxygen therapy.
Review of the resident’s nurses notes dated between 7/23/18 and 8/22/18 showed staff
documented multiple episodes of non-compliance to wear oxygen. Further review showed
several episodes the resident became hypoxic after smoking and had to be placed back on
his/her oxygen.
Review of the resident’s physician’s orders [REDACTED].
5. Review of Resident #35’s Significant Change in Status MDS, dated [DATE], showed staff
assessed the resident as follows:
-Severely Cognitively Impaired;
-Required total dependence on two or more staff members for bed mobility, transfer,
dressing, and toileting;
-Required total dependence of one staff member for locomotion, eating, and hygiene;
-Required total dependence for bathing;
-Unclear or slurred speech, mumbled words;
-Rarely or never understands others;
-No behaviors or changes in behavior;
-[DIAGNOSES REDACTED]. type with a progressive decline in mental abilities), and [MEDICAL
CONDITION] (a chronic disorder in which a person has uncontrollable, recurring thoughts
and behaviors).
Review of the residents’ plan of care, dated 8/8/18, showed the following:
-Staff are directed to allow resident time to answer and to verbalize feelings,
perceptions, and fears;
-Staff are directed to allow the resident to provide feedback;
-Staff are directed to encourage the resident to state thoughts;
-Staff are to monitor behavior episodes and minimize potential for any disruptive
behaviors by offering tasks which divert attention.
During an interview on 8/21/18 at 2:38 P.M., the resident’s family member said that the
resident has had a slow steady decline and sleeps a lot. He/she said that the resident
does not have any behaviors. He/she said the resident is unable to communicate his/her
feelings and thoughts.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
6. During an interview on 8/23/18 at 6:57 A.M., the Minimum Data Set (MDS) Coordinator
said the charge nurses are expected to update the care plans with every new order. He/she
said it is the responsibility of every nurse to update the care plans. He/she said he/she
double checks the care plans for accuracy during quarterly reviews, and does not know why
the care plans are not updated.
During an interview on 8/23/18 at 7:05 A.M., LPN H said the nurses are responsible for
updating care plans. He/she said staff are expected to update the care plans when there is
a change in medications, and a change in condition whether it be an improvement or
decline.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to ensure three
residents received treatment and care in accordance with professional standards of
practices by not completing accurate and timely wound assessments for two residents
(Resident #19 and Resident #91), and failing to notify the physician of one resident’s
(Resident #27) refusal to wear oxygen after smoking, failing to monitor the oxygenation of
the resident during and after smoking, and failing to document education of the risks of
not wearing the oxygen after smoking. The facility census was 44.
1. Review of the National Pressure Ulcer Advisory Panel, dated (MONTH) (YEAR), showed the
following definitions:
-Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you
press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness).
Presence of blanchable [DIAGNOSES REDACTED] and changes in sensation, temperature, or
firmness may precede visual changes;
-Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the
thick layer of living tissue below the top layer of skin that forms the true skin). The
wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new
connective tissue), slough (dead tissue in the process of separating from the body which
is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or
falls off from health skin) are not present;
-Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible
in the ulcer and granulation tissue and rolled wound edges are often present. Slough and
eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue
damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a
thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not
exposed;
-Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or
eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges,
undermining and or tunneling often occur. Depth varies by location;
-Unstageable pressure injury is a full thickness skin and tissue loss in which the extent
of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or
eschar;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Deep Tissue Pressure Injury is intact or non-intact skin with localized area of
persistent non-intact skin with localized area of persistent non-blanchable deep red,
maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or
blood filled blister. This injury results from intense and/or prolonged pressure and shear
forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual
extent of tissue injury, or may resolve without tissue loss. If necrotic tissue,
subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures
are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or
stage 4 pressure injury).
2. Review of Resident #19’s comprehensive Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 6/20/18, showed the staff assessed the
resident as follows:
-Moderate Cognitive Impairment;
-Requires extensive assistance of two staff members for bed mobility, and dressing;
-Requires total dependence on two staff members for transfers, and toileting;
-[DIAGNOSES REDACTED].
-At risk for developing pressure ulcers;
-No pressure ulcers present on admission, or at time of assessment;
-Utilizes a pressure reducing device to his/her chair and bed, and has a
turning/reposition program in place.
Review of the resident’s (MONTH) (YEAR) progress notes showed an unidentified staff member
documented on 7/19/18 the resident had a two centimeter by four centimeter fluid filled
area to heel, skin blanchable, heels floated.
Further review of the (MONTH) and (MONTH) (YEAR) progress notes showed they did not
contain further documentation in regards to the blister to the resident’s heel.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s Treatment Administration Record (TAR) dated 7/17/18 to 8/16/18,
showed it did not contain a treatment order for the resident’s heel.
Review of the resident’s plan of care, dated 7/29/18, showed it did not contain direction
for the staff in regards to the blister to the resident’s heel.
Review of the resident’s TAR dated 8/17/18 to 9/16/18, showed it did not contain a
treatment order for the resident’s heel.
Review of the resident’s medical record showed the following wound assessments:
-8/1/18: 2cm x 4 cm, no depth, no drainage, no odor, surrounding skin pink, no culture
performed, resident experiences pain from wound, rated a 5 on a scale of 0-10 (0 being no
pain 10 being worst pain).
Further review of assessment showed it did not contain the stage of the wound, the
appearance of the wound bed, or the location of the wound.
-8/8/18: Review of the resident’s wound assessment showed it did not contain any
documentation related to the blister or heel.
-8/15/18: 2 cm x 3 cm, no depth, no drainage, no odor, wound bed with normal skin, no
culture performed, resident experienced pain from the wound, rated a 5 on a scale of 0-10.

Further review of the assessment showed it did not contain the stage of the wound, or the
location of the wound.
Review of the resident’s POS, dated 8/17/18 to 8/21/18, showed they did not contain an
order for [REDACTED].
Observation on 8/22/18 at 10:00 A.M., showed the resident lay in his/her bed. Further
observation showed the resident to have an irregular shaped wound to his/her left heel.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
Additional observation showed the wound bed consisted of white tissue that adhered to the
skin surface with redness surrounding the white tissue.
During an interview on 8/22/18 at 10:15 A.M., Licensed Practical Nurse (LPN) I said the
top layer of the skin has peeled off and revealed the tissue underneath it. He/she said
that the white tissue appeared to be slough. Furthermore, he/she said the Director of
Nursing (DON) is the only nurse who stages wounds in the facility.
3. Review of Resident #91’s Entry MDS, dated [DATE], showed the staff assessed that the
resident was admitted to the facility on [DATE] from an acute care hospital.
Review of the resident’s hospital discharge orders showed the following:
-Sacrum (tailbone) Dressing- use Mesalt (a wound dressing used on infected wounds) with
abdominal pads and paper tape. Change dressing daily and as needed (PRN);
-Left Heel Wound- use Mesalt dressing, dry dressing, and kling wrap (gauze wrap). Change
daily.
-Multiple open areas on bilateral (both) lower legs, ankles, and hip- Use [MEDICATION
NAME] (an absorbent foam dressing).
Review of the resident’s medical record showed it did not contain an initial wound
assessment conducted by the facility staff.
Further review of the resident’s medical record showed it did not contain a plan of care
for the resident.
Review of the resident’s POS’s, dated 8/9/18, showed the following orders:
-Follow hospital discharge orders;
-And, weekly skin assessment.
Review of the resident’s TAR, dated 8/9/18 showed the following:
-Weekly Skin Assessment;
-Left Heel: Apply nonadherent pad daily;
-Left Lower Leg: [MEDICATION NAME] border to two blisters every three days;
-Left Hip: [MEDICATION NAME] border to hip every three days;
-And Coccyx/Buttock: Wet/dry dressing abdominal pad daily and PRN.
The medical record did not contain an assessment for the wounds to the resident’s right
hip, right inner knee, left inner knee, or the left heel.
Further review of the TAR showed staff did not document a skin assessment had been
completed from 8/9/18 to 8/19/18.
Review of the resident’s medical record showed the following wound assessments:
-8/13/18: 3 cm in circumference, 1.7 cm in depth, small amount of serous drainage with
slight odor, wound bed tissue characterized as slough and eschar, surrounding tissue
macerated.
Further review of the assessment showed it did not contain the stage of the wound, or the
location of the wound. No other wound assessments were documented.
Review of the resident’s TAR, dated 8/17/19 to 9/16/18, showed staff completed a skin
assessment on 8/22/18, thirteen days after the resident was admitted .
Observation and interview on 8/21/18 at 9:30 A.M., showed the resident in his/her bed.
Further observation showed an unidentified nurse removed a dressing to the resident’s
coccyx and revealed a large wound consisting of 75% white tissue and 25% gray tissue to
the wound bed, and pink tissue surrounding the wound. Licensed Practical Nurse (LPN) J
said the charge nurses do not stage the wounds. Additional observations showed the
resident had a small circular wound to his/her right hip with a small area of yellow
tissue covering the wound bed, a circular wound to his/her left inner knee with wound bed
consisting of 75% yellow tissue and 25% pink tissue, a circular wound to his/her right
inner knee with wound bed consisting of 50% yellow tissue and 50% pink tissue, and a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
circular wound to his/her left heel that was 100% covered in black thick tissue. LPN J
said the tissue on the resident’s heel is eschar.
During an interview on 8/22/18 at 3:15 P.M., LPN I said staff are expected to complete
wound assessments on all wounds once per week, and the assessment is to include
measurements. He/she said the DON is responsible for staging the wounds.
During an interview on 8/22/18 at 3:30 P.M., the Director of Nursing (DON) said all wounds
should have weekly documentation that includes measurements. He/she said that he/she does
not know why the assessments have not been completed as expected.
4. Review of Resident #27’s plan of care, dated 12/28/17, showed it did not contain
direction for staff related to the resident’s non-compliance with oxygen use, education of
the resident regarding possible outcomes related to smoking and not using oxygen, and
interventions to encourage the resident to wear his/her oxygen more consistently after
smoking.
Review of the resident’s quarterly MDS completed by facility staff, dated 7/18/18 showed
staff assessed the resident as follows:
-Cognitively Intact;
-Independent with bed mobility, eating, and toileting;
-Requires supervision of one staff for dressing and transfers;
-[DIAGNOSES REDACTED].
-And uses oxygen therapy.
Review of the resident’s nurses notes dated between 7/23/18 and 8/22/18 showed staff
documented the resident refused to wear his/her oxygen on multiple occasions. Further
review showed several times the resident became hypoxic (low oxygen saturation) after
smoking and had to be placed back on his/her oxygen.
Review of the resident’s physician’s orders [REDACTED].
Observation on 8/20/18 at 1:15 P.M., showed Resident #27 in his/her wheelchair at the
table and oxygen not in use. Further observation showed him/her with a glazed look and his
face bluish gray in color as staff removed him/her from the area.
Observation on 8/21/18 at 1:47 P.M., showed staff propelled Resident #27 in a wheelchair
by the nurses’ station. Further observation showed his/her head back, mouth open, color
gray, and oxygen not in use.
During an interview on 8/21/18 at 2:57 P.M., LPN G (Licensed Practical Nurse) said the
resident is non-compliant with using his/her oxygen. The resident has been educated on
his/her disease and the risk of smoking but refuses to quit, and refuses to put oxygen
back on when he/she comes in from smoke break. He/She said the physician’s orders
[REDACTED].
During an interview on 8/23/18 at 7:17 A.M., the DON said if a physician’s orders
[REDACTED].

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review facility staff failed to provide an
ongoing program of activities designed to meet the residents’ interest during the weekend
and for five sampled residents (Residents #2, #11, #13, #18, and #36). The facility census
was 44.
1. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
following:
-Saturday, 8/4/18: Welcome Visitors (not a scheduled activity), 1:30 P.M. Church group;
-Sunday, 8/5/18: Welcome Visitors;
-Saturday, 8/11/18: Welcome Visitors;
-Sunday, 8/12/18: Welcome Visitors;
-Saturday, 8/18/18: Welcome Visitors, 1:30 P.M. Church group;
-Sunday, 8/19/18: Welcome Visitors;
-Saturday, 8/25/18: Welcome Visitors;
-Sunday, 8/26/18: Welcome Visitors; 2:30 P.M Church group;
-Saturday 8/30/18: Welcome Visitors.
Staff did not plan weekend activities other than church and music.
2. Review of Resident #2’s care plan, dated 2/9/17, showed staff are directed to do the
following:
-Encourage to attend activities;
-Receive new monthly calendar every month;
-Explain importance of social interaction;
-Encourage participation by inviting to each activity;
-Preferred activities are watching television (TV) in room;
-Is a smoker;
-Prefers a bedtime between 9:30 P.M. and 10:00 P.M.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
tool, dated 2/14/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Very important to participate in music, group, outdoor activities, and church;
-Dependent with bed mobility, transfers, and toileting;
-Independent for eating, and locomotion.
During a group interview on 8/22/18 at 08:58 A.M., Resident #2 said there is nothing to do
in the facility on weekends besides sit around and sleep.
3. Review of Resident 11’s care plan, dated 3/02/17, showed staff are directed to do the
following:
-Encourage to attend activities;
-Engage simple, structured activities that avoid overly demanding tasks;
-Receive new monthly calendar every month;
-Provide a program of activities that accommodates my abilities, band, religious services,
one on one activities.
Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively impaired;
-Somewhat important to participate in music, favorite activities, and outdoor activities;
-Dependent with bed mobility, transfers, and toileting.
Observation on 8/20/18 at 11:47 A.M., showed Resident #11 in his/her room in a wheelchair.
Staff did not engage the resident in an activity.
Observation on 8/21/18 at 09:10 A.M., showed Resident #11 in his/her bed. Staff did not
engage the resident in an activity.
Observation on 8/22/18 at 2:10 P.M., showed Resident #11 in his/her bed. Staff did not
engage the resident in an activity.
4. Review of Resident 13’s admission MDS, dated [DATE], showed staff assessed the resident
as follows:
-Cognitively impaired;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-Somewhat important to participate in music, favorite activities, and outdoor activities;
-Dependent with transfers;.
-Extensive assist of two staff for bed mobility, and toileting.
Review of the resident’s care plan, dated 3/14/18, showed staff are directed to do the
following:
-Encourage to attend activities;
-One on one bedside/in room visits and activities if unable to attend out of room events;
-Receive new monthly calendar every month;
-Provide me with materials for individual activities as desired.
Observation on 8/20/18 at 11:53 A.M., showed Resident #13 in his/her room, tearful, in
his/her wheelchair.
Observation on 8/21/18 at 09:11 A.M., showed Resident #13 in his/her bed. Staff did not
engage the resident in an activity.
Observation and interview on 8/22/18 at 2:12 P.M., showed Resident #13 in his/her bed.
Staff did not engage the resident in an activity. The resident said, I am not doing
anything, there is nothing here to do.
5. Review of Resident 18’s care plan, dated 9/21/17, showed staff are directed to do the
following:
-Encourage to attend activities;
-One on one bedside/in room visits and activities if unable to attend out of room events;
-Receive new monthly calendar every month;
-Provide materials for individual activities as desired;
-Provide assistance/escort to activity functions;
-Invite to scheduled activities;
-Preferred activities are: church, music, some crafts, going outside, and parties.
Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively intact;
-Very important to participate in music, favorite activities, and outdoor activities;
-Dependent with bed mobility, toileting, and transfers;
Observation on 8/21/18 at 9:42 A.M., showed Resident #18 in his/her bed. Staff did not
engage the resident in an activity.
Observation on 8/22/18 at 2:11 P.M., showed Resident #18 in his/her bed. Staff did not
engage the resident in an activity.
Observation and interview on 8/22/18 at 3:19 P.M., showed Resident #18 in his/her bed.
Staff did not engage the resident in an activity. The resident said, There is nothing to
do around here on the weekends, we generally just lay around and sleep, if they would
offer crafts or something outside I would attend.
6. Review of Resident #36’s care plan, dated 5/03/18, showed staff are directed to do the
following:
-Encourage to attend activities;
-Receive new monthly calendar every month;
-Preferred activities are: sometimes birthday parties, music, I go with friends to play
golf, and I like to watch TV
-Encourage participation by inviting to each activity.
Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively intact;
-Very important to participate in music, favorite activities, and outdoor activities;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-Indpendent with bed mobility, transfers, and toileting.
During a group interview on 8/22/18 at 08:58 A.M., Resident #36 said there are a lot of
visitors who come in on the weekends and occasionally a church group, but for residents
who don’t have visitors, there really isn’t anything for them to do.
7. During an interview on 8/22/18 at 2:30 P.M., CNA E (Certified Nursing Assistant) said
he/she works every other weekend and the Activity Director (AD) schedules church sometimes
on the weekends but the AD is not there on weekends and no one is in charge of activities
on the weekends.
During an interview on 8/22/18 at 2:33 P.M. CNA F said there is church some Sundays and a
band on occasion but no activities throughout the day on weekends.
During an interview on 8/22/18 at 2:48 P.M., LPN D (Licensed Practical Nurse) said there
is church sometimes and music sometimes but really the weekends are just open to visitors.

During an interview on 8/23/18 at 8:30 A.M., the Activity Director (AD) said he/she knows
the weekend activities are a problem they have been working to solve, either by changing
the AD’s weekday hours or hiring someone else but they just haven’t solved it yet.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the facility
must (1) assess a resident for safety risk; (2) review these risks and benefits with the
resident/representative; (3) get informed consent; and (4) Correctly install and maintain
the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to complete an
entrapment assessment for the use of side rails and mobility devices for eight residents
(Residents #4, #13, #18, #19, #23, #24, #39, and #91). The facility census was 44.
1. Review of Federal Drug Administration (FDA) documents entitled, Hospital Bed System
Dimensional and Assessment Guidance to Reduce Entrapment dated (MONTH) 10, 2006 shows 413
people died as a result of entrapment events in the United States. Further review reveals
those among the most vulnerable for these entrapment type events are elderly patients and
residents especially those who are frail, confused, restless, or who have uncontrolled
body movement.
2. Review of the FDA documents entitled, Practice Hospital Bed Safety, dated (MONTH) 2013
identifies seven different potential, zones of entrapment. This guidance characterizes the
head, neck, and chest as key body parts that are at risk of entrapment.
3. Review of the FDA documents entitled, Guide to Bed Safety Rails in Hospitals, Nursing
Homes and Home Health Care: The Facts showed the potential risk of bed rails may include:
-Strangling, suffocating, bodily injury or death when patients or part of their body are
caught between rails or between the bed rails and mattress;
-More serious injuries from falls when patient climb over rails;
-Skin bruising, cuts and scrapes;
-Inducing agitated behavior when bed rails are used as a restraint;
-Feeling isolated or unnecessarily restricted;
-And preventing patients, who are able to get out of bed, from performing routine
activities such as going to the bathroom, or retrieving something from a closet.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
4. Review of the facility’s Policy and Procedure for Side Rail Use, undated, showed staff
are directed as follows:
-It is the policy of Community Care Centers, Inc. that anyone using siderails, regardless
of the reason, shall have a Restraint Assessment for Side Rails completed and the Side
Rail Safety Check at least quarterly using The Standards of Practice set out in
Restraints: Bed Rail Safety Check three page guidelines set out by Primaris, as well as
the Dimensional Limits for Identified Entrapment Zones ,[DATE] pages ,[DATE] and page 12
(which describes the key body part dimensions used for the basis of their findings), set
forth by the FDA.
5. Review of Resident #4’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated [DATE], showed facility staff assessed
the resident as follows:
-Moderate cognitive impairment;
-Required limited to extensive assistance for bed mobility, transfers, toileting and
dressing.
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails, as directed by facility policy.
Observation on [DATE] at 1:40 P.M., showed the resident in his/her bed. Further
observation showed the resident with half side rails up on both sides of bed.
6. Review of Resident 13’s admission MDS, dated [DATE], showed staff assessed the resident
as follows:
-Cognitively impaired;
-Dependent with transfers;
-Extensive assist of two staff for bed mobility, and toileting.
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails, as directed by facility policy.
Observation on [DATE] at 9:11 A.M., showed the resident in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
Observation on [DATE] at 2:12 P.M., showed the resident in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
7. Review of Resident 18’s annual MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively intact;
-Dependent with bed mobility, toileting, and transfers.
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails, as directed by facility policy.
Observation on [DATE] at 9:42 A.M., showed the resident lay in his/her bed. Further
observation showed the resident with grab bars up on both sides of the bed.
Observation on [DATE] at 2:11 P.M., showed the resident lay in his/her bed. Further
observation showed the resident with grab bars up on both sides of the bed.
8. Review of Resident #19’s annual MDS, dated [DATE], showed staff assessed the resident
as follows:
-Moderate Cognitive Impairment;
-Requires extensive assistance of two staff members for bed mobility, and dressing;
-And requires total dependence on two staff members for transfers, and toileting.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], showed the resident is to have two
padded half side rails for positioning.
Review of the resident’s medical record showed staff did not complete an entrapment risk
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
assessment for the use of siderails, as directed by facility policy.
Observation on [DATE] at 11:29 A.M., showed the resident in his/her bed. Further
observation showed both side rails up.
During an interview on [DATE] at 6:53 A.M., Certified Nursing Assistant (CNA) K said the
resident will sometimes grab his/her siderail while he/she is being turned in bed, but the
resident cannot turn in bed independently by only using the siderail.
9. Review of Resident #23’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively impaired;
-Total dependence on two staff members for bed mobility, transfers, toileting and eating.
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails.
Observation on [DATE] at 1:30 P.M., showed the resident in his/her bed. Further
observation showed the resident with half side rails up on both sides of bed.
10. Review of Resident #24’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe Cognitive Impairment;
-Requires limited assistance of one staff member for bed mobility, transfers, dressing,
toileting, and dressing;
-No bed rail, bed alarm used daily.
Review of the resident’s Physician order [REDACTED].>Review of the residents’ plan of
care, dated [DATE], showed staff did not document the resident requires the use of
bilateral upper side rails for positioning.
Review of the resident’s medical record showed staff did not document an entrapment risk
assessment for the use of siderails, as directed by facility policy.
Observation on [DATE] at 10:11 A.M., showed side rails on both sides of the resident’s
bed.
Observation on [DATE] at 7:00 A.M., showed the resident in bed with both side rails up.
11. Review of Resident #39’s Quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively impaired;
-Dependent with transfers and toileting;
-Extensive assist of two staff for bed mobility, and dressing.
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails.
Observation on [DATE] at 11:55 A.M., showed the resident in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
Observation on [DATE] at 9:09 A.M., showed the resident in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
Observation on [DATE] at 2:15 P.M., showed the resident in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
12. Review of Resident #91’s Entry MDS, dated [DATE], showed staff assessed the resident
was admitted to the facility on [DATE] from an acute care hospital.
Review of the resident’s POS’s, dated [DATE]-[DATE], showed it did not contain an order
for [REDACTED].>Review of the resident’s medical record showed staff did not document a
plan of care.
Review of the resident’s medical record showed staff did not document an entrapment risk
assessment for the use of siderails, as directed by facility policy.
Observation on [DATE] at 10:33 A.M., showed the resident in his/her bed. Further
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
observation showed the resident to have both upper siderails up.
During an interview on [DATE] at 6:53 A.M., CNA K said the resident does not use his/her
siderails for positioning while in bed. He/she said the resident is unable to assist the
staff to turn himself/herself in bed.
13. During an interview on [DATE] at 7:04 A.M., the MDS Coordinator said he/she is
responsible for completing the side rails assessments quarterly. Furthermore, he/she said
there is nothing in the assessment that specifically mentions entrapment.
During an interview on [DATE] at 7:17 A.M., The DON (Director of Nursing) said, We just
talked about those entrapment things yesterday, they aren’t being done by anyone as of
now, we were talking about starting them but we just haven’t yet.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to perform Gradual Dose
Reductions (GDRs) on [MEDICAL CONDITION] medications required for three residents
(Resident’s #13, #24, and #27) and failed to ensure that as needed (PRN) [MEDICAL
CONDITION] medication orders were limited to 14 days unless specific duration and clinical
rationale were provided for two residents (Residents #13 and #27). Staff also failed to
obtain an appropriate [DIAGNOSES REDACTED].# 36). The facility census was 44.
1. Review of the facility’s [MEDICAL CONDITION] Drugs Policy, undated, shows staff are
directed as follows:
-The resident will be assessed on admission and quarterly to evaluate the presence or
absence of [DIAGNOSES REDACTED].
2. Review of Resident #13’s Admission Minimum Data Set (MDS), a federally mandated
assessment, dated 3/13/18, showed staff assessed the resident as follows:
-Did not have any behaviors;
-Did not refuse care;
-Minimal depression.
Review of the resident’s care plan, dated 3/14/18, showed staff did not plan direction for
staff related to the resident’s antianxiety medication use.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s Medication Administration Record [REDACTED].
Review of the resident’s record showed staff did not document they attempted a gradual
dose reduction, did not obtain a 14 day stop date, or a rationale for continued use beyond
14 days.
3. Review of Resident #24’s Quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 7/7/18, showed the staff assessed the
resident as follows:
-Severe Cognitive Impairment;
-No behaviors;
-[DIAGNOSES REDACTED].
-Received an antipsychotic 1 out of 7 days in the look back period and an antidepressant 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
out of 7 days in the look back period (7 day period of time before the assessment is
completed to capture the status of a resident).
Review of the resident’s Physician order [REDACTED].
Review of the resident’s medical record showed staff did not document they attempted a GDR
of the resident’s [MEDICAL CONDITION] medication. Staff did not document any interventions
regarding behaviors or rationale to continue the medication without a GDR.
4. Review of Resident #27’s Quarterly MDS dated [DATE], showed staff assessed the resident
as follows:
-Did not have any behaviors;
-Did not refuse care;
-Minimal depression.
Review of the resident’s care plan, dated 12/28/17, showed it directed staff:
-Administer medication as ordered;
-Monitor for adverse reactions and side effects;
-[DIAGNOSES REDACTED].
-Did not display any behavior episodes.
Review of the resident’s POS, dated 8/17-9/16/18 showed staff obtained a physician’s
orders [REDACTED].
Review of the resident’s Medication Administration Record [REDACTED].
Review of the resident’s medical record showed staff did not document they attempted a
gradual dose reduction, obtain a 14 day stop date, or a rationale for continued use beyond
the 14 days.
5. Review of Resident #36’s Quarterly MDS, dated [DATE], showed facility staff assessed
the resident as follows:
-Cognitively Intact;
-No signs and symptoms of [MEDICAL CONDITION] (an acutely disturbed state of mind);
-Feeling down, depressed or hopeless;
-Trouble falling asleep, or sleeping too much;
-Feeling tired or having little energy;
-Feeling bad about oneself;
-No hallucinations;
-No behaviors;
-Independent with with Activities of Daily of Living (ADLs);
-Received an antipsychotic medication seven days out of the seven day look back period;
-Gradual dose reduction was attempted and declined by the physician on 2/13/18 due to
being contraindicated;
-And [DIAGNOSES REDACTED].
Review of the resident’s Physician order [REDACTED].
Further review of the medical record showed staff did not document an appropriate
[DIAGNOSES REDACTED].
6. During an interview on 8/23/18 at 7:01 A.M., the MDS Coordinator said it is the
responsibility of the Director of Nursing (DON) to ensure that Gradual Dose Reductions
(GDRs) are completed. Furthermore, he/she said the DON is also responsible for ensuring
the residents have the appropriate [DIAGNOSES REDACTED]. He/she said that they rely on the
pharmacy consultant to tell them when a GDR is recommended, and he/she would not know why
they would not be completed.
During an interview on 8/23/18 at 7:17 A.M., the DON (Director of Nursing) said the
pharmacist comes in once a month and is responsible for the recommended gradual dosage
reductions. He/She said other than that no staff is responsible for tracking them.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, facility staff failed to wash their
hands as often as necessary using approved techniques to prevent cross-contamination. The
facility census was 44.
1. Review of the (YEAR) Food and Drug Administration Food Code, Chapter 2, Section 301.12
(Cleaning Procedure) showed:
(A) Except as specified in paragraph (D) of this section, FOOD EMPLOYEES shall clean their
hands and exposed portions of their arms, including surrogate prosthetic devices for hands
or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is
equipped as specified under § 5-202.12 and Subpart 6-301.
(B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean
their hands and exposed portions of their arms, including surrogate prosthetic devices for
hands and arms:
(1) Rinse under clean, running warm water;
(2) Apply an amount of cleaning compound recommended by the cleaning compound
manufacturer;
(3) Rub together vigorously for at least 10 to 15 seconds while:
(a) Paying particular attention to removing soil from underneath the fingernails during
the cleaning procedure, and
(b) Creating friction on the surfaces of the hands and arms or surrogate prosthetic
devices for hands and arms, finger tips, and areas between the fingers;
(4) Thoroughly rinse under clean, running warm water; and
(5) Immediately follow the cleaning procedure with thorough drying using a method as
specified under § 6-301.12.
(C) To avoid recontaminating their hands or surrogate prosthetic devices, FOOD EMPLOYEES
may use disposable paper towels or similar clean barriers when touching surfaces such as
manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door.
(D) If APPROVED and capable of removing the types of soils encountered in the FOOD
operations involved, an automatic handwashing facility may be used by FOOD EMPLOYEES to
clean their hands or surrogate prosthetic devices.
Review of the (YEAR) Food and Drug Administration Food Code, Chapter 2, Section 301.14
(When to Wash) showed:
FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified
under § 2-301.12 immediately before engaging in FOOD preparation including working with
exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE SERVICE and SINGLE-USE
ARTICLES and:
(A) After touching bare human body parts other than clean hands and clean, exposed
portions of arms;
(B) After using the toilet room;
(C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in
paragraph 2-403.11(B);
(D) Except as specified in paragraph 2-401.11(B), after coughing, sneezing, using a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 14)
handkerchief or disposable tissue, using tobacco, eating, or drinking;
(E) After handling soiled EQUIPMENT or UTENSILS;
(F) During FOOD preparation, as often as necessary to remove soil and contamination and to
prevent cross contamination when changing tasks;
(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD;
(H) Before donning gloves to initiate a task that involves working with FOOD; and
(I) After engaging in other activities that contaminate the hands.
2. Review of the facility’s Hand Washing policy, undated, showed the following:
-Hands should be thoroughly washed before and after providing care resident care;
-Proper hand-washing techniques must be followed at all times;
-Procedure:
1. Stand so clothing does not touch sink.
2. Wet hands well.
3. Apply soap and work up a lather. Using friction (rubbing), wash entire surface of hands
for at least 10 seconds. Wash well between fingers, under nails and around wrists.
4. Rinse with hands lowered to allow soiled water to drain directly into sink. So not
splash water onto clothing. Do not allow hands to touch sink. Do not touch faucet with wet
hands.
5. Dry hands well, especially between fingers.
6. Use disposable hand towel to turn off faucet.
3. Observation on 08/21/18 at 11:14 A.M., showed Cook L washed his/her hands at the
handwashing sink. Further observation showed the cook used his/her wet bare hands to turn
the faucet off and, without drying his/her hands, donned a pair of gloves.
4. Observation on 08/21/18 at 11:18 A.M., showed Cook L rinsed out a dirty pan at the
dirty side of the mechanical dishwashing station and placed it in the dishwasher. Further
observation showed the cook rinsed his/her hands under running water from the faucet at
the handwashing sink and then turned the faucet off with his/her bare wet hands.
5. Observation on 08/21/18 at 11:19 A.M., showed Dietary Aide (DA) M washed his/her hands
at the handwashing sink. Further observation showed the DA used his/her bare hand to lift
up the trash can lid to dispose of the paper towel he/she used to dry his/her hands and
then donned a pair of gloves.
6. Observation on 08/21/18 at 11:21 A.M., showed Cook L rinsed his/her hands under running
water from the faucet at the handwashing sink and then turned the faucet off with his/her
bare wet hands. Further observation showed, without drying his/her hands, the cook opened
the reach-in cooler and obtained food items.
7. Observation on 08/21/18 at 11:23 A.M., showed DA M washed his/her hands at the
handwashing sink. Further observation showed the DA used his/her bare hand to lift up the
trash can lid to dispose the paper towel he/she used to dry his/her hands and then put
away dishes from the clean side of the mechanical dishwashing station.
During an interview on 08/21/18 at 11:24 A.M., the DA said staff should wash their hands
after touching anything dirty and before handling food. The DA said he/she would consider
the trash can lid to be dirty and he/she should have washed his/her hands again.
8. Observation on 08/22/18 at 10:52 A.M. Observation showed DA N washed kitchenware at the
mechanical dishwashing station. Observation showed the DA briefly rubbed soap on his/her
hands, rinsed and turned the faucet off with his/her bare hands. Further observation
showed the DA handled sanitized kitchenware from the clean side of the dishwashing
station. Observation showed the DA repeated this process two additional times.
Additionally, at 10:54 A.M., observation showed the DA prepared glasses of tea for service
to residents.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 15)
9. Observation on 08/22/18 at 11:00 A.M., showed DA N washed his/her hands at the
handwashing sink. Observation showed the DA gently rubbed soap on his/her hands for three
seconds, rinsed his/her hands, turned the faucet off with a paper towel and then used the
same towel to dry his/her wet hands.
During an interview on 08/22/18 at 11:01 A.M., the DA said the purpose of using the paper
towel to turn off the faucet is so you do not recontaminate your hands. The DA said he/she
did not think about recontiminating his/her hands by using the same paper towel that
he/she used to turn off the faucet. The DA said you should scrub your hands for 30 seconds
to a minute before rinsing and he/she did not realize he/she did not do so.
10. During an interview on 08/22/18 at 11:23 A.M., the Dietary Manager (DM) said staff
should wash their hands between tasks, when they enter the kitchen, before they exit the
kitchen, and after touching trash can lids. The DM said the procedure for hand washing
would be to turn the water on, put soap on your hands, rub hands together with the soap
for 20 seconds, dry and then turn the faucet off with paper towel. The DM said it is not
acceptable to dry your hands with the same paper towel used to turn off the faucet. The DM
said he/she had not watched how staff wash their hands lately, but all staff are trained
on when and how to wash their hands upon hire and routinely during inservices.
11. During an interview on 08/22/18 at 11:30 A.M., the administrator said staff should
wash their hands all the time, including after touching anything dirty as well as before
and after glove use. The administrator said staff should rub soap on all parts of their
hands for at least 20 seconds before they rinse and should turn off the faucet with
separate paper towel. The administrator said all staff are trained on handwashing
procedures upon hire and he/she would expect the DM to routinely monitor how and when
dietary staff washed their hands and provide instruction as necessary.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to develop and implement
policies and procedures for the inspection, testing and maintenance of the facility water
systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak
of Legionnaire’s Disease (LD). Facility staff also failed to properly store and label
oxygen tubing when not in use for six residents (Residents #11, #14, #18, #19, #39, and
#91). The facility census was 44.
1. Review of the facility’s building maintenance, inspection and testing records, showed
the records did not contain documentation of a water management program to monitor the
facility’s water systems for the growth of waterborne pathogens and prevent LD.
During an interview on 08/22/18 at 10:00 A.M., the administrator said the facility did not
have a complete water management program. The administrator said he/she was still working
on it and could not provide any documentation of policies and procedures for the
inspection, testing and maintenance of the facility water systems. The administrator also
said he/she had not formed a water management committee or completed a risk assessment.
Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification
(S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed:
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at
risk. Those at risk include persons who are at least [AGE] years old, smokers, or those
with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 16)
Outbreaks have been linked to poorly maintained water systems in buildings with large or
complex water systems including hospitals and long-term care facilities. Transmission can
occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and
decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial
growth in building water systems that reduce the risk of growth and spread of Legionella
and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies
and procedures to reduce the risk of growth and spread of Legionella and other
opportunistic pathogens in building water systems. An industry standard calling for the
development and implementation of water management programs in large or complex building
water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by
American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In
(YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this
ASHRAE Standard(https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html).
Environmental, clinical, and epidemiological considerations for healthcare facilities are
described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management
implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic
waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,
nontuberculous mycobacteria, and fungi) could grow and spread in the facility water
system;
-Implement a water management program that considers the ASHRAE industry standard and the
CDC toolkit, and includes control measures such as physical controls, temperature
management, disinfectant level control, visual inspections, and environmental testing for
pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the
results of testing and corrective actions taken when control limits are not maintained.
2. Review of the facility’s Oxygen Equipment Change Schedules Policy, undated, showed
staff are directed as follows:
-Nursing will change out the tubing and all pertinent equipment on oxygen concentrators
that are being used continuous on a weekly basis;
-And nursing will change out the tubing and all pertinent equipment on oxygen
concentrators that are being used as needed (PRN) on an every two week basis.
3. Review of Resident #11’s Annual MDS Assessment, dated 8/06/18, shows the facility staff
assessed that the resident received oxygen therapy, and was dependent on staff for all
ADLs.
Review of the resident’s plan of care, dated 3/02/17, showed staff are directed to
administer oxygen as ordered by the physician.
Review of the resident’s Physician order [REDACTED].>Observation on 8/20/18 at 11:47
A.M., showed the resident in his/her room in his/her wheelchair. Further observation
showed the resident’s oxygen tubing lay on the floor next to his/her wheelchair.
Additional observation showed the oxygen tubing undated, and without a bag for storage.
Observation on 8/22/18 at 2:30 P.M., showed the resident in his/her room in his/her bed.
Further observation showed the resident’s oxygen tubing lay on the floor next to his/her
bed. Additional observation showed the oxygen tubing undated, and without a bag for
storage.
4. Review of Resident #14’s Quarterly MDS Assessment, dated 6/13/18, shows the facility
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 17)
staff assessed that the resident received oxygen therapy, and was independent for all
ADLs.
Observation on 8/20/18 at 11:47 A.M., showed the resident in his/her room in his/her
chair. Further observation showed the resident’s oxygen tubing undated, and without a bag
for storage.
5. Review of Resident #18’s Annual MDS Assessment, dated 12/20/17, showed the facility
staff assessed that the resident received oxygen therapy, and was dependent on staff for
all ADLs.
Review of the resident’s plan of care, dated 9/21/17, showed staff are directed to
administer oxygen as ordered by the physician.
Review of the resident’s Physician order [REDACTED].>Observation on 8/21/18 at 9:42
A.M., showed the resident in his/her room in his/her bed. Further observation showed the
resident’s oxygen tubing lay on the floor next to his/her bed. Additional observation
showed the oxygen tubing undated, and without a bag for storage.
6. Review of Resident #19’s Annual MDS Assessment, dated 6/20/18, shows the facility staff
assessed that the resident received oxygen therapy, and was dependent on staff for all
ADLs.
Review of the resident’s plan of care, dated 7/29/18, showed staff are directed to
administer oxygen as ordered by the physician.
Review of the resident’s Physician order [REDACTED].>Observation on 8/21/18 at 11:31
A.M., showed the resident in his/her room in his/her wheelchair. Further observation
showed the resident’s oxygen tubing lay on the floor next to his/her bed. Additional
observation showed the oxygen tubing undated, and without a bag for storage.
7. Review of Resident #39’s Quarterly MDS Assessment, dated 8/10/18, showed the facility
staff assessed that the resident received oxygen therapy, and was dependent on staff for
all ADLs.
Review of the resident’s plan of care, dated 11/09/17, showed staff are directed to
administer oxygen as ordered by the physician.
Review of the resident’s Physician order [REDACTED].>Observation on 8/20/18 at 11:55
A.M., showed the resident in his/her room in his/her bed. Further observation showed the
resident’s oxygen tubing lay on the floor next to his/her bed. Additional observation
showed the oxygen tubing undated, and without a bag for storage.
Observation on 8/22/18 at 2:15 P.M., showed the resident in his/her room in his/her bed.
Further observation showed the resident’s oxygen tubing lay on the floor next to his/her
bed. Additional observation showed the oxygen tubing to be undated, and without a bag for
storage.
8. Review of Resident #91’s entry MDS Assessment, dated 8/9/18, showed staff assessed the
resident was admitted to the facility on [DATE] from an acute care hospital.
Review of the resident’s medical record showed it did not contain a plan of care.
Review of the resident’s POSs dated 8/17/18 to 9/16/18 showed an order for
[REDACTED].>Observation on 8/21/18 at 10:30 A.M., showed the resident lay in his/her
bed with oxygen on. Further observation showed the humidifier canister and oxygen tubing
not dated, or initialed.
9. During an interview on 8/23/18 at 7:05 A.M., LPN H said that anyone can change and date
the oxygen tubing. He/she said it is generally the night nurse that does it. He/she said
he/she did not know if there was a schedule and not sure when at night the night staff
does it.
During an interview on 8/23/18 at 7:17 A.M., the Director of Nursing (DON) said he/she
expected the night nurse to change the oxygen tubing once per week and it should have a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 18)
piece of tape attached with the date is was changed. He/She said it should be kept off the
floor and in a bag when not in use.

F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and
all bed rails and mattresses must attach safely to the bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to complete
regular inspections of all bed frames, mattresses, and bed rails as part of a regular
maintenance program to identify areas of possible entrapment for nine residents (Resident
#4, #13, #18, #19, #23, #24, #26, #39, and #91). The facility census was 44.
1. Review of Federal Drug Administration (FDA) documents entitled, Hospital Bed System
Dimensional and Assessment Guidance to Reduce Entrapment dated (MONTH) 10, 2006 showed 413
people died as a result of entrapment events in the United States. Further review revealed
those among the most vulnerable for these entrapment type events are elderly patients and
residents especially those who are frail, confused, restless, or who have uncontrolled
body movement.
2. Review of the FDA documents entitled, Practice Hospital Bed Safety, dated (MONTH) 2013
identifies seven different potential, zones of entrapment. This guidance characterizes the
head, neck, and chest as key body parts that are at risk of entrapment.
3. Review of the FDA documents entitle, Guide to Bed Safety Rails in Hospitals, Nursing
Homes and Home Health Care: The Facts. Shows the potential risk of bed rails may include:
-Strangling, suffocating, bodily injury or death when patients or part of their body are
caught between rails or between the bed rails and mattress;
-More serious injuries from falls when patient climb over rails;
-Skin bruising, cuts and scrapes;
-Inducing agitated behavior when bed rails are used as a restraint;
-Feeling isolated or unnecessarily restricted;
-And preventing patients, who are able to get out of bed, from performing routine
activities such as going to the bathroom, or retrieving something from a closet.
4. Review of resident #4’s Quarterly MDS, dated [DATE], shows facility staff assessed the
resident as follows:
-Moderate cognitively impaired;
-Required limited to extensive assistance for bed mobility, transfers, toileting and
dressing.
Review of resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], showed no documentation of side rails
for the resident.
Review of the resident’s medical record showed staff did not complete an entrapment
assessment to assess the resident for risk of entrapment in the siderails. Further review
showed staff did not complete a maintenance inspection to ensure side rails were properly
secured to the resident’s bed.
Observation on [DATE] at 1:40 P.M., showed the resident lay in his/her bed. Further
observation showed the resident with half side rails up on both sides of bed.
5. Review of Resident #13’s Admission MDS, dated [DATE], showed staff assessed the
resident as follows:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-Cognitively impaired;
-Dependent with transfers;
-Extensive assist of two staff for bed mobility, and toileting.
Review of resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], showed no documentation of side rails
for the resident.
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails. Further review showed staff did not
complete a maintenance inspection to ensure side rails were properly secured to the
resident’s bed.
Observation on [DATE] at 9:11 A.M., showed the resident lay in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
Observation on [DATE] at 2:12 P.M., showed the resident lay in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
6. Review of Resident 18’s Annual MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively intact;
-Dependent with bed mobility, toileting, and transfers.
Review of resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], showed documentation of quarter side
rails for the resident.
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails. Further review showed staff did not
complete a maintenance inspection to ensure side rails were properly secured to the
resident’s bed.
Observation on [DATE] at 9:42 A.M., showed the resident lay in his/her bed. Further
observation showed the resident with grab bars up on both sides of the bed.
Observation on [DATE] at 2:11 P.M., showed the resident lay in his/her bed. Further
observation showed the resident with grab bars up on both sides of the bed.
7. Review of #19’s Annual Minimum Data Set (MDS), a federally mandated assessment tool
completed by facility staff, dated [DATE], showed the staff assessed the resident as
follows:
-Moderate Cognitive Impairment;
-Requires extensive assistance of two staff members for bed mobility, and dressing;
-And requires total dependence on two staff members for transfers, and toileting.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], shows that the resident is to have
two padded half side rails for positioning.
Review of the resident’s medical record did not show that staff completed an entrapment
assessment to assess the resident for risk of entrapment in the siderails. Further review
showed staff did not complete a maintenance inspection to ensure side rails were properly
secured to the resident’s bed.
Observation on [DATE] at 11:29 A.M., showed the resident is in his/her bed. Further
observation showed the resident to have bilateral side rails up.
During an interview on [DATE] at 6:53 A.M., Certified Nursing Assistant (CNA) K said that
the resident will sometimes grab his/her siderail while he/she is being turned in bed, but
that he/she can not turn only using the siderail.
8. Review of Resident #23’s Quarterly MDS, dated [DATE], shows facility staff assessed the
resident as follows:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Cognitively impaired;
-Total dependent with two staff member assist for bed mobility, transfers, toileting and
eating.
Review of resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], showed side rail reduction attempt on
[DATE], resident fell out of bed [DATE]. No other interventions or documentation of side
rails for the resident in plan of care.
Review of the resident’s medical record did not show that staff completed an entrapment
assessment to assess the resident for risk of entrapment in the siderails. Further review
showed staff did not complete a maintenance inspection to ensure side rails were properly
secured to the resident’s bed.
Observation on [DATE] at 1:30 P.M., showed the resident lay in his/her bed. Further
observation showed the resident with half side rails up on both sides of bed.
9. Review of Resident #24’s Quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated [DATE], showed the staff assessed the
resident as follows:
-Severe Cognitive Impairment;
-Requires limited assistance of one staff member for bed mobility, transfers, dressing,
toileting, and dressing;
-no bed rail, bed alarm used daily.
Review of the resident’s Physician order [REDACTED].>Review of the residents’ plan of
care, dated [DATE], showed staff did not document the resident required the use of
bilateral upper side rails for positioning.
Review of the resident’s medical record showed staff did not complete an entrapment
assessment to assess the resident for risk of entrapment in the side rails.
Observation on [DATE] at 10:11 A.M., showed bilateral side rails on both sides of the bed.
Further observation on [DATE] at 7:00 A.M., showed resident in bed with both bilateral
side rails up.
10. Review of Resident #26’s Quarterly MDS, dated [DATE], showed facility staff assessed
the resident as follows:
-Cognitively Intact;
-Required no assistance of from staff for transfers, toileting or bed mobility, and set up
only for dressing, and eating.
Review of resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], showed staff did not document
regarding side rails for the resident.
Review of the resident’s medical record showed staff did not complete an entrapment
assessment to assess the resident for risk of entrapment in the siderails. Further review
showed staff did not complete a maintenance inspection to ensure side rails were properly
secured to the resident’s bed.
Observation on [DATE] at 11:45 P.M., showed the resident’s bed with a quarter-side rail.
11. Review of Resident #39’s Quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively impaired;
-Dependent with transfers and toileting;
-Extensive assistance of two staff for bed mobility, and dressing.
Review of resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated [DATE], showed staff did not document
regarding side rails for the resident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A206

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SALEM CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1203 N JACKSON, PO BOX 29
SALEM, MO 65560

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
Review of the resident’s medical record showed staff did not document a required
entrapment assessment for the use of side rails. Further review showed staff did not
complete a maintenance inspection to ensure side rails were properly secured to the
resident’s bed.
Observation on [DATE] at 11:55 A.M., showed the resident lay in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
Observation on [DATE] at 9:09 A.M., showed the resident lay in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
Observation on [DATE] at 2:15 P.M., showed the resident lay in his/her bed. Further
observation showed the resident with half side rails up on both sides of the bed.
12. Review of Resident #91’s Entry MDS, dated [DATE], showed the facility staff assessed
that the resident was admitted to the facility on [DATE] from an acute care hospital.
Review of the resident’s POSs, dated [DATE]-[DATE] showed no order for siderails.
Review of the resident’s medical record showed staff did not complete a plan of care.
Review of the resident’s medical record showed staff did not complete an entrapment
assessment to assess the resident for risk of entrapment in the siderails. Further review
showed staff did not complete a maintenance inspection to ensure side rails were properly
secured to the resident’s bed.
Observation on [DATE] at 10:33 A.M. showed the resident in his/her bed. Further
observation showed the resident to have bilateral upper siderails up.
During an interview on [DATE] at 6:53 A.M., CNA K said that the resident does not use
his/her siderails for positioning while in bed. He/she said that the resident is unable to
assist the staff with turning in bed.
13. During an interview on [DATE] at 3:17 P.M., the Maintenance Director said he/she does
not do entrapment assessments or any type of measurements on the bedrails.
During an interview on [DATE] at 7:04 A.M., the MDS Coordinator said the Maintenance
Supervisor is responsible for completing the entrapment assessments when the side rails
are first put on, and then yearly. He/she said that the maintenance supervisor measures
the bed to ensure they are appropriate.