Inspection·December 22, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure Resident #60's fall interventions were in place to help prevent falls. This affected one Resident (#60) out of one Resident reviewed for accidents. The facility census was 57. Findings include: Review of Resident #60's medical record revealed an admission date of 11/23/22. Diagnoses included psychotic disorder with delusions, delusional disorders, cognitive communication deficit, difficulty in walking, and weakness. Review of Resident #60's admission Minimum Data Set 3.0 assessment, dated 11/30/22, revealed the resident had impaired cognition and needed physical extensive assistance of two persons for bed mobility, transfers, and walking. Review of Resident #60's initial fall risk evaluation, dated 11/30/22, revealed the resident had a moderate risk for falls. Review of Resident #60's 48-hour admission care plan, dated 11/23/22, revealed the resident was at risk for falls. Interventions included place call bell within reach and keep the bed in the lowest position. Observation on 12/19/22 at 10:52 A.M. Resident #60 was observed lying in bed. Her call light was out of reach, positioned at the bottom of her bed between the wall and her bed. Observation on 12/21/22 at 2:25 P.M. Resident #60 was lying in bed asleep. Her bed was in a high position. Her call light was out of reach, positioned at the bottom of her bed between the wall and her bed. Interview and observation on 12/21/22 at 2:35 P.M. with Licensed Practical Nurse #813 confirmed Resident #60's bed was in a high position, and her call light was out of reach. Interview on 12/21/22 at 3:03 P.M. with the Director of Nursing confirmed that Resident #60's fall interventions of bed in low position and call light within reach were not in place for Resident #60. 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 4 Event ID: 366104 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 366104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem North Healthcare Center 250 Continental 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)