Salem Health & Rehabilitation

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, Resident interview, staff interview and facility document review the facility staff failed to ensure call bell was accessible for 1 of 7residents, Resident #5.The findings included:For Resident #5

the facility staff failed to ensure the resident's call bell was within reach.Resident #5's face sheet listed diagnoses which included but not limited to idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness.Resident #5's most recent minimum data set with an assessment reference date of 06/18/25 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Surveyor observed Resident #5 on 08/26/25 at 2:30 pm. Resident was resting in bed with eyes closed. Call bell was observed lying on the floor next to bed. Surveyor observed resident on 08/27/25 at 9:45 am. Resident was sitting up

in bed, call bell was observed in floor beside bed. Surveyor observed resident on 08/27/25 at 1:20 pm.

Resident was seated in wheelchair at bedside. Call bell was lying on opposite side of bed out of reach of resident. Surveyor asked resident if they could reach the call bed, and resident stated, I guess I could get to

it if I really had to. Surveyor observed resident on 08/28/25 at 8:35 am. Resident was sitting up in bed, call bell in floor beside bed. Surveyor spoke with the director of nursing (DON) on 08/28/25 at 1:00 pm regarding call bell placement. DON stated that call bells should be placed within reach of the resident whether they are in bed or sitting in chair. Surveyor requested and was provided with a copy from Mosby's Textbook for Long-Term Care Assistants which read in part, Always keep the call light within the person's reach--in the room, bathroom, and shower or tub room.The concern of not maintaining the resident's call bell within reach was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services on 08/28/25 at 4:00 pm.No further information was provided prior to exit.

Residents Affected - Few

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem Health & Rehabilitation

1945 Roanoke Blvd Salem, VA 24153

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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice

before a change is made.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of a room change prior to the change for 1 of 10 sampled residents (Resident #3). The findings included: For Resident #3, the facility staff failed to provide the resident with written notification of a room change including reason for the change prior to moving the resident to another room

in the facility. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Malignant Neoplasm of the Frontal Lobe and Spondylosis with Radiculopathy of Cervical Region.The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/10/25 assigned the resident a brief

interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. According to Resident #3's clinical record, he changed rooms within the facility on 1/23/25. The resident's clinical record included a Room Change Notification form dated 1/23/25 completed by a facility social worker, Other Staff Member (OSM) #4. The form indicated Resident #3's Power of Attorney (POA) was notified of the room change on 1/23/25 at 11:00 AM and gave consent for the change. The form documented the reason for the change as Medical Management. On 8/27/25 at 2:50 PM, surveyor spoke with OSM #4 who stated she notified Resident #3 and the family verbally of the room change. OSM #4 further stated that now they provide written notification of room changes and have been doing so for several months but Resident #3 was not provided with written notification. Surveyor spoke with OSM #4 again on 8/28/25 at 1:16 PM regarding the Room Change Notification form dated 1/23/25. Question number 10 on

the form read Resident and/or RP [responsible party] were provided with a copy of notification and yes was checked. OSM #4 stated she marked yes in error on the form. Surveyor requested and received the facility policy titled Bed Management/Room Changes dated 9/30/22 which read in part .4. Provide timely and efficient room changes through internal transfers with proper documentation using the Room Change Assessment Notification form.On 8/28/25 at 4:00 PM, the survey team met with the Administrator, Administrator in Training, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff failing to provide written notification of a room change for Resident #3.No further information regarding this concern was presented to the survey team prior to the exit conference on 8/28/25.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem Health & Rehabilitation

1945 Roanoke Blvd Salem, VA 24153

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

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

observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide activities of daily living (ADL) care to 1 of 10 dependent residents, Resident #5.The findings included:For Resident #5 the facility staff failed to provide nail care. Resident #5's face sheet listed diagnoses which included but not limited to idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness.Resident #5's most recent minimum data set with an assessment reference date of 06/18/25 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #5's comprehensive care plan was reviewed and contained a plan for the resident requires assistance with ADL's (activities of daily living).Surveyor spoke with Resident #5 on 08/27/25 at 9:45 am. Resident was sitting up in bed, alert and oriented. Surveyor observed resident's nail to be long, jagged and with brownish debris underneath. Surveyor asked resident if nails being long bothered him, and resident stated that it does. Surveyor asked resident if staff trimmed their nails, and resident stated, I chew them. Surveyor spoke with resident on 08/27/25 at 1:20 pm regarding fingernails, and resident stated, I have asked to have them cut, but nobody ever does it. Surveyor spoke with Resident #5 on 08/28/25 at 8:35 am regarding fingernails.

Resident stated they would like to have their fingernails cut. Surveyor told resident they would let staff know, and resident stated they would appreciate it.Surveyor spoke with director of nursing (DON) on 08/27/25 at 11:15 am. Surveyor asked DON who is responsible for providing nail care to resident, and DON stated usually certified nurse's aides (CNA), but nurse's do it as well.Surveyor spoke with CNA #6 on 08/27/25 at 1:15 pm regarding nail care. CNA #6 stated they provide nail care every day and trim residents' nails as needed. Surveyor asked CNA #6 if they worked with Resident #5, and CNA #6 stated they do not. Surveyor spoke with CNA #5 on 08/28/25 at 9:00 am regarding resident's nail care. CNA #5 stated they do nail care at least once a week including trimming, cleaning, and filing. Surveyor asked CNA #5 if they worked with Resident #5, and CNA #5 stated they have but not this week. Surveyor requested and was provided with a facility policy entitled Nursing Care and Services which read in part, Nursing staff will provide nursing care and services following current standards of practice recognized by state boards of nursing as informed by national nursing organizations and by hiring individuals who graduate from an approved nursing school and/or nurse aide curriculum and have or will have successfully passed a licensing and/or certification examination. 1. The center will utilize Mosby's Textbook for Long-Term Care Assistants by Kostelnick and/or Clinical Nursing Skills & Techniques by [NAME], [NAME], and Ostendorff, as a reference for nursing services and skill not otherwise provided in the Policies and Procedures Manuals.The concern of not providing nail care for Resident #5 was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing and regional director of clinical services on 08/28/25 at 4:00 pm.No further information was provided prior to exit.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem Health & Rehabilitation

1945 Roanoke Blvd Salem, VA 24153

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 10 sampled residents. Resident #6.The findings included:For Resident #6, the facility staff failed to check blood glucose levels and failed to administer the medication Novolog as ordered by a medical provider.

Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, Muscle Weakness, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Cerebral Infarction, Anxiety Disorder, Depression, Cognitive Communication Deficit, and Chronic Pain. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/14/25, assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A medical provider orders with a start date of 4/25/25 read in part, .Novolog FlexPen Subcutaneous (situated or applied under the skin) Solution Pen-injector 100 UNIT/ML (units/milliliters).Inject 15 unit subcutaneously before meals and at bedtime for T2DM (Type 2 Diabetes Mellitus). A medical provider order with a start date of 4/25/25 read in part,.Novolog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML.Inject as per sliding scale: if 0-60=0 If asymptomatic give Med Plus as ordered. If symptomatic give Glucagon as ordered from stat box; 61-199=0; 200-249=4 Units; 250-299=6 Units; 300-349=8 Units; 350-399=10 Units; 400-499=12 Units; 450-499=14 Units; 500+ = 16 Units.subcutaneously before meals and at bedtime. A review of the August 2025 MAR (medication administration record) revealed Resident #6 did not have any blood glucose checks documented or any evidence of Novolog being administered, refused, or held on the following dates and times: 8/15/25-6AM, 4PM, and 9PM8/16/25-6AM8/20/25-6AM8/24/25-6AM8/25/25-6AM A review of the person-centered comprehensive care plan had a focus which read in part, .DIABETES MELLITUS: The resident is at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with: insulin use. An intervention related to the focus read in part, .administer medications as ordered.

Further review of the plan of care disclosed another focus which read in part, .HYPOGLYCEMIC: the resident is at risk for complications related to the use of hypoglycemic medications. Interventions related to

the focus read in part, .monitor of signs/symptoms of hypoglycemia.vitals as needed. On 8/27/25 at 12:57 PM, surveyor spoke with the director of nursing and reviewed the August 2025 MAR for Resident #6. The director of nursing stated she would look for evidence of why the medication was not administered. The director of nursing informed surveyor she could not find any evidence of the Novolog being held, given, or refused by the resident on the days that were blank on the August 2025 MAR. This concern was discussed at the pre-exit meeting on 8/28/25 at 4:00PM with the administrator, administrator-in-training, director of nursing, assistant director of nursing and regional director of clinical services. Surveyor requested and received a facility policy titled, Administration Procedures for All Medications which read in part, .III .1 .a.

Check the MAR .for the order .d. Check for vital signs or other tests to be done during or prior to medication administration . No further information regarding this concern was presented to the survey team prior to exit

on 8/28/25.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem Health & Rehabilitation

1945 Roanoke Blvd Salem, VA 24153

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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Manuals.Surveyor was provided with an excerpt from Clinical Nursing Skills & Techniques for applying a dressing, which read in part, 1. Perform hand hygiene and apply clean gloves. 2. Gently remove tape, bandages, or ties .5. Fold dressings with drainage contained inside and remove gloves inside out over dressing. Dispose of gloves and soiled dressing according to agency policy .8. Clean wound. a. Perform hand hygiene and apply clean gloves. Use gauze or cotton ball moistened in saline or antiseptic swab for each cleaning stroke or spray wound surface with wound cleaner. 9. Apply antiseptic ointment (if ordered) with sterile cotton-tipped applicator or gauze along wound edges. Dispose of gloves. Perform hand hygiene.

1. 10. Apply dressing.The concern of RN #2 failing to provide care and treatment to promote healing of a

pressure ulcer was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services on 08/28/25 at 4:00 pm.No further information was provided prior to exit.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem Health & Rehabilitation

1945 Roanoke Blvd Salem, VA 24153

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

AM or 6:00 AM8/20/25 at 6:00 AM8/24/25 at 6:00 AM8/25/25 at 12:00 AM or 6:00 AM On 8/27/25 at 12:57 PM, surveyor spoke with the director of nursing and reviewed the August 2025 MAR for Resident #6. The director of nursing stated she would check. The director of nursing provided surveyor with a copy of a Controlled Drug Administration Record that revealed Resident #6 received the scheduled doses of oxycodone on the dates/times in question. The director of nursing stated the nurses did record the medications were given on the NARC log (controlled drug administration record), but the nurses failed to document the administration on the MAR. This concern was discussed at the pre-exit meeting on 8/28/25 at 4:00PM with the administrator, administrator-in-training, director of nursing, assistant director of nursing and regional director of clinical services. Surveyor requested and received a facility policy titled, Administration Procedures for All Medications which read in part, .III .1 .a. Check the MAR .for the order .IV .7. document administration in the MAR . No further information regarding this concern was presented to the survey team prior to exit on 8/28/25.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem Health & Rehabilitation

1945 Roanoke Blvd Salem, VA 24153

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 - Few

administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services on 08/28/25 at 4:00 pm.

No further information was provided prior to exit.

1. 2. For Resident #10, the facility staff failed to maintain infection control measures during the use of a

multiuse bottle of Dakins Solution.

On 8/28/25 at 3:20 PM, surveyor observed Licensed Practical Nurse (LPN) #10 perform a dressing change to the left ischium for Resident #10. LPN #10 transported a multiuse bottle of Dakins Solution into the resident’s room in a clean plastic bag and then removed the Dakins Solution container and placed it directly on the resident’s overbed table. LPN #10 had not cleaned the overbed table prior to sitting

the container down. Following the dressing change, LPN #10 picked up the Dakins Solution and then sat

the bottle directly on Resident #10’s roommate’s fabric chair seat cushion while she washed her hands. LPN #10 then returned the bottle of Dakins Solution to the unit treatment cart and placed the container in the bottom cart drawer among other items without sanitizing the bottle.

On 8/28/25 at 3:45 PM, surveyor spoke with the facility Infection Preventionist (IP) and discussed the

observations regarding the bottle of Dakins Solution. IP stated the Dakins Solution should have been placed in a zip lock bag in the treatment cart and he would discard the Dakins Solution and get a new bottle for Resident #10 and place it in the treatment cart.

On 8/28/25 at 4:00 PM, the survey team met with the Administrator, Administrator in Training, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed the infection control concerns with LPN #10 actions regarding the multiuse bottle of Dakins Solution.

No further information regarding this concern was presented to the survey team prior to the exit conference

on 8/28/25.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Salem Health & Rehabilitation

1945 Roanoke Blvd Salem, VA 24153

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 0921 Level of Harm - Minimal harm or potential for actual harm

the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand.

On 8/27/25 at 12:05 PM, surveyor spoke with other staff #8 (OS#8) via phone conversation and she stated

she does not clean the resident rooms every day.

Residents Affected - Few

On 8/27/25 at 11:05 AM, surveyor observed the bathroom in room [ROOM NUMBER] and the toilet bowl in

the bathroom was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand.

On 8/27/25 at 3:10 PM, surveyor asked the administrator what time housekeeping left for the day and the administrator informed surveyor they were leaving now.

On 8/27/25 at 3:15 PM, surveyor observed the bathroom in room [ROOM NUMBER] and the toilet bowl in

the bathroom was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand.

On 8/28/25 at 8:24 AM, surveyor and the DON observed room [ROOM NUMBER]’s bathroom and

the toilet bowl in the bathroom was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand. The DON stated she would let them know.

This concern was discussed at the pre-exit meeting on 8/28/25 at 4:00 PM with the administrator, AIT (administrator-in-training), director of nursing, assistant director of nursing, and regional director of clinical services.

Surveyor requested and received a facility policy titled, “Daily Resident/Patient Room Cleaning”, which read in part, “…Required Items…Quaternary disinfectant (a chemical used in cleaning products to kill germs on non-porous surfaces)…Bowl brush, cleaning rags…spot clean all necessary areas…” No further information was provided to the survey team prior to exit on 8/28/25.

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

Event ID:

Facility ID:

If continuation sheet