Salem Hills Rehabilitation And Nursing Center

Based on observations, record review, and interviews conducted during the recertification survey from 04/21/ 2026 to 04/28/2026, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for one (1) of seven (7) residents (Resident #25) reviewed for activities of daily living. Specifically, Resident #25, required dependent assistance with activities of daily living was observed sitting in a wet soiled diaper.Findings include:The facility policy Activities of Daily Living, last reviewed on 11/ 07/ 2023, documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Resident # 25 had diagnoses including Parkinson's disease with dyskinesia, cerebral infarction and functional quadriplegia.The quarterly Minimum Data Set (an assessment tool) dated 04/08/2026 documented the resident had impaired cognition, was frequently incontinent of bowel and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and abbreviated survey (NY00323734) from 5/9/24 to 5/16/24, the facility did not ensure adequate supervision was provided and that the resident's environment remained as free of accidents hazards as possible for 3 of 7 residents (Residents #89, #72, and #3) reviewed for accidents. Specifically,1) Resident #89 did not receive 1:1 supervision as per plan of care, resulting in a fall, 2) Resident #72 had multiple oral medications and eye drops (left by nursing) in their room on a dementia unit with twelve residents with wandering behaviors, and 3) Resident #3 had medicated creams (left by nursing) in their room on a dementia unit with twelve residents with wandering behaviors. The findings are: The facility policy and procedure, titled Accident Prevention/Falls last revised 12/15/2023 documented it was the policy of the facility to provide adequate supervision, assistance, and assistive devices to prevent accidents. 1. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview conducted during the recertification survey from 5/9/2024 to 5/16/2024, the facility did not ensure each resident was treated with respect and dignity in an environment that promotes maintenance of their quality of life for 2 of 3 residents (Resident #33 and #105) reviewed for dignity. Specifically, 1, Resident #33 was observed on several occasions wearing socks with name labels that were visible on the outside of both socks, and 2, Resident #105 was noted with photographs depicting the resident in positioning devices on the wall above the head of the bed and visible from the door. The findings are: Policy and Procedure reviewed 4/18/2024 documented all residents have a right to a dignified existence including the right to privacy and confidentiality. 1. Resident #33 was admitted with diagnoses including Alzheimer Disease, Cancer and Depression. The 4/2/24 Quarterly Minimum Data Set documented Resident #33 was rarely/never understood, used a wheelchair, was dependent for upper and lower body dressing, putting on/taking off footwear,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey from 5/9/24 to 5/16/24, the facility did not ensure that the call bell system was accessible for 1 of 5 residents (Resident #123) reviewed for environment. Specifically, multiple observations revealed that the call bell designated for Resident #123, was not within the resident's reach. The findings are: Resident #123 was admitted with diagnosis including but not limited to major depressive disorder, overactive bladder, and poly-osteoarthritis. The Risk for Falls care plan dated 4/5/24 documented interventions including answering calls for assistance promptly and call bell to be within reach. The admission Minimum Data Set ( resident assessment tool) dated 4/11/24 documented Resident #123 had intact cognition, required setup with eating, was dependent with toileting and transfers, and required extensive assist with bed mobility. Furthermore, the admission Minimum Data Set, dated [DATE] documented Resident #123 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the recertification survey from 5/09/24-5/16/2024, it was determined that for one (Resident #3) of seven residents reviewed for accidents, the facility did not ensure a comprehensive care plan that included measurable goals and interventions based on resident assessment was provided to maintain the resident's highest practicable physical well-being. Specifically, Resident #3 did not have a care plan in place for self-medication administration. The Findings Are: Resident #3 was admitted with diagnosis including but not limited to bilateral primary osteoarthritis of the knee, polymyalgia rheumatica, and primary osteoarthritis of the shoulder. The Comprehensive Minimum Data Set, dated [DATE] documented that Resident #3 had intact cognition, required moderate assist with toileting, transfers, and bed mobility, and was independent with eating. On 05/09/24 at 11:08 AM, Resident #3 was observed in their room and multiple tubes of medicated creams…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview conducted during the recertification survey from 5/9/24 to 5/16/24, the facility did not ensure 1 of 3 residents (Resident #57), reviewed for positioning, received treatment and care in accordance with professional standards of practice. Specifically, Resident #57 was observed on multiple occasions sitting in their wheelchair without their footrest extender. The findings are: The facility policy titled, Wheelchair and Positioning Devices, reviewed 8/15/2023 documented it was the policy of the rehabilitation department to determine and provide the appropriate wheelchair and positioning devices for residents. Resident #57 had diagnoses which included depression, dementia, and spinal stenosis, The Activities of Daily Living Functioning Care Plan dated 1/24/23 documented the resident required 1-person extensive assistance with locomotion in wheelchair and 2-person dependent assistance with transfers. The Quarterly Minimum Data Set (resident assessment tool) dated 2/25/24 documented Resident #57 had severely impaired, impairment on both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview conducted during the recertification survey from 5/9/2024 to 5/16/2024, the facility did not ensure that residents received treatment and services to prevent pressure ulcers for 2 of 8 residents (Residents #105 and #33 ) reviewed for pressure ulcers. Specifically, 1)Resident #105 was observed without a thigh cushion to off load their heels as ordered by the physician, and 2) Resident #33 who was assessed at high risk for pressure ulcers was observed on multiple occasions with their right heel resting on the metal wheelchair foot rest. The findings are: 1. Resident #105 was admitted with diagnoses which included dementia, depression, and glaucoma. The physician order dated 3/5/2024, documented during supine (lying on back) in bed put heels up cushion under thighs, and black skill care abductor-contracture cushion between lower legs and feet, except for during skin care and hygiene. The Braden Scale completed on 3/25/2024 documented the resident was a moderate risk for pressure ulcers. The Annual Minimum Data Set (an assessment tool)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview during the recertification survey from 5/9/24 to 5/16/24, the facility did not ensure that needed services, care and equipment were provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for 1 of 3 residents (Resident #89) reviewed for position and mobility. Specifically, Resident #89 was observed on 3 occasions without a right resting hand splint in place as ordered by the physician to prevent further contractures. Findings include: The facility policy & procedure titled Splinting reviewed 2/12/24 documented the purpose, indications, treatment procedure, and wearing schedules of splints. Resident #89 had diagnoses which included primary osteoarthritis, non-Alzheimer's dementia, and frontotemporal neurocognitive disorder. The medical note dated 1/11/24 documented Resident #89 was seen for slight swelling to right hand/fingers. Decreased range of motion to the right hand, wrist, and fingers. Minimal swelling noted, no tenderness.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review during the recertification survey from 5/9/24 to 5/16/24, the facility did not properly establish and/or maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, 1) the facility did not ensure that an infection surveillance plan based on facility assessment was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks, 2) the facility water management plan had not been reviewed or updated since 2019, and 3) staff did not perform proper hand hygiene during dining for Resident #21. The findings are: The facility policy and procedure titled Infection Control Program dated 1/12/2010 and last reviewed 4/2/2024, documented a surveillance program was essential to the prevention and control of infection within the facility. Its purpose was to detect and record nosocomial infections in order to institute effective control measures. Data was recorded on resident surveillance reports and infection line listing reports. 1. The infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey and an abbreviated survey (complaint #NY00218018) the facility did not ensure that a care plan was developed with person-centered goals and interventions to address the use of medications for 2 of 6 residents (Residents #88 and #29) reviewed for unnecessary medications and did not ensure that the plan of care was implemented for 1 of 2 residents ((Resident #374) reviewed for injuries of unknown origin. Specifically, 1) Resident #88 did not have a plan of care to address the use of a pancreatic enzyme replacement medication (Creon); 2) the plan of care for Resident #29 did not address the use of a thyroid medication; and 3) the activities of daily living plan of care for Resident #374 was not implemented as written to prevent accidents/injuries. The findings are: 1. Resident #88 was admitted to the facility on [DATE] with diagnoses including; Gastroesophageal Reflux Disease (GERD) Exocrine Pancreatic Insufficiency and Diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that the comprehensive care plan was revised for 1 of 5 residents (#63) reviewed for positioning and mobility. Specifically, the care plan was not updated to address the use of a left leg skil care relief boot. The findings are: The 9/24/18 Annual MDS (Minimum data Set-an assessment tool) indicated Resident #63 was cognitively impaired and required total assist of 2 staff for bed mobility and transfers. It further documented the resident had unilateral functional limitation of the upper extremity. The 4/5/19 Quarterly MDS indicated that Resident #63 was cognitively impaired, required extensive assist of 2 staff for bed mobility and total assist of 2 staff for transfers and had unilateral functional limitation of the upper and lower extremity. Physician's orders documented: 8/1/17 wears skil care relief boot (has a bar to help modify the rotation of the hip) for the left leg when out of bed (OOB) in HTR (recliner) chair. Review of the comprehensive care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review conducted during the recertification survey the facility did not ensure that residents received care and treatment in accordance with professional standards of practice in order to meet the resident's physical, mental, and psychological needs. Specifically, the facility did not ensure that positioning devices were applied per physician's orders. This was evident for 1 of 5 residents reviewed for positioning and mobility. (Resident #63). The findings are: Resident #63 was admitted to the facility with diagnoses of Alzheimer's Dementia, Hemiplegia, and Diabetes Mellitus. The 9/24/18 Annual MDS (minimum data set: an assessment tool) indicated that Resident #63 was cognitively impaired and required total assist of 2 for bed mobility and transfers and had unilateral functional limitation of the upper extremity. The 4/5/19 Quarterly MDS indicated Resident #63 was cognitively impaired and required extensive assist of 2 for bed mobility, total assist of 2 for transfers and had unilateral functional limitation of the upper and lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey, the facility did not ensure that the attending physician acted upon the pharmacy consultant's recommendations regarding each resident's medications. This was evident for 1 of 6 residents reviewed for Drug Regimen Review. (Resident #77). The findings are: Resident #77 was admitted to the facility on [DATE] with diagnoses of Deep Vein Thrombosis, Non Alzheimer's Dementia and Psychotic Disorder. The 10/11/18 admission MDS (Minimum Data Set- an assessment tool) indicated Resident #77 had cognitive impairment and received antipsychotic and anticoagulant therapies for the look back period of 7 days. The 4/8/19 Quarterly MDS indicated Resident #77 had cognitive impairment and received antipsychotic, antidepressant and anticoagulant therapies for the look back period of 7 days. Review of the physician's orders revealed: 11/15/18 Quetiapine 25mg- 0.5 tab (12.5 mg) oral route 2 times daily. The Pharmacy Medication Regimen Review dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.