Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Salem Care Center during CMS and state inspections, most recent first.
Facility staff failed to properly sanitize kitchen wares, leading to potential contamination. Observations showed staff did not follow manufacturer's instructions for the dish machine and 3-compartment sink, with incorrect sanitizer concentration and improper rinsing procedures. The dietary manager and administrator were unaware of the correct procedures, and the dish machine was not reaching the required temperature.
Facility staff failed to implement and educate on enhanced barrier precautions (EBP) for residents with conditions requiring such measures. Observations showed a lack of signage and PPE outside resident rooms, and staff were not wearing gowns during high-risk care activities. Interviews revealed staff were unaware of EBP requirements, and the administration mistakenly believed EBP were recommendations, not regulations.
The facility failed to maintain a clean and homelike environment, with observations of unsanitary conditions such as dirty oxygen concentrators, non-functional lights, and a leaking toilet. The shower room was consistently disorganized, and staff interviews revealed a lack of clarity regarding cleaning responsibilities. The Maintenance Supervisor and DON acknowledged issues with cleaning and maintenance, while the administrator admitted to the absence of a formal plan to address these problems.
Facility staff failed to secure hazardous items such as chemicals and razors in the 300 hall shower room and beauty shop/shower room, leaving them accessible to residents. Observations showed these areas were repeatedly left unlocked and unattended, with unsecured personal care products and a bag of ice melt chemical present. Interviews with staff revealed a lack of awareness and responsibility for securing these items, with the DON and administrator unaware of missing locks on storage units.
The facility failed to destroy discontinued and expired medications in a timely manner, leading to an accumulation of such medications in the storage room and on medication carts. Staff interviews revealed a lack of clarity and responsibility regarding medication disposal, with the Director of Nursing and Administrator unaware of the issue's extent. Observations showed expired medications in storage, contrary to facility policy.
The facility staff failed to adhere to nutritional guidelines for pureed foods, using unmeasured amounts of water and bread instead of following standardized recipes. The Dietary Manager admitted to a lack of recipes for the meal of the month, and the Registered Dietician did not review meal substitutions for nutritional adequacy. Observations showed discrepancies in meal portions and missing menu items, with the administrator unaware of the lack of RD review.
A resident's debit card was misappropriated by a CNA, leading to unauthorized charges of $755. The resident, who was cognitively intact and had multiple medical conditions, noticed the issue and reported it to the administration. The facility's policy on abuse prevention was not effectively implemented, as staff were unaware of the misuse until after it occurred. The CNA was identified and terminated, and the police were notified.
The facility did not submit complete and accurate direct care staffing information to CMS via the PBJ for a specified period. The facility lacked a PBJ policy, and the CMS report did not include data for that time. The Administrator indicated it was the corporate office's responsibility, but the office staff did not report the data. The Corporate PBJ staff mistakenly believed submission was unnecessary due to the facility's non-Medicare Certified status, leading to miscommunication.
Improper Sanitization of Kitchen Wares
Penalty
Summary
The facility staff failed to sanitize kitchen wares properly, leading to potential contamination. Observations revealed that staff did not follow the manufacturer's instructions for the dish machine and the 3-compartment sink sanitization process. Specifically, staff were observed rinsing items after sanitizing them, which is contrary to the instructions. Additionally, the sanitizer concentration was found to be below the required level, and large items were not fully immersed in the sanitizer solution. The dietary manager and staff were not aware of the correct procedures for using the sanitizer, including the required soak time and concentration levels. The dietary manager admitted to not knowing the correct soak time and relied on incorrect signage. The administrator also lacked knowledge about the correct sanitization process and relied on the dietary manager to ensure compliance. The dish machine was not functioning correctly, as indicated by the failure of the temperature test strips to turn orange, which would signify the correct temperature was reached. Staff recorded incorrect temperatures on the log, and the dietary manager was unaware of the discrepancies. The facility lacked the appropriate chlorine test strips, and the dietary manager was not informed about the non-functioning temperature test strips.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to develop, implement, and educate on an enhanced barrier precautions (EBP) system for residents requiring such precautions. This deficiency was observed in four residents who had conditions such as unhealed wounds, indwelling medical devices, and cognitive impairments. The facility did not have a policy for EBP, and there was no signage or personal protective equipment (PPE) available outside the residents' rooms to alert staff of the need for EBP. Observations revealed that staff did not wear gowns during high-risk care activities such as wound care, transfers, and incontinence care for residents with conditions that necessitated EBP. Interviews with staff, including registered nurses and certified nurse aides, indicated a lack of awareness and training regarding EBP. Staff members were not informed about which residents required EBP and were unsure of what EBP entailed, leading to inadequate infection control practices. The facility's administration and infection prevention personnel were also unaware of the requirements for EBP, mistakenly believing them to be mere recommendations rather than regulations. This lack of awareness and training resulted in the absence of a system or policy for EBP, leaving residents at risk due to insufficient infection prevention measures.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of unsanitary and disorganized conditions. Resident #39's room had an oxygen concentrator with dirt and food debris, non-functional lights, and a leaking toilet with a blanket around its base. The resident reported notifying staff about these issues three months prior, but no action had been taken. Additionally, Resident #13's privacy curtain was stained, and Resident #200's oxygen concentrator was dirty. Resident #15's electric wheelchair and the electronic lift were also observed to be unclean, with the infection preventionist noting that equipment should be cleaned between residents to prevent the spread of germs. The shower room on the 300-hall was consistently found in disarray over several days, with unlocked carts, personal items scattered, and stained walls. CNA L expressed uncertainty about who was responsible for cleaning the shower rooms and noted that the floors were only mopped once per day. Other observations included Resident #12's motorized wheelchair being dirty, Resident #43's bathroom having a red stain, and a partially torn window curtain in another room. The dining room had an air conditioner with towels and blankets stacked underneath, peeling baseboards, and numerous unlit ceiling lights, with a family member commenting on the facility's maintenance issues. Interviews with staff revealed a lack of clarity and responsibility regarding cleaning and maintenance tasks. The Maintenance Supervisor mentioned that fly strips should not be used in resident rooms and acknowledged the absence of a housekeeping supervisor. The Director of Nursing noted a time management issue among nursing staff and a lack of involvement in cleaning shower rooms. The administrator admitted to the absence of a formal plan to address facility issues and expressed a desire to update rooms systematically. Overall, the facility's failure to maintain a clean and safe environment was evident through the numerous observations and staff interviews.
Failure to Secure Hazardous Items in Shower Rooms
Penalty
Summary
The facility staff failed to maintain a safe environment free from accident hazards by not securing hazardous items such as chemicals and razors behind locked doors, as required by the facility's hazardous storage policy. Observations over several days revealed that the 300 hall shower room was repeatedly left unlocked and unattended, with a large unlocked cart and cabinet containing loose razors and a bag of ice melt chemical on the floor. Additionally, multiple unlabeled bottles, cans, and tubes of personal care products were found unsecured in the shower room. Similar unsecured conditions were observed in the 300 hall beauty shop/shower room, where a container of disinfectant chemical wipes was left accessible on a shelf. Interviews with facility staff, including a CNA, the Maintenance Director, the DON, and the administrator, highlighted a lack of awareness and responsibility regarding the storage of hazardous items. The CNA acknowledged the risk of residents wandering into the shower room and getting hurt but was unsure of who was responsible for securing the items. The Maintenance Director admitted to storing ice melt in the shower room for scale calibration without considering the potential hazard. The DON and the administrator were unaware of the missing locks on the storage cart and cabinet, and both acknowledged that hazardous items should not be stored in the shower rooms unless secured. The administrator noted that locks had been replaced multiple times but was unaware of the current unsecured state.
Failure to Timely Destroy Discontinued and Expired Medications
Penalty
Summary
The facility failed to destroy medications in a timely manner for both current and discharged residents, as observed during a survey. Medications that were discontinued or belonged to discharged residents were found stored in the medication room, rather than being destroyed as per the facility's policy. Certified Medication Technician (CMT) Q was observed handling a large trash bag of medications intended for destruction, indicating a backlog of medications that had not been properly disposed of. The facility's policy requires that discontinued or expired medications be removed and destroyed promptly, but this was not adhered to, leading to an accumulation of medications in the storage room. Further observations revealed that expired medications were present in the over-the-counter medication storage cabinet and on medication carts. These included various supplements and medications with expiration dates that had passed, yet they remained in storage. Interviews with staff, including CMTs, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs), revealed a lack of clarity and responsibility regarding the disposal of medications. Staff members were unsure of the policy details and admitted to not having a specific process in place for timely disposal of medications. The Director of Nursing (DON) and the Administrator were both unaware of the extent of the issue, despite their expectations that medications should be destroyed immediately upon discontinuation or resident discharge. The DON is responsible for auditing the medication storage room, while the nursing staff and CMTs are tasked with maintaining it. However, the lack of a clear process and accountability led to the accumulation of expired and discontinued medications, which were not being disposed of in accordance with the facility's policies.
Failure to Follow Nutritional Guidelines for Pureed Foods
Penalty
Summary
The facility staff failed to serve pureed food in accordance with the nutritionally calculated recipes and menus. Observations revealed that staff did not follow the facility's Pureed Foods instructions, which required specific measurements and ingredients for pureeing food items. Instead, staff used unmeasured amounts of water and bread, deviating from the standardized recipes. The Dietary Manager (DM) acknowledged that kitchen staff did not have recipes for the meal of the month and relied on posted puree guidance when standardized recipes were unavailable. The administrator confirmed that the DM was responsible for ensuring meals were prepared according to recipes and that bread should not be added to every puree item. Additionally, the facility's Registered Dietician (RD) policy was not adhered to, as the RD did not review meal substitutions for nutritional adequacy. The Week At a Glance menu indicated specific portion sizes and items to be served, but observations showed discrepancies in the actual meal served. Residents were overserved the entree, underserved the dessert, and did not receive a salad as per the menu. The DM admitted that the RD did not approve the noon meal and was unaware of the meal of the month details due to the absence of a substitution log. Interviews with the RD revealed that they had not observed the preparation of pureed items and were not informed of the resident choice meal prior to serving. The RD expected certain ingredients in the gumbo that were not present, indicating a lack of oversight in meal preparation. The administrator was unaware that meals were served without RD review, highlighting a breakdown in communication and responsibility within the facility's dietary management.
Unauthorized Use of Resident's Debit Card by CNA
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's debit card, which was used without authorization, resulting in unauthorized charges totaling $755. The resident, who was cognitively intact and had a medical history including cancer, renal failure, stroke, urinary tract infection, and manic depression, noticed a decrease in their bank balance and reported the issue to the administration. The investigation revealed that a Certified Nurse Aid (CNA) was responsible for the unauthorized transactions. The facility's policy on abuse prevention and prohibition was not effectively implemented, as staff were unaware of the misuse until after it occurred. The resident confronted the CNA, who refused to discuss the matter, prompting the resident to inform the administration. The Director of Nursing and the administrator became aware of the theft after reviewing the resident's bank statement, which identified the CNA as the perpetrator. The CNA was subsequently terminated, and the local police department was notified for further investigation.
Failure to Submit PBJ Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) for the period from January 1, 2024, to March 31, 2024. The facility had a census of 46 residents during this time. A review of the facility's policies revealed the absence of a PBJ policy. Additionally, the CMS PBJ Staffing Data Report dated August 1, 2024, did not include data for the specified period. During an interview, the Administrator stated that it was the corporate office's responsibility to submit the PBJ data, but the office staff failed to report it despite being informed of the requirement. The Corporate PBJ staff believed that submission was not necessary since the facility was not Medicare Certified during that period, indicating a miscommunication between the facility and corporate staff regarding the need for data submission.
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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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Nursing homes near Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seville Care Center | 1.8 mi | ★★★★★ | 4 | 0 |
| Salem Memorial District Hospital | 1.8 mi | ★★★★★ | 3 | 0 |
| Hickory Manor | 20.9 mi | ★★★★★ | 0 | 0 |
| Stonecrest Healthcare | 22.6 mi | ★★★★★ | 0 | 0 |
| Aurora Health And Rehabilitation | 23.7 mi | ★★★★★ | 10 | 0 |
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