Inspection·April 10, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interviews the facility failed to ensure all staff were wearing the appropriate Personal Protective Equipment (PPE) to help prevent the spread of COVID-19 in the facility. This had the potential to affect 32 residents who were not COVID-19 positive (#2, #4, #7, #8, #9, #14, #15, #17, #19, #20, #21, #26, #28, #29, #30, #32, #34, #35, #36, #37, #40, #41, #42, #45, #46, #48, #50, #52, #54, #55, #57,and #58) and residing in the facility at the time of the survey. The facility census was 53. Residents Affected - Some Findings include: Record review of facility line list revealed there were 21 residents (#1, #5, #6, #10, #12, #18, #22, #23, #24, #25, #31, #33, #38, #39, #43, #44, #47, #49, #51, #53 and #56) currently residing in the facility and two employees who tested positive for COVID-19 from 04/05/24 to 04/08/24. Observations made on 04/09/24 upon arrival to the facility at 9:30 A.M. revealed the facility was in a current outbreak of COVID-19 with 23 residents in droplet isolation due to testing positive of COVID-19. The Administrator, receptionist and multiple other staff members who were present throughout the facility were not wearing any type of source control including N95 masks or surgical masks. Interview on 04/09/24 at 10:05 A.M. with the Director of Nursing revealed it was the expectation of the facility administration that all staff were to wear surgical masks when not on the COVID-19 unit and when on the COVID-19 unit staff were to wear N95 masks as source control measures. Interview on 04/09/24 at 10:39 A.M. with the Administrator revealed she confirmed herself, the Receptionist and multiple other staff members were not wearing any type of source control including N95 masks or surgical masks. Observation on 04/09/24 at 2:10 P.M. of Licensed Practical Nurse (LPN) #701 at the nurses station on the COVID-19 unit with her N95 mask down around her neck while she was charting on the computer with residents who were positive for COVID-19 walking around by the nurses station, and the facility van driver was walking around on the COVID-19 unit continually pulling his mask down when speaking to staff and residents. Interview on 04/09/24 at 2:10 P.M. with LPN #701 revealed she confirmed she was at the nurses station with her mask down, she stated she took it down to put on chap stick and did not put it back up. LPN #701 confirmed the facility van driver was walking around the COVID unit continually pulling his mask down to speak to staff and residents. Interviews on 04/10/24 from 10:07 A.M. to 12:08 P.M. with Residents #7, #8, #20, and #36 revealed (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 04/10/2024 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)