SALEM CARE CENTER

**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.

**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;

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.

**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

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.

**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.

**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

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

**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.

**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: