Salem West Healthcare Center

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to honor a resident's documented code status. This affected one (Resident #73) of two residents reviewed for advance directives.Findings include:Review of Resident #73 ' s medical record revealed diagnoses including late onset Alzheimer ' s disease, history of sudden cardiac arrest, hypertension, gastrostomy status, and cognitive communication deficit. Resident #73 had a signed Do Not Resuscitate Comfort Care - Arrest (DNR CC-A) order signed [DATE REDACTED]. The form indicated a resident with a DNRCC-A would be treated as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care protocol would be implemented. The form instructed if a resident had a DNR providers would not perform cardiopulmonary resuscitation (CPR).A nursing note dated [DATE REDACTED] at 2:38 P.M. indicated the nurse found Resident #73 to be cyanotic with a respiratory rate of three breaths per minute. Staff went to retrieve oxygen supplies while Licensed Practical Nurse (LPN) #115 grabbed the crash cart and another nurse called 911. CPR was initiated and one round of chest compressions and respirations were provided before Resident #73 ' s pulse stopped and all breaths ceased as confirmed by two nurses. Emergency medical technicians (EMT) arrived and confirmed. The hospice nurse also arrived and was updated on Resident #73 ' s death.During an interview on [DATE REDACTED] at 10:49 A.M., the Director of Nursing (DON) confirmed staff had initiated CPR on Resident #73 on [DATE REDACTED] as they were confused about the DNRCC-A order. The DON stated she educated nurses regarding a resident with a DNRCC-A should not have had CPR initiated.

During an interview on [DATE REDACTED] at 2:10 P.M., LPN #115 stated she nor Registered Nurse (RN) #150 understood what the A at the end of the DNRCC-A meant. CPR was initiated with one set of chest compressions and one set of breaths delivered before they stopped and verified they could not detect a pulse or respirations. It was during this assessment that EMTs arrived and scanned Resident #73 ' s hospital bracelet and determined he had a DNR order and confirmed Resident #73 was absent of breaths and heart beat. CPR was discontinued.This deficiency represents noncompliance investigated under Complaint Number 1374412 (OH00167460)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem West Healthcare Center

2511 Bentley Drive Salem, OH 44460

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, review of the medical record, and interview with staff, the facility failed to ensure a wound treatment order was obtained and transcribed in the medical record for Resident #35. This affected one resident (Resident #35) of three residents reviewed for wounds. Findings Include:Review of the medical

record revealed Resident #35 was admitted to the facility on [DATE REDACTED]. Diagnoses included diabetes, dementia, bacteremia, chronic obstructive pulmonary disease, hypertension, anxiety disorder, depression, Alzheimer's disease, intermittent explosive disorder, dysphagia, and absence of part of the right foot.Review of the nurses note dated 10/16/25 at 6:45 P.M. revealed Resident #35 arrived with two emergency medical technicians (EMT) via an ambulance from the hospital. Resident #35 received a head to toe assessment upon admission and it was observed he had lost his right great toe.Review of the admission assessment dated [DATE REDACTED] revealed Resident #35 had moderately impaired cognition and no open areas.Review of the nurses note dated 10/26/25 at 6:21 P.M. revealed Resident #35 was screaming in his room and saying he wanted to kill himself and he was unable to calm down and he was throwing items at staff. The resident was sent to the local hospital. Review of the nurse's note dated 10/31/25 at 5:30 P.M. revealed Resident #35 was readmitted from the hospital with a one by one (no standard unit listed) scab, dark in color with no drainage noted. The top of the right foot had a dry dressing. Review of the November 2025 physician's orders revealed Resident #35 did not have an order for a treatment to his right foot.

Review of the November 2025 Treatment Administration Record revealed no documentation of a treatment being completed to the right foot of Resident #35.An observation on 11/03/25 at 1:00 P.M. revealed Resident #35 was sitting at the nurses station with a border foam dressing on the top of the right foot dated 11/01. Licensed Practical Nurse #101 stated she did not know why it was there. She checked the orders and verified there was no order for him to have a dressing to the top of his right foot. An interview on 11/04/25 at 10:35 A.M. with Regional Director of Clinical Operations (RDCO) #100 revealed the dressing to

the right foot was placed for a pad and protect. She stated they notified the nurse practitioner on 11/01/25; However, the nurse did not put the order in the computer, but it was just a pad and protect, she stated the resident did not have any open areas or scabbed areas to the right foot. She stated they would have caught

it when they completed his weekly skin check. Observation on 11/04/25 at 11:00 A.M. of Resident #35's right foot, with the Director of Nursing (DON) and RDCO #100, revealed the resident had a border foam dressing to the area of his right foot where his great toe used to be. The DON pulled the dressing back halfway to just expose his healed surgical incision. When the dressing was completely removed it exposed

a dime sized scabbed area to the top of his foot, close to the second toes, and three pea sized scabs to the top of the second toe. The DON stated they did not have a treatment to the scabs because they were closed wounds.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem West Healthcare Center

2511 Bentley Drive Salem, OH 44460

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 0697

1374412 (OH00167460).

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem West Healthcare Center

2511 Bentley Drive Salem, OH 44460

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)

Federal health inspectors cited SALEM WEST HEALTHCARE CENTER in SALEM, OH for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-08-25.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of SALEM WEST HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-04.