Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Care Center during CMS and state inspections, most recent first.
A resident receiving liquid Lorazepam had incomplete controlled-medication documentation, including missing administration details and an unaccounted amount of medication. In addition, two med carts had repeated shift-change count sheets signed by only one staff member instead of two, despite staff and DON expectations for dual verification and documentation of controlled substances.
Insufficient Surety Bond for Resident Funds: Facility staff failed to maintain a surety bond large enough to secure resident funds held by the facility. Review of the trust fund account showed an average monthly balance that required a bond of $75,000 or more, but the facility only had a $70,000 approved non-cancelable Escrow Agreement Account. The BOM and administrator both stated they were responsible for resident funds and were not aware the bond was insufficient.
Facility staff failed to ensure three NAs completed the required training program within the 4-month timeframe. Records for three NAs lacked documentation of CNA training completion, and interviews with the DON and Administrator confirmed the aides were outside the 120-day requirement and had not yet been certified, with the delay attributed to coordination issues and pending testing.
Failure to Maintain a Homelike Environment: Facility observations showed multiple burned-out light bulbs, missing ceiling light and call light covers, peeling sheetrock, chipped and missing paint, and resident room damage with exposed moisture and holes. A resident said he/she wanted the facility to maintain the area and did not feel staff did a good job with repairs. The ADM knew about the missing covers, and the maintenance director was aware of needed repairs but did not keep an updated written list of projects.
Insulin pens were not stored separately as required by facility policy. Observations found multiple residents' insulin pens kept together in baskets and even loose in a drawer on the med cart, including 13 pens in one basket, 11 pens in another, and additional pens grouped in several other baskets. RN B said this had always been the practice, and the DON stated opened pens were dated and placed in designated baskets in the cart.
Failure to maintain safe temperatures for pureed foods: staff blended pureed peppered pork loin, mashed potatoes and gravy, and pureed green beans, then placed them in pans and hot water without checking internal temps before service. The foods were later measured at 96 F, 96 F, and 91 F, and the DS stated he/she forgot to check temps before serving.
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.
Controlled Medication Counts and Documentation Not Completed
Penalty
Summary
Facility staff failed to ensure controlled medication counts were completed at each shift change with two staff members and failed to consistently document administration details for a resident’s liquid Lorazepam, a controlled substance. The facility policy required controlled medications to be inventoried at each shift change or when keys were surrendered, with the results documented on the controlled substances shift change sheet, and required administration details to be recorded on the controlled medication utilization record. The census was 49. For one resident with severe cognitive impairment who received antianxiety medication, the controlled medication utilization record did not document the details of each Lorazepam administration, and the EMAR did not show documentation of the resident’s 6:00 P.M. dose or a refusal. The controlled medication utilization record also did not document the resident’s Lorazepam administration on that date. The facility’s investigation found the packaging for the medication was moist to touch and approximately 4.75 mL of the medication was unaccounted for, and staff conducted a drug screen on all licensed staff. Review of the controlled drugs shift change forms for two medication carts showed repeated instances where only one staff signature was present instead of two at shift change or key transfer. The 100/200 hall cart and the 300 hall cart both had multiple dates with incomplete count documentation. During interviews, staff and leadership stated their expectation was for two staff to count controlled medications and sign the forms at each shift change, and they acknowledged that failing to do so made it difficult to determine responsibility for a missing medication or discrepancy in the count.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was deficient because facility staff failed to purchase a surety bond in an amount sufficient to cover all resident funds held by the facility. The facility census was 44.1, and review of the resident trust fund account for March 2025 through February 2026 showed an average monthly balance of $47,132.42, which required a surety bond of $75,000 or greater. Review of the DHSS database showed the facility had an approved non-cancelable Escrow Agreement Account in the amount of $70,000. During interviews, the BOM stated he/she was responsible for resident funds and ensuring the bond was sufficient but was not aware it needed to be increased, and the administrator stated the BOM was responsible for resident funds and ensuring the surety bond was sufficient but was not aware the bond was insufficient.
Nurse Aides Not Completed Training Within Required Timeframe
Penalty
Summary
Facility staff failed to ensure three nurse aides completed the nurse aide training program within four months of employment. Review of the facility’s Nurse Aide Qualifications and Training Requirements showed nursing assistants who do not successfully complete the required training program within the first four months of employment may be terminated or reassigned to non-nursing related services. The census was 44.1. Record review showed NA A transferred from housekeeper to NA on 8/15/25, but the file did not contain documentation that the NA completed a nurse aide training program. NA D’s personnel record showed a hire date of 07/09/25, and the record also lacked documentation of completion of a nurse aide training program. NA E transferred from housekeeper to NA on 09/15/25, and the file did not contain documentation that the NA completed a nurse aide training program. During interviews, the DON said he/she was responsible for NA qualifications and ensuring certification within four months of hire, and acknowledged the aides were outside the compliance dates. The Administrator also stated the requirement was to have the NAs certified within 120 days from the date of hire and said the issue was due to a lack of coordination between staff.
Failure to Maintain a Homelike Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment. Observations across multiple areas of the facility showed 13 light bulbs needing replacement in the main dining hall, four ceiling light fixtures missing covers, a ceiling light fixture in the egress between the lobby and the nurse's desk missing its cover, and additional ceiling light fixture covers missing on the 200 hall, 300 hall, and above rooms 106, 107, 109, 302, 304, 310, and the beauty shop. The facility also had a missing ceiling light fixture cover in the egress area, and the administrator acknowledged awareness of the missing call light covers and missing ceiling light fixture covers. Other observations showed physical deterioration in resident areas and common areas, including peeling sheetrock next to a resident room hallway doorframe, a large amount of paint missing and surfaces excessively scuffed, scraped, and chipping on the shower room door frame and front door, and resident-occupied rooms with baseboards off the wall, exposed moisture, chipped paint, exposed holes, and black and brown spots. One resident stated that if this was where he/she had to live, he/she would like the facility to maintain it and said he/she did not feel staff did a good job with repairs. The maintenance director stated there had been major projects completed and was aware of rooms, light covers, and broken lights needing repair, but did not keep a written document of projects to complete or updated. The administrator stated staff could submit paper work orders in a designated mailbox, but was unable to provide a specific schedule for collection or a time frame for completion.
Insulin Pens Stored Together in Medication Cart
Penalty
Summary
Facility staff failed to store insulin pens in a safe and effective manner when opened insulin pens for multiple residents were kept together rather than stored separately according to the facility policy. The policy titled, "Policy and Procedure; Medication Storage," dated 11/1/2013, stated medications and biologicals are to be stored in a safe, secure manner and that each resident is assigned a cubicle or drawer to prevent the possibility of a drug for one resident being given to another. Observations showed insulin carts containing multiple insulin pens from different residents stored together in baskets and, at one point, loose in the bottom of a drawer. One observation found 13 insulin pens for 13 residents stored together in one basket, another found 11 insulin pens for 11 residents stored together in the same basket, and another found 11 pens loose in a drawer, 9 pens in one basket, 4 pens in a second basket, and 2 pens in a third basket. RN B stated this was how insulin pens had always been stored and that staff identified them by the label on each pen. The DON stated opened insulin pens were dated and placed in designated baskets in the medication cart, and the Administrator stated the DON oversaw medication storage practices.
Failure to Maintain Safe Temperatures for Pureed Foods
Penalty
Summary
Food and drink were not kept at a safe and appetizing temperature when staff failed to ensure pureed hot foods remained at the required holding temperature before service. The facility’s policies stated potentially hazardous foods must be held at the designated temperature, and mechanically altered hot foods for modified consistency diets must stay above 135 F during preparation. The menu identified pureed peppered pork loin, mashed potatoes and gravy, pureed spinach, and pureed dinner roll for residents on pureed diets, and the facility had two residents receiving pureed diets. During observation, the dietary supervisor blended pureed peppered pork loin, mashed potatoes and gravy, and pureed green beans, placed each item into pans, and put them into the steam table or into large pans with hot water without checking the internal temperatures. The dietary supervisor later moved food from the steam table to hot water pans because there was not enough space, and continued serving without checking temperatures. When measured, the pureed peppered pork loin was 96 F, the mashed potatoes and gravy were 96 F, and the pureed green beans were 91 F. The dietary supervisor stated he/she forgot to check the internal temperatures before service, and the administrator and interim dietary supervisor stated hot food items were expected to be checked before service and remain on the steam table.
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 | ★★★★★ | 17 | 0 |
| Stonecrest Healthcare | 22.6 mi | ★★★★★ | 0 | 0 |
| Aurora Health And Rehabilitation | 23.7 mi | ★★★★★ | 10 | 0 |
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