Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Salem Home during CMS and state inspections, most recent first.
Unsanitary Food Storage and Kitchen Conditions: Surveyors observed multiple sanitation issues in the kitchen and kitchenette, including frost and food buildup in freezers, food residue on the refrigerator and microwave, dried fluids and dust on surfaces, no trash can at the hand-washing sink, residue on container lids, and buildup in the floor drain. An LTC dietary staff member confirmed the findings and stated the areas should be cleaned and food stored and prepared in sanitary condition to prevent foodborne illnesses.
A resident with dementia and moderately impaired cognition was left medication cups in his room even though his care plan directed staff to administer meds. An LPN left the meds after the resident declined observation, and the resident then picked up a dropped pill from the floor and swallowed an unidentified medication. The EMR lacked documentation for self-administration, and the DON stated meds should not be left in rooms unless care-planned for self-administration.
Failure to Protect Resident Privacy During Peri-Care: Two residents with cerebral infarction and moderately impaired cognition were left naked from the waist down during peri-care. Staff left blinds open for one resident and exited and re-entered the room while the other resident remained uncovered, exposing the resident to people in the hall. A nurse and an administrative nurse stated residents should be covered during care to protect privacy, and the facility policy stated residents have the right to a dignified existence.
Failure to change soiled clothing: A resident with a stroke history, impaired cognition, and dependence for dressing was left in a dirty T-shirt with food debris and spilled fluids after being transferred to bed by an LN and CMA. The resident was later seen in the dining room still wearing the soiled shirt, and the CMA confirmed staff had not changed it even though clothes should be changed when dirty.
Failure to Provide Ordered BiPAP Therapy: A resident with sleep apnea and Friedreich ataxia was ordered BiPAP at bedtime, with staff assistance for application and use. The resident repeatedly reported the BiPAP was broken after it fell, and charting showed it remained unusable for about a month while staff noted it was waiting for repair. The EMR lacked documentation of ongoing contact with the equipment company and lacked documentation that the provider was notified that the BiPAP was not working.
Inadequate Competency for PEG Tube Feeding and Medication Administration: A resident with CVA, hemiplegia, dysphagia, and dementia depended on a PEG tube for nutrition, hydration, and meds. CMAs administered his tube feedings and meds even though two CMAs lacked current annual competency check-offs for PEG feeding and PEG med administration, and staff confirmed the competencies were overdue.
A resident’s BiPAP mask was repeatedly found on the floor beside the bed, and staff reported the BiPAP machine had been broken for about a month and no bag was available to store the mask. In a separate observation, a CNA provided incontinent care to another resident and used the same gloves to cleanse the buttocks and then the urinary meatus and groin without hand hygiene or changing gloves between tasks, contrary to staff statements and facility policy.
The facility failed to keep dumpster lids closed after use. During a kitchen tour, three dumpsters were observed with piled, bagged trash that kept the lids open, and an LDT staff member confirmed the lids should be closed to contain trash and debris. The facility’s Dumpster Policy stated lids must be closed after each use to help control pests, odors, and weather-related contamination.
The facility failed to store, prepare, and distribute food safely, with milk and nutritional supplements served at incorrect temperatures. Observations revealed unsanitary conditions in the kitchen, including black substances on vents, peeling varnish on cabinets, and improper ice machine drainage. Staff interviews confirmed confusion over cleaning responsibilities and worn dishware patterns.
The facility failed to submit accurate staffing data through PBJ, as the report showed missing 24-hour nursing coverage on certain dates. Despite adequate hours in the schedule and payroll data, a 30-minute lunch deduction in the PBJ submission led to inaccuracies. An Administrative Nurse confirmed the discrepancy, noting that staff were scheduled for shifts without lunch breaks.
A nurse treatment cart containing insulin and wound care supplies was found unlocked and unattended, servicing nine residents, including two confused individuals. The facility's policy requires carts to be locked when not in sight, but a nurse admitted to leaving it unsecured, failing to ensure resident safety.
The facility failed to ensure pureed foods were nutritionally and flavor compatible with the menu for two residents requiring pureed diets. Dietary staff substituted mashed beans and mashed potatoes for corn and fiesta rice without a nutritionally equivalent guide. Interviews revealed the facility had a computerized program for dietary substitutes but did not routinely use a pureed diet guide.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to store and prepare food in the main kitchen and kitchenette under sanitary conditions. During an initial tour of the South Kitchen, surveyors observed built-up frost on three shelves in the reach-in freezer, food stuck to the top of two deep freezers, dried-on fluids on the white plastic legs of the table holding coffee pots and a tea machine, dust buildup on the wooden board behind that table, food on the bottom and front of the bottom door of the side-by-side two-door refrigerator, no trash can by the hand-washing sink, flour and sugar on top of the lids of the flour and sugar containers, and a buildup of an unknown substance in the kitchen floor drain. During a tour of the kitchenette, surveyors observed dried food throughout the inside of the microwave and dried food and liquids on the top and sides of the trash can. Dietary Staff BB later confirmed these findings and stated that the identified areas should be cleaned and food should be stored and prepared in a sanitary condition to prevent foodborne illnesses. The facility policy, Sanitation of Equipment and Supplies, issued 04/2022, stated that refrigerators shall be cleaned weekly, freezers shall be cleaned bi-weekly, and kitchen floors shall be sanitized daily at the end of the day.
Failure to Assess Self-Administration Ability Before Leaving Medications in Room
Penalty
Summary
The facility failed to assess and ensure that a cognitively impaired resident was able to safely self-administer medications before leaving medications in the resident’s room for self-administration. The resident had a diagnosis of dementia, a BIMS score of 10 indicating moderately impaired cognition, and was receiving multiple scheduled medications including an antidepressant and an opioid. The resident’s care plan directed staff to administer medications as ordered and monitor for side effects and effectiveness, and the EMR did not contain documentation of self-administration of medications. During observation, a licensed nurse left two medication cups in the resident’s room on a stand next to the recliner after the resident said he did not want her to watch him take his medications and wanted to finish breakfast. Shortly afterward, the resident leaned to his right, picked up a pill from the floor after stating he had dropped it, and placed the unidentified medication into his mouth. The nurse later removed the remaining medications from the room and reported that she had left medications in the resident’s room before and had always gone back to make sure he took them, but she did not realize he had dropped a pill and taken it. The administrative nurse stated that no medications should be left in residents’ rooms unless they were care-planned for self-administration.
Failure to Protect Resident Privacy During Peri-Care
Penalty
Summary
The facility failed to provide privacy for two residents while staff performed peri-care in their rooms. One resident had a diagnosis of cerebral infarction, a BIMS score of 8 indicating moderately impaired cognition, and was documented as always incontinent of bowel and bladder and dependent on staff for toileting hygiene and transfers. During care, two CNAs performed peri-care while the resident lay on the bed naked from the waist down, and the blinds to the windows facing the courtyard were left open. One CNA stated the staff does not typically close the resident's blinds while performing cares in the room. A second resident also had a diagnosis of cerebral infarction, a BIMS score of 9 indicating moderately impaired cognition, and was documented as always incontinent of bowel and bladder and requiring total staff assistance with toileting hygiene. During peri-care, two CNAs performed care while the resident lay on the bed naked from the waist down. One CNA exited and re-entered the room by opening and closing the door while the resident remained uncovered, exposing the resident to staff, other residents, and workmen in the hall outside the room. A nurse and an administrative nurse stated staff should cover residents during care to prevent exposure and protect privacy, and the facility's Resident Rights policy stated each resident has the right to a dignified existence.
Failure to Change Soiled Clothing
Penalty
Summary
The facility failed to provide appropriate ADL assistance to a resident with a history of cerebral infarction, moderately impaired cognition, and left-sided ROM limitations. The resident’s MDS documented a BIMS score of eight, the ADL/rehabilitation potential CAA noted that he required staff assistance with dressing, and the care plan directed staff to provide total assistance for dressing. The EMR task records also showed that he required substantial to maximum staff assistance with upper body dressing. On 06/08/2026 at 08:50 AM, an LN and a CMA transferred the resident from his wheelchair to his bed while he was wearing a white T-shirt with food debris and spilled fluids on the front. Staff did not change the soiled shirt before leaving the room. Later that morning, the resident was observed in the dining room awaiting lunch and was still wearing the same shirt with food debris and dried fluids on the front. The CMA confirmed she had not changed the dirty t-shirt before leaving the room and stated staff should change residents’ clothes when they are dirty. An Administrative Nurse stated it was the expectation for staff to change residents’ clothes when they became dirty.
Failure to Provide Ordered BiPAP Therapy
Penalty
Summary
The facility failed to provide Resident 17 with BiPAP therapy as ordered. Resident 17 had diagnoses of sleep apnea and Friedreich ataxia, required total staff dependence with bed mobility, and had care plan instructions for staff to assist with applying the BiPAP mask, turning the BiPAP on and off, and ensuring the mask fit appropriately without other devices underneath it. Physician orders directed staff to assist with applying the BiPAP at bedtime for obstructive sleep apnea and to use it at present settings. Resident 17 repeatedly reported that the BiPAP equipment was broken after it fell to the floor, and multiple nursing notes documented that the device was not working and was waiting for repair. The record showed staff discussed the broken BiPAP with the resident and attempted to contact the company, but the EMR lacked documentation of further contact attempts and lacked documentation that the provider was updated that the BiPAP was not working from 05/10/2026 through 06/09/2026. During interview, a nurse stated the BiPAP had been broken for about a month and was unsure whether the provider was aware, and an administrative nurse confirmed the EMR lacked documentation of repeated company contact and provider notification.
Inadequate Competency for PEG Tube Feeding and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to care for a resident who had a PEG tube for nutrition, hydration, and medication administration. The resident had diagnoses including CVA, hemiplegia, dysphagia, and dementia, was severely cognitively impaired, was dependent on staff for total assistance with eating, and received nothing by mouth. His care plan directed staff to administer medications via PEG tube, provide tube feedings and water flushes, monitor and report signs of aspiration, tube dislodgement or malfunction, infection at the tube site, and other related symptoms, and provide local PEG site care as ordered. Review of the MAR/TAR showed that two CMAs administered the resident’s tube feedings and medications via PEG. Review of competency records showed that one CMA’s most recent annual competency for administering PEG feedings and medications was seven months overdue, and another CMA’s was three months overdue. Staff interviews confirmed that CMAs were administering the resident’s tube feeding and medications, that the two reviewed CMAs did not have current competencies, and that annual competency completion was expected for delegated tasks. The facility policy stated that employees must demonstrate competency before providing care and that the DON defines the competencies required for staff providing care and services.
Infection Control Lapses With BiPAP Equipment and Incontinence Care
Penalty
Summary
The facility failed to implement adequate infection control practices related to respiratory equipment for one resident who used BiPAP. On 06/08/2026 and again on 06/09/2026, the resident’s BiPAP mask was observed lying directly on the floor next to the bed. The resident stated he had no place to put the mask when he removed it. A CNA reported she did not handle the BiPAP equipment, and a LN reported the BiPAP machine had been broken for about a month, that the mask should not be on the floor, and that it should be placed in a bag; the LN also verified there was no bag in the room for the mask. The facility also failed to follow hand hygiene and incontinence care practices for another resident during bowel and urinary incontinence care. During observed care, a CNA removed gloves, washed hands, and applied new gloves after removing the soiled brief, but then used the same gloves to cleanse the resident’s buttocks, urinary meatus, and groin without performing hand hygiene between cleansing the bowel movement and the front peri area. The CNA later stated she should have removed her gloves, performed hand hygiene, and applied new gloves before cleansing the front area. An LN and the Infection Preventionist both stated that staff should remove gloves and wash hands before cleansing the resident’s peri area after cleansing bowel movement from the buttocks. The facility’s policies for BiPAP, incontinent care, and infection control were also reviewed.
Open Dumpsters With Trash Preventing Lids From Closing
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly in a closed dumpster. During the initial kitchen tour on 06/10/2026 at 09:13 AM, three dumpsters were observed with piled, bagged trash that prevented the lids from closing and securing the garbage and refuse. Dietary Staff BB confirmed that the dumpster lids were open and should be closed to contain trash and debris. The facility policy, titled Dumpster Policy and issued 05/2024, stated that dumpster lids must be closed after each use to help control pests, odors, and weather-related contamination.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in a manner that prevents foodborne illness among residents. Observations revealed that room trays for residents were set with beverages, including milk and a nutritional supplement, at temperatures above the recommended 41 degrees Fahrenheit. Dietary staff confirmed that the milk and nutritional supplements were not at the correct temperature, with readings of 60 degrees and 57 degrees Fahrenheit, respectively. The staff attributed this to the milk not having cooled down sufficiently after delivery. Additionally, the trays were set up 30 minutes before serving, which may have contributed to the temperature issues. Further observations during an environmental tour of the kitchen identified several areas of concern, including black substances on air vents and ceilings, peeling varnish and stains on wooden cabinet drawers, grime and debris on shelves, and black substances on omelet pans. The ice machine drain was also improperly installed without the required two-inch air gap. Interviews with dietary and maintenance staff revealed confusion over cleaning responsibilities and confirmed the presence of worn dishware patterns. The facility did not provide a policy for food temperatures prior to serving, and the existing sanitation and safety policy instructed staff to maintain acceptable sanitary conditions, which was not adhered to.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ). Specifically, the facility did not accurately submit hourly staffing data for all nursing personnel for Fiscal Year Quarter 3 - 2023. The PBJ Staffing Data Report indicated that the facility lacked Licensed Nursing Coverage for 24 hours a day on several specific dates. However, a review of the nursing schedule and payroll data sheets for those dates showed that there were adequate hours to account for 24-hour nursing coverage. The discrepancy arose because the PBJ submission deducted a 30-minute period for lunch, even though nursing staff were scheduled for shifts where no lunch was taken. This issue was confirmed by an Administrative Nurse who reported that both payroll data and scheduling data reflected 24-hour nursing coverage, but the PBJ submission did not accurately reflect this due to the lunch deduction.
Unattended and Unlocked Medication Cart Poses Risk
Penalty
Summary
The facility failed to ensure the safety of nine residents by not maintaining a locked nurse treatment cart containing insulin and general wound care supplies. On the 200 hall, a treatment cart was observed unlocked and unattended, which was confirmed by a Licensed Nurse (LN) who admitted to leaving the cart unsecured while going to the nurses' station. The cart serviced nine residents, including two self-mobile and confused individuals, increasing the risk of unauthorized access to medications. The facility's Medication Administration Policy, dated June 2024, mandates that medication carts, including nurse treatment carts, must be locked when not in the direct line of sight of medical personnel. Despite this policy, the incident occurred, and the Administrative Nurse confirmed the expectation for all staff to lock medication carts before leaving them unattended. This oversight in securing the medication cart represents a failure to provide a safe environment for the residents.
Failure to Provide Nutritionally Compatible Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to maintain nutritional and flavor compatibility with the menu, affecting two residents who required pureed diets. During an observation, Dietary Staff CC prepared a pureed diet for these residents, substituting mashed beans for corn and mashed potatoes and gravy for fiesta rice, as the facility's Mechanically Soft Level Two Diet form indicated that corn and regular rice should be avoided. However, there was no nutritionally equivalent substitute guide available for the spanish rice or fiesta corn for pureed diets. Interviews with Dietary Staff BB and Dietary Consultant GG revealed that the facility had a computerized program for dietary substitutes but did not routinely use a pureed diet guide other than the posted Mechanically Soft (Level 2) Diet and a regular menu. Dietary Consultant GG noted that substitutes should be nutritionally appropriate for pureed foods and offered to provide guidelines/menus. The facility's guidelines and policies instructed staff to follow the regular menu and provide consistency modifications as ordered by the physician, but the facility failed to provide nutritionally and flavor-compatible pureed food substitutes for the two residents.
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What surveyors actually found near you
We read the 104 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkside Homes | 0.1 mi | ★★★★★ | 0 | 0 |
| Bethesda Home | 10.1 mi | ★★★★★ | 0 | 0 |
| St Luke Living Center | 10.6 mi | ★★★★★ | 19 | 0 |
| Access Mental Health | 13.1 mi | — | 21 | 1 |
| Peabody Health And Rehab | 13.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.