Inspection Reports for
Salem Place Nursing and Rehabilitation Center, Inc.
2401 Christina Lane, Conway, AR, 72034
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 15, 2026
Visit Reason
The document is an annual inspection report for Salem Place Nursing and Rehabilitation Center, Inc, conducted as part of regulatory oversight.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 9
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for Salem Place Nursing and Rehabilitation Center, Inc.
Findings
The facility was found to have multiple deficiencies including failure to notify the ombudsman of hospital transfers, inaccurate discharge assessments, medication administration and storage issues, food preparation and safety violations, infection control lapses, and failure to properly document influenza and pneumococcal immunizations for several residents.
Deficiencies (9)
Failed to notify the ombudsman of a hospital transfer for Resident #95.
Failed to ensure a discharge Minimum Data Set (MDS) assessment accurately reflected Resident #13's discharge status.
Medications left at bedside and missing handrail end-cap creating accident hazards for Resident #64.
Failed to ensure all medications were safely stored; antifungal medication left at Resident #15's bedside.
Meals were not prepared and served according to the planned menu, affecting nutritional needs.
Meals served were not palatable or at acceptable taste due to improper preparation methods.
Dietary staff failed to practice proper hand washing; dairy products thawed; hot foods not maintained at safe temperatures.
Laundry linen delivery cart uncovered during delivery, risking spread of harmful bacteria.
Failed to ensure influenza and pneumococcal immunizations were administered, offered, and documented for 4 of 5 sampled residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 84
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed Resident #95 was not included on hospital transfer notification list | |
| Administrator | Confirmed hospital transfer notification failure and lack of policy; provided interviews on immunization documentation | |
| MDS Coordinator #9 | Responsible for MDS discharge assessments; acknowledged notification system for overdue MDS | |
| Licensed Practical Nurse (LPN) #2 | Observed medication administration and failure to observe resident swallowing medications | |
| Assistant Director of Nursing (ADON) | Confirmed medication storage and administration deficiencies; provided Safety Data Sheet for antifungal ointment | |
| Maintenance Supervisor | Acknowledged missing handrail end-cap and potential hazard | |
| Dietary [NAME] (DC) #5 | Dietary Cook | Failed to serve correct portion sizes and follow menu during meal service |
| Dietary [NAME] (DC) #7 | Dietary Cook | Used excessive water in pureed foods affecting taste and nutritive value |
| Dietary Aide (DA) #6 | Observed thawed ice cream and milk; acknowledged improper food safety | |
| Dietary [NAME] (DC) #7 | Dietary Cook | Observed cross contamination due to improper glove use |
| Dietary Aide #8 | Measured unsafe temperatures of hot food items on steam table | |
| Laundry and Housekeeping Supervisor | Acknowledged lack of policy for laundry delivery; stated laundry carts should be covered | |
| Laundry Employee #11 | Observed delivering laundry with uncovered cart | |
| Laundry Employee #3 | Stated training on covered laundry transport | |
| Licensed Practical Nurse (LPN) #10 | Described immunization administration and documentation process | |
| Certified Medication Technician (CMT) #1 | Described immunization administration and documentation process | |
| Registered Nurse (RN) #4 | Described immunization administration and documentation process |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, medication management, dietary services, immunizations, and facility policies at Salem Place Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to notify the ombudsman of hospital transfers, incomplete discharge assessments, medication administration and storage issues, dietary service deficiencies including improper meal preparation and food safety, inadequate infection control practices related to laundry delivery, and failure to properly document influenza and pneumococcal immunizations for several residents.
Deficiencies (9)
Failure to notify the ombudsman of a hospital transfer for Resident #95.
Failure to ensure a discharge Minimum Data Set (MDS) assessment accurately reflected Resident #13's discharge status.
Medications left at bedside and missing handrail end-cap creating accident hazards for Resident #64.
Failure to ensure all medications were safely stored, evidenced by antifungal medication left at Resident #15's bedside.
Meals not prepared and served according to planned menu, affecting nutritional needs of residents.
Meals served were not palatable or at safe appetizing temperature, affecting 7 residents.
Dietary staff failed to practice proper hand washing; dairy products thawed; hot foods not maintained at safe temperatures.
Laundry linen delivery cart uncovered during delivery, risking spread of harmful bacteria.
Failure to ensure influenza and pneumococcal immunizations were administered, offered, and documented for 4 of 5 sampled residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 7
Residents affected: 84
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed Resident #95 was not included in hospital transfer notification list | |
| Administrator | Confirmed hospital transfer notification failure and lack of policy | |
| MDS Coordinator #9 | MDS Coordinator | Responsible for MDS discharge assessments; noted notification system for overdue MDS discharge |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Administered medications but did not observe resident swallowing |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Confirmed medication administration and storage deficiencies; provided Safety Data Sheet for antifungal ointment |
| Maintenance Supervisor | Observed missing handrail end-cap and acknowledged hazard | |
| Dietary [NAME] (DC) #5 | Dietary Cook | Used incorrect scoop sizes and did not follow menu |
| Dietary [NAME] (DC) #7 | Dietary Cook | Used incorrect portion sizes and added excessive water to pureed foods |
| Dietary Aide (DA) #6 | Dietary Aide | Observed thawed ice cream and milk |
| Dietary Aide #8 | Dietary Aide | Checked temperatures of hot food items and found them below safe levels |
| Laundry and Housekeeping Supervisor | Acknowledged lack of policy for laundry delivery and proper cart covering | |
| Laundry Employee #11 | Observed delivering laundry with uncovered cart | |
| Resident #18 | Resident | Did not remember if immunizations were offered or received |
| Resident #60 | Resident | Did not remember if immunizations were offered or received |
| Licensed Practical Nurse (LPN) #10 | Licensed Practical Nurse | Described immunization administration and documentation process |
| Certified Medication Technician (CMT) #1 | Certified Medication Technician | Described immunization administration and documentation process |
| Registered Nurse (RN) #4 | Registered Nurse | Described immunization administration and documentation process |
Inspection Report
Deficiencies: 1
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding residents' ability to call for assistance, specifically ensuring call lights were within reach.
Findings
The facility failed to ensure that call lights were within reach for 1 of 3 sampled residents, as Resident #1 could not reach the call light due to its placement relative to his position in bed.
Deficiencies (1)
Failed to ensure call lights were within reach to enable residents to call for assistance for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Confirmed Resident #1 could not reach the call light based on its placement. | |
| Registered Nurse #1 | Confirmed Resident #1 could not reach the call light based on its placement. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident care, specifically focusing on the accessibility of call lights for residents.
Findings
The facility failed to ensure that call lights were within reach for 1 of 3 sampled residents, as Resident #1 could not reach the call light due to its placement relative to his position in bed. Both CNA #1 and Registered Nurse #1 confirmed this during interviews.
Deficiencies (1)
Failed to ensure call lights were within reach to enable residents to call for assistance for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in call light placement finding |
| Registered Nurse #1 | Registered Nurse | Named in call light placement finding |
Inspection Report
Routine
Deficiencies: 13
Date: Aug 11, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to maintain wheelchair arm rests and flooring, incomplete and untimely resident assessments, inadequate care plans, inaccurate transcription of physician orders, improper respiratory care, medication administration and documentation errors, improper medication storage, lack of routine dental care, food safety violations, and inadequate infection prevention practices.
Deficiencies (13)
Failed to ensure wheelchair arm rests were free of rips and tears and flooring was free of rips and tears.
Failed to complete annual comprehensive resident assessments within 14 calendar days for 8 residents.
Failed to complete quarterly resident assessments within regulatory time frames for 6 residents.
Failed to accurately record Resident Assessment for 1 resident.
Failed to develop and implement complete care plans addressing all resident needs for 3 residents.
Failed to revise comprehensive care plans quarterly and accurately identify care needs for 4 residents.
Failed to ensure physician orders were transcribed accurately and treatments provided as ordered for 1 resident.
Failed to ensure oxygen was administered at prescribed flow rates, staff were trained on CPAP equipment, and nebulizer masks were stored properly for 2 residents.
Failed to accurately document removal of narcotics at time of administration and ensure periodic reconciliation for controlled medications.
Failed to ensure medications including insulin, nasal sprays, and inhalers were dated and disposed of per manufacturer instructions and stored securely.
Failed to provide routine dental services for 1 resident requiring oral care.
Failed to ensure food items in freezer were properly sealed and dietary staff used clean utensils to prevent foodborne illness.
Failed to disinfect multi-resident use glucometer after each use and staff failed to perform hand hygiene during medication administration for 3 residents.
Report Facts
Residents affected by incomplete annual assessments: 8
Residents affected by incomplete quarterly assessments: 6
Residents affected by inaccurate resident assessment: 1
Residents affected by incomplete care plans: 3
Residents affected by failure to revise care plans quarterly: 4
Residents affected by improper respiratory care: 2
Residents affected by infection control deficiencies: 3
Total census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and narcotic documentation deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in infection control and medication administration deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in medication storage and insulin handling deficiencies |
| LPN #5 | Licensed Practical Nurse | Named in respiratory care and infection control deficiencies |
| LPN #6 | Licensed Practical Nurse | Named in respiratory care deficiencies |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Named in care plan importance interview |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Named in nebulizer mask storage interview |
| Certified Nursing Assistant (CNA) #5 | Certified Nursing Assistant | Named in medication storage interview |
| Certified Nursing Assistant (CNA) #6 | Certified Nursing Assistant | Named in wheelchair arm rest and floor rip reporting interview |
| Maintenance #1 | Maintenance Staff | Named in wheelchair arm rest and floor rip repair interview |
| MDS Coordinator | Minimum Data Set Coordinator | Named in resident assessment and care plan deficiencies |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in medication and infection control interviews |
| Administrator | Facility Administrator | Named in policy and dental care interviews |
| Dietary Assistant Manager | Dietary Assistant Manager | Named in food storage deficiencies |
| Dietary Employee #1 | Dietary Employee | Named in food preparation deficiencies |
| Social Director | Social Director | Named in dental care scheduling interview |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Aug 11, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to maintain wheelchair arm rests and flooring in safe condition, incomplete and untimely resident assessments, inadequate care planning, inaccurate transcription of physician orders, improper respiratory care, medication administration and documentation errors, improper medication storage and labeling, failure to provide routine dental care, unsafe food handling practices, and inadequate infection prevention practices including improper glucometer disinfection and hand hygiene.
Deficiencies (13)
Failed to ensure wheelchair arm rests were free of rips and tears and flooring was free of rips and tears.
Failed to complete and transmit annual comprehensive resident assessments within 14 calendar days for 8 residents.
Failed to complete quarterly resident assessments within required timeframes for 6 residents.
Failed to accurately record Resident Assessment for 1 resident.
Failed to develop and implement complete care plans for 3 residents addressing all needs and medications.
Failed to revise comprehensive care plans quarterly for 4 residents to accurately identify care needs and provide care.
Failed to ensure physician orders were transcribed accurately for 1 resident.
Failed to ensure oxygen was administered at prescribed flow rates and staff were trained on CPAP equipment for 2 residents; nebulizer masks were not stored properly.
Failed to ensure licensed staff accurately documented removal of narcotics at time of administration and ensured periodic reconciliation.
Failed to ensure vials of insulin, nasal sprays, and inhalers were dated and disposed of according to manufacturer instructions; medications were stored improperly including at bedside.
Failed to provide routine dental services for 1 resident requiring oral care.
Failed to ensure food items in freezer were properly sealed to prevent freezer burn; dietary employees used unclean utensils during food preparation.
Failed to disinfect multi-resident use glucometer after each use and failed to perform hand hygiene during medication administration for 3 residents.
Report Facts
Residents with incomplete annual assessments: 8
Residents with incomplete quarterly assessments: 6
Residents with inaccurate assessments: 1
Residents without complete care plans: 3
Residents with incomplete care plan revisions: 4
Residents affected by infection control lapses: 3
Residents affected by food safety issues: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and narcotic documentation deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in infection control and medication administration deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in medication storage and labeling deficiencies |
| LPN #5 | Licensed Practical Nurse | Named in respiratory care and infection control interviews |
| LPN #6 | Licensed Practical Nurse | Named in respiratory care interviews |
| Certified Nursing Assistant #1 | CNA | Interviewed about importance of care plan content |
| Certified Nursing Assistant #2 | CNA | Interviewed about nebulizer mask storage |
| Certified Nursing Assistant #5 | CNA | Interviewed about medication storage |
| Maintenance #1 | Maintenance Staff | Interviewed about work order reporting and repairs |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed about assessment completion and care planning |
| Assistant Director of Nursing | ADON | Interviewed about medication administration, infection control, and dental care policies |
| Administrator | Facility Administrator | Interviewed about policies and dental care |
| Dietary Assistant Manager | Dietary Staff | Interviewed about food storage practices |
| Dietary Employee #1 | Dietary Staff | Observed preparing food with unclean utensils |
| Social Director | Social Services | Interviewed about dental care scheduling |
Inspection Report
Routine
Census: 83
Deficiencies: 8
Date: May 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, food service, infection control, and documentation at Salem Place Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to complete timely Minimum Data Set assessments after significant changes, inaccurate coding of anticoagulant therapy, incomplete care plans for residents with urinary catheters and colostomies, inadequate supervision and control of residents' smoking materials, serving food at unsafe temperatures and poor food palatability, improper preparation of pureed diets, unsafe food handling practices, and lapses in infection prevention and control practices including improper handling of medication syringes and unclean stethoscope use.
Deficiencies (8)
Failure to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change in condition for a resident admitted to hospice.
Failure to accurately code anticoagulant therapy on the Minimum Data Set assessment for a resident receiving anticoagulant medication.
Failure to complete baseline and comprehensive care plans addressing the use of urinary catheter and colostomy for a resident.
Failure to ensure residents' smoking materials were securely maintained and smoking assessments completed per facility policy.
Failure to serve food at safe and appetizing temperatures and maintain food palatability, affecting multiple meals.
Failure to prepare pureed food items to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure food items stored in the refrigerator were covered or sealed, improper use of leftover food, and failure of dietary staff to wash hands before handling clean equipment or food items.
Failure to properly clean reusable equipment before and after use on residents and improper handling of medication syringes during administration.
Report Facts
Residents affected by hospice MDS assessment deficiency: 12
Residents affected by anticoagulant therapy coding deficiency: 1
Residents affected by incomplete care plans for catheter and colostomy: 1
Residents affected by smoking materials supervision deficiency: 4
Total census: 83
Food temperature readings: 46
Food temperature readings: 104
Food temperature readings: 98
Food temperature readings: 102
Food temperature readings: 110
Food temperature readings: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication administration and syringe handling deficiency |
| Director of Nursing | DON | Interviewed regarding hospice orders, smoking policy, and infection control practices |
| Licensed Practical Nurse #2 | LPN | Named in infection control deficiency related to stethoscope use |
| Dietary Employee #1 | Dietary Staff | Observed preparing pureed food and handling food without proper hand hygiene |
| Certified Nursing Assistant #3 | CNA | Observed checking food temperatures |
| Certified Nursing Assistant #4 | CNA | Observed checking food temperatures |
| Certified Nursing Assistant #5 | CNA | Observed checking food temperatures |
| Licensed Practical Nurse #3 | LPN | Interviewed about smoking assessment responsibilities |
| Licensed Practical Nurse #4 | LPN | Interviewed about smoking assessment responsibilities |
| Social Services Director | SSD | Interviewed about smoking policy education and admissions paperwork |
Inspection Report
Routine
Census: 83
Deficiencies: 9
Date: May 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, food service, and medication administration at Salem Place Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to complete timely Minimum Data Set assessments after significant changes, inaccurate coding of anticoagulant therapy, incomplete care plans for residents with urinary catheters and colostomies, inadequate supervision and storage of smoking materials, serving food at unsafe temperatures and poor food quality, improper preparation of pureed diets, failure to maintain food safety and hygiene standards in the kitchen, and lapses in infection prevention practices related to medication administration and equipment cleaning.
Deficiencies (9)
Failure to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change in condition for a resident admitted to hospice.
Inaccurate coding of anticoagulant therapy on the Minimum Data Set for a resident receiving anticoagulant medication.
Failure to complete baseline and comprehensive care plans addressing the use of urinary catheter and colostomy for a resident.
Failure to ensure physician orders for hospice care, indwelling urinary catheter, and colostomy were documented.
Failure to ensure residents' smoking materials were securely maintained and smoking assessments completed according to facility policy.
Failure to serve food at safe and appetizing temperatures and maintain food palatability, affecting many residents.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure food items in the refrigerator were covered or sealed, proper use of leftovers, and dietary staff hand hygiene to prevent foodborne illness.
Failure to properly clean reusable equipment and handle syringes during medication administration, risking cross-contamination.
Report Facts
Residents affected: 12
Residents affected: 7
Residents affected: 6
Residents affected: 4
Residents affected: 82
Temperature: 46
Temperature: 84
Temperature: 50
Temperature: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding MDS assessments, physician orders, smoking policy, and infection control practices |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed improperly handling medication syringes and interviewed about infection control |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed using stethoscope without cleaning before and after resident use |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about smoking assessment responsibilities and policies |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about smoking assessment responsibilities and policies |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about smoking materials policy and resident supervision |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed food temperature checks and interviewed about food quality |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed food temperature checks and interviewed about food quality |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Observed food temperature checks and interviewed about food quality |
| Dietary Employee #1 | Dietary Employee | Observed preparing pureed food and handling food without proper hygiene |
| Dietary Supervisor | Dietary Supervisor | Provided food temperature data, food quality assessments, and facility policies |
| Social Services Director | Social Services Director | Interviewed about admissions paperwork and smoking policy education |
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