Deficiency Records for Salem Village Nursing and Rehab
Updated as of January 01, 2020
This is not the most recent data for Salem Village Nursing and Rehab. For the most recent information, click here.
A list of the most recent deficiencies for Salem Village Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-17 | 2019-10-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-17 | 2019-10-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-30 | 2019-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-09-30 | 2019-10-11 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-19 | 2019-08-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-06-19 | 2019-07-29 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-06-19 | 2019-07-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-19 | 2019-07-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-14 | 2019-07-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-14 | 2019-07-05 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-06-14 | 2019-07-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-14 | 2019-07-05 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-06-14 | 2019-07-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-06-14 | 2019-07-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-14 | 2019-07-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-14 | 2019-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-14 | 2019-07-05 | N |
| Dispose of garbage and refuse properly. | Health | 2019-06-14 | 2019-07-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-14 | 2019-07-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-14 | 2019-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-14 | 2019-07-03 | N |
| 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. | Health | 2019-06-14 | 2019-07-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-14 | 2019-07-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-03-29 | 2019-04-09 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-03-29 | 2019-04-09 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-03-08 | 2019-03-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-19 | 2019-02-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-19 | 2019-02-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-01-30 | 2019-02-15 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-01-23 | 2019-01-25 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-01-23 | 2019-01-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-23 | 2019-01-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-22 | 2018-10-29 | Y |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2018-09-04 | 2018-10-26 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2018-09-04 | 2018-10-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-04 | 2018-10-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-04 | 2018-10-04 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-09-04 | 2018-10-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-04 | 2018-09-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-04 | 2018-09-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-09-04 | 2018-09-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-09-04 | 2018-09-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-24 | 2018-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-24 | 2018-09-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-08-24 | 2018-09-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-24 | 2018-09-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-24 | 2018-09-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-08-24 | 2018-09-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-24 | 2018-09-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-08-24 | 2018-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-24 | 2018-09-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-15 | 2018-08-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-24 | 2018-08-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-09 | 2018-07-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-07-09 | 2018-07-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-07-09 | 2018-07-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-06-08 | 2018-06-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-05-01 | 2018-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-01 | 2018-05-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-01 | 2018-05-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-01 | 2018-05-17 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2018-03-22 | 2018-03-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-03-22 | 2018-03-23 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-03-09 | 2018-03-20 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-03-02 | 2018-03-16 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-01-19 | 2018-02-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-01-19 | 2018-02-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2017-11-29 | 2017-11-30 | Y |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2017-07-19 | 2017-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-19 | 2017-08-08 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-07-13 | 2017-08-04 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-13 | 2017-08-04 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-07-13 | 2017-08-04 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-13 | 2017-08-04 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-07-13 | 2017-08-04 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-07-13 | 2017-08-04 | N |
| Provide food in a way that meets a resident's needs. | Health | 2017-07-13 | 2017-08-04 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-07-13 | 2017-08-04 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-13 | 2017-08-04 | N |
| Have a properly installed medical gas master alarm panel. | Fire Safety | 2017-07-19 | 2017-08-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-07-19 | 2017-08-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-07-19 | 2017-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-07-19 | 2017-07-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-07-19 | 2017-07-28 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-07-19 | 2017-07-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-07-19 | 2017-07-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-07-19 | 2017-07-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-07-19 | 2017-07-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-19 | 2017-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-07-19 | 2017-07-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-07-19 | 2017-07-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-07-19 | 2017-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-07-19 | 2017-07-19 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-06-05 | 2017-06-16 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-05 | 2017-06-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-06-05 | 2017-06-16 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2017-04-05 | 2017-04-13 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-03-14 | 2017-03-31 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-14 | 2017-03-31 | Y |
