Inspection·November 8, 2022

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interviews the facility did not ensure palatable food was served to all the residents eating meals from the kitchen. This had the potential to affect all residents in the facility, with the exception of Residents #4, #17 and #37 the facility identified as consuming nothing by mouth. The facility census was 58. Residents Affected - Many Finding include: Interviews conducted intermittently on 10/31/22 between 9:18 A.M. and 3:33 P.M. with Residents #16, #22, #24, #27, #31, #35, #38, #43, #44, #51, #52 and #53 revealed multiple, pervasive complaints of cold, poor tasting food. Observation was conducted on 10/31/22 beginning at 10:30 A.M. of [NAME] #855 preparing the lunch meal which consisted of breaded fish on bun, marinated chicken thighs, seasoned green beans, potato wedges, rice pilaf and dinner rolls. [NAME] #855 pureed the fish for residents requiring pureed diets and during the pureeing process, added juice from the green beans to the pureed fish. She verified she used green bean juice to add moisture to the pureed fish. Cook #855 was observed to start lunch meal service on the tray line without taking temperatures of the foods in the steam table. She verified she did not take the temperatures of the food prior to starting tray line. When asked by the surveyor what the safe food temperature range would be at the point of service on tray line for hot foods [NAME] #855 said the food should reach 165 degrees prior to being served. [NAME] #855 took the temperature of the potato wedges which read 145 degrees Fahrenheit (F) and removed the pan from the steam table to place back in the oven. When the surveyor asked [NAME] #855 what the minimum temperature at which hot food could be held in the steamtable for service, she said she did not know. The lunch meal service came to a stop while [NAME] #855 reheated the food to reach 165 degrees F. Observation of a test tray was conducted on 10/31/22 and the test tray was placed on the last cart which left the kitchen at 1:39 P.M. At 2:03 P.M. the test tray was delivered to the Culinary Director (CD) #871 who confirmed the temperature of the green beans was 116 degrees Fahrenheit (F) and the potatoes wedges were 111 degrees F. The coffee was one forth cup full with a temperature of 70 degrees F. The surveyor tasted the potatoes and the potatoes were bland with no seasoning or butter and formed a ball more consistent with mashed potatoes than potato wedges. CD #871 said the potatoes did not look like potato wedges, nor did they appear to have any seasoning. CD #871 did not taste test the food. Interview on 11/01/22 at 7:24 A.M. with CD #871 revealed all foods should be served to the resident at a minimum temperature of 120 degrees for palatibility. CD #871 explained all cooks were trained (continued on next page) 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 Page 1 of 2 Event ID: 366096 Printed: 05/15/2026 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 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2022 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)