Salem West Healthcare Center: Medication Errors - OH
The inspection, conducted April 28, 2026, was triggered by a complaint. Inspectors observed medication administration for five residents and found three errors across 26 opportunities, an 11.1 percent error rate affecting two people.
The first problem surfaced at 8:42 in the morning, when Licensed Practical Nurse #110 began preparing medications for a resident identified in the report as Resident #36. The nurse discovered that nifedipine, a calcium channel blocker used to treat high blood pressure and chest pain, wasn't in the medication cart. She checked the Pyxis dispensing machine. Not there either. She told inspectors she would need to contact the pharmacy and let them know the medication wasn't available. Resident #36 received everything else on the list. The nifedipine, which a physician had ordered every day since February 2025, was not administered.
The nurse documented the gap and said she would call the pharmacy for a refill. What the report doesn't contain is any explanation for how a daily cardiac medication ran out entirely, with no backup supply and no system that caught the shortage before a dose was missed.
The second set of problems appeared less than an hour later, at 9:32 a.m., when Registered Nurse #130 administered medications to Resident #5. Among what he gave: one tablet of furosemide, 40 milligrams, and one tablet of magnesium oxide, 400 milligrams.
Furosemide is a diuretic. It had been ordered for Resident #5 at some point, then discontinued on December 19, 2024, more than 16 months before the inspection. There was no current order for it. The resident received it anyway.
The magnesium was wrong in a different way. Resident #5 had an active order, but not for magnesium oxide. The order called for two tablets of SlowMag, a delayed-release formulation containing magnesium chloride and calcium carbonate, given twice daily. Magnesium oxide and SlowMag are not the same medication.
At 10:08 that morning, RN #130 told inspectors how his process worked. He did not individually check the medications listed on the packets, each of which contained multiple drugs. Instead, he scanned the barcodes on the packets and then looked for any medications flagged as missing. He said he gave magnesium oxide because SlowMag wasn't available, and he confirmed to inspectors that he understood the two were not equivalent.
He gave it anyway.
A corporate registered nurse, identified as RN #100, was interviewed at 12:25 p.m. She said that when medication packets were scanned, a warning was supposed to appear on the screen if a resident had a discontinued medication in the packet. She told inspectors she would have to call the pharmacy and inform them that no such warning had appeared when RN #130 scanned Resident #5's packet before administering the discontinued furosemide.
The facility's own medication administration policy, undated in the inspection record, calls for reading the medication label three times before administering anything and comparing that label against the Medication Administration Record each time. It lists ensuring the right medication and right dose as core requirements.
RN #130's account of his own practice described something different from that, in his own words, to inspectors.
The inspection report classifies the harm level as minimal or potential for actual harm. What it doesn't resolve is what furosemide did to Resident #5 that morning, or how many prior mornings Resident #36 went without a cardiac medication that was supposed to arrive every day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salem West Healthcare Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
SALEM WEST HEALTHCARE CENTER in SALEM, OH was cited for violations during a health inspection on April 30, 2026.
The inspection, conducted April 28, 2026, was triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.