Average — CMS composite of the measures below.
The next survey window likely opens around September 2026
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 Memorial District Hospital during CMS and state inspections, most recent first.
Facility staff did not ensure that a licensed pharmacist completed and documented required monthly drug regimen reviews, including chart reviews, for multiple residents with complex medical conditions and extensive medication regimens. Despite residents having diagnoses such as diabetes, heart disease, stroke, dementia, Alzheimer’s disease, non‑traumatic brain dysfunction, anxiety, and depression, and receiving opioids, anticoagulants, antipsychotics, antidepressants, anti‑anxiety agents, antiplatelets, diuretics, antibiotics, and insulin, their records contained no evidence of monthly pharmacist review or reporting of irregularities to the attending physician, medical director, or DON. The facility director reported that the pharmacist reviews charts monthly and only leaves documentation when recommending changes, and the Administrator acknowledged that the documentation provided did not show that the required pharmacy reviews were completed.
Facility leadership assigned an unqualified individual as Director of Food and Nutrition Services without required dietary management experience or related degree/certification, despite job expectations to supervise all dietary functions and ensure regulatory compliance. Personnel records lacked evidence of required qualifications, and the director confirmed having no prior nursing-facility dietary management experience or formal food service management credentials. The RD worked only part-time, and there were no full-time certified or clinically qualified nutrition staff. The CEO acknowledged knowing the director did not meet position requirements but believed there was a grace period for obtaining necessary certification.
A resident with paraplegia and generalized muscle weakness had an outpatient discharge order for PT at least one hour per day, five days per week, for strengthening, ROM, transfers, and mobility, and the care plan called for restorative ROM as ordered. However, the PT/restorative orders were never entered on the POS, and the resident reported not receiving PT for about six weeks despite expecting restorative therapy and wanting more exercise to maintain independence. An LPN stated the clinic order should have been faxed to the physician for approval and then transcribed, but could not recall a response; the facility director confirmed the PT order did not appear to have been transcribed, and the administrator stated nursing staff and leadership are responsible for following up on all orders. The physician reported not recalling receipt of the faxed PT order and stated that, if received, it would have been approved, resulting in the ordered PT not being provided.
Facility staff failed to follow professional standards by pre-popping medications and leaving them unattended, contrary to policy. An LPN prepared medication cups in advance and left them on the cart, while also failing to notify physicians of late medication administrations for three residents. The unattended medications posed a risk, and the late administrations were not documented as required.
The facility failed to obtain informed consent and conduct entrapment risk assessments for the use of bed rails for several residents. Observations showed residents with quarter rails in the upright position without necessary documentation or physician's orders. Interviews with staff revealed a lack of awareness and understanding of the requirements for bed rail use, indicating a systemic issue in policy implementation.
A facility experienced a 60% medication error rate due to late administration of medications to three residents. An LPN administered medications significantly past the scheduled time, citing delays in getting residents out of bed. The LPN did not notify supervisory staff or the physician about the errors, contrary to facility policy. Interviews with the CNO, Unit Nurse Manager, and CEO highlighted the importance of adhering to the policy to prevent potential negative outcomes.
Facility staff failed to store and handle food properly, leading to potential contamination and food-borne illness risks. Observations showed undated and improperly stored food items, and pureed foods were not reheated to safe temperatures. Additionally, kitchen wares were not fully sanitized, and waste containers were left uncovered, increasing pest risks. Staff interviews revealed a lack of awareness and adherence to proper protocols.
The facility failed to implement an effective QA/QAPI program, as staff did not meet to discuss interventions for systemic issues in LTC. Despite a policy requiring monthly multidisciplinary meetings, no documentation of such a program was found. The CNO noted the absence of LTC-specific discussions, and the CEO admitted to starting from scratch, unaware of any previous program.
Lack of Documented Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
Facility staff failed to ensure that a licensed pharmacist completed and documented monthly drug regimen reviews, including review of the medical chart, for all sampled residents as required by facility policy dated 06/20/22. The policy stated that each resident’s drug regimen must be reviewed at least once a month by a licensed pharmacist and that this review must include the resident’s medical chart. For five sampled residents, their medical records contained no documentation that a pharmacist had conducted these monthly reviews or reported any medication irregularities to the attending physician, medical director, or DON. This lack of documentation occurred despite residents having multiple diagnoses and receiving various high‑risk medications. One resident assessed as cognitively intact had diagnoses including diabetes, UTI, and paraplegia and was receiving opioids, anticoagulants, antibiotics, anti‑anxiety medications, and insulin injections, yet there was no record of a pharmacist’s monthly review. Another cognitively intact resident with diabetes, coronary artery disease, peripheral vascular disease, renal failure, stroke, anxiety, and depression was receiving anti‑anxiety, antidepressant, diuretic, opioid, and antiplatelet medications, also without documented pharmacist review. A cognitively impaired, delusional resident with heart disease, malnutrition, stroke, dementia, depression, arthritis, and hemiplegia, who was receiving PRN pain medication, antipsychotic, antidepressant, and antiplatelet medications, had a care plan directing monthly pharmacy review, but no such documentation was found. Two additional residents with severe cognitive impairment, non‑traumatic brain dysfunction, heart disease or atrial fibrillation, Alzheimer’s disease, anxiety, and depression, who were receiving antipsychotic, antidepressant, and anti‑anxiety medications, likewise had no documented monthly pharmacist review. In interviews, the facility director stated the pharmacist chooses a day each month to review charts and leaves a sheet only if changes are recommended, and acknowledged there is no documentation when no changes are made, while the Administrator confirmed the available documentation did not indicate that required reviews were completed.
Unqualified Director of Food and Nutrition Services Without Full-Time Clinical Nutrition Coverage
Penalty
Summary
Facility staff failed to designate a qualified individual to serve as Director of Food and Nutrition Services when the facility did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The job description for the Food Service Director, dated 04/08/21, stated that the position was responsible for supervision over all dietary functions and staff, including planning, organizing, developing, implementing, and directing the dietary services department and its programs in accordance with current rules, regulations, and guidelines. Review of the personnel records for the person hired into the Food Service Director position on 01/27/25 showed no documentation of prior dietary management experience in a nursing facility, nor certification or other education required for the Director of Food and Nutrition Services role. During interview, the Food Service Director reported having served in that role since January 2025, confirmed having no prior experience as a dietary manager in a nursing facility, and stated they did not have a degree or certification related to food service management. The Food Service Director reported enrolling in an online certified dietary manager course on 10/13/25 but had not yet started the course. The Food Service Director also stated that the facility’s registered dietitian worked only part-time and that the facility did not employ any certified or clinically qualified nutritional staff full-time. In a separate interview, the CEO confirmed that the Food Service Director had been in the role since January 2025, acknowledged that the registered dietitian worked part-time, and confirmed there were no full-time certified or clinically qualified nutritional staff. The CEO further stated that they were aware the Food Service Director did not meet the required qualifications but believed there was a grace period for obtaining certification and did not know the requirements had to be met upon hire.
Failure to Initiate and Transcribe Physical Therapy Orders
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when a physical therapy order for one cognitively intact resident with paraplegia and generalized muscle weakness was not initiated or transcribed into the medical record. The resident’s care plan identified goals related to paraplegia and general weakness, including remaining as independent as possible and receiving restorative care for passive/active range of motion as ordered. Outpatient discharge records contained an order for physical therapy at least one hour per day, five days per week, for core and bilateral lower extremity strength, range of motion, transfers, and mobility. However, review of the physician order summary showed no corresponding order for restorative care or physical therapy. The resident reported having previously received physical therapy but stated that it had not been provided for about a month and a half, despite the expectation of restorative therapy and a desire for additional exercise to maintain strength and independence. An LPN stated that the process for activating outside clinic orders involved faxing them to the physician for approval and then transcribing approved orders, and believed the physical therapy order had been sent but did not recall receiving a response. The facility director stated that outside orders should be communicated to the physician and, once approved verbally or in writing, transcribed by nursing staff, but acknowledged that the physical therapy order appeared not to have been transcribed. The administrator stated that the physician reviews new orders and that nursing staff and the director are responsible for follow-up on all orders. The physician reported having tried to obtain physical therapy for the resident for a long time, did not recall receiving a faxed order for this therapy, and stated that if it had been received, it would have been approved, indicating that the ordered therapy was never implemented.
Medication Administration and Security Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of medication administration, as evidenced by the preparation of medication cups in advance of the scheduled medication pass. An LPN was observed preparing four medication cups with various pills and leaving them on the medication cart unattended. The LPN admitted to pre-popping medications for the morning pass while waiting for residents to be assisted out of bed, despite being unsure of the facility's policy on this practice. Interviews with the Chief Nursing Officer, Unit Nurse Manager, and CEO confirmed that medications should be prepared immediately before administration and not pre-popped. Additionally, the facility staff did not secure medications properly, leaving them unattended on the medication cart. An LPN was observed leaving a medication cup on top of the cart and stepping away from the cart, leaving it out of sight. This action was contrary to the facility's Medication Security policy, which requires medications to be stored in lockable containers or areas. The unattended medications posed a risk of being taken by residents or being misplaced. Furthermore, the facility staff failed to notify physicians of late medication administrations for three residents. Medications scheduled for 8:00 A.M. were administered late, and there was no documentation in the residents' medical records indicating that the physicians were informed of the late administration. The LPN acknowledged the oversight, stating that they did not think to notify the Unit Nurse Manager or the physician. Interviews with the CNO, Unit Nurse Manager, and CEO confirmed that late administration of medications is considered a medication error, and the physician should be notified for further directions.
Failure to Obtain Consent and Conduct Risk Assessments for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails and did not complete entrapment risk assessments or obtain physician's orders for several residents. Specifically, Resident #5 did not have a signed consent form, an entrapment assessment, or a physician's order for the use of side rails. Observations showed the resident in bed with quarter rails in the upright position, and the Unit Nurse Manager admitted to not realizing the consent form was incomplete. For Residents #8, #11, #12, and #13, the facility also failed to conduct entrapment assessments or obtain physician's orders for the use of side rails. These residents were observed with quarter rails in the upright position, despite their varying levels of cognitive and physical impairments. The medical records for these residents lacked necessary documentation, indicating a systemic issue in the facility's handling of bed rail use. Interviews with facility staff, including the Activities Director, Chief Nursing Officer, Unit Nurse Manager, and Chief Executive Officer, revealed a lack of awareness and understanding regarding the requirements for entrapment assessments, consents, and physician's orders for bed rails. The staff admitted to not being familiar with the procedures or the necessity of these assessments, highlighting a significant gap in training and policy implementation within the facility.
Medication Administration Errors Due to Late Administration
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a 60% error rate during the observation of 25 medication administration opportunities. This deficiency affected three residents out of seven sampled, with errors primarily due to late administration of medications. The Licensed Practical Nurse (LPN) responsible for administering the medications was observed giving them significantly past the scheduled time, citing delays in getting residents out of bed as the reason for the lateness. The medications were administered between one hour and 50 minutes to three hours late, which was outside the acceptable timeframe of 7 A.M. to 9 A.M. The LPN acknowledged the late administration but did not notify the Unit Nurse Manager or the physician about the errors, as required by the facility's policy. Interviews with the Chief Nursing Officer (CNO), Unit Nurse Manager, and Chief Executive Officer (CEO) revealed that the facility's policy mandates notification of supervisory staff and the physician in the event of a medication error. The CNO and CEO emphasized the importance of following the policy to prevent potential negative outcomes for residents due to late medication administration.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to adhere to proper food storage and handling protocols, leading to potential contamination and food-borne illness risks. Observations revealed that the walk-in cooler contained opened and undated bags of various vegetables, and the walk-in freezer had improperly stored items, including frost-covered pork and salmon patties, as well as boxes of frozen foods placed directly on the floor. Additionally, the reach-in refrigerator contained opened and undated bags of cooked bacon, shredded cheese, and carrots. Interviews with staff indicated a lack of consistent labeling and dating of food items, and improper storage practices, such as placing food on the floor, were acknowledged. The facility also failed to ensure that pureed foods were reheated to safe temperatures to prevent the growth of food-borne pathogens. During meal preparation, pureed items like baked beans and hamburgers were placed on the steam table without checking their temperatures. Subsequent temperature checks revealed that the pureed hamburger and chicken noodle soup were served at temperatures significantly below the required safe levels. Staff interviews highlighted a lack of awareness regarding the specific requirements for reheating pureed foods, and the interim Dietary Supervisor admitted to not being informed about these requirements. Furthermore, the facility did not properly sanitize kitchen wares, as observed when a staff member failed to fully submerge food processor parts in the sanitizer solution for the required duration. The same staff member also improperly sanitized a thermometer by wiping it with a cloth after using an alcohol wipe, which was not in accordance with proper sanitization procedures. Additionally, kitchen waste containers were left uncovered, increasing the risk of pest attraction. Interviews with staff and the interim Dietary Supervisor confirmed these lapses in following proper sanitization and waste management protocols, with the interim DS acknowledging the absence of trash can lids and the need for covered waste containers.
Failure to Implement Effective QA/QAPI Program
Penalty
Summary
The facility staff failed to implement an effective Quality Assurance (QA) and Quality Assurance Performance Improvement (QAPI) program. The deficiency was identified through interviews and record reviews, revealing that staff did not meet to discuss interventions for ongoing systemic issues in the Long Term Care (LTC) unit. The facility's LTC QAPI policy, revised in June 2022, outlined the need for a multidisciplinary team to meet monthly to evaluate current projects and identify areas for improvement. However, there was no documentation of a QAPI/QA program being implemented. During interviews, the Chief Nursing Officer (CNO) acknowledged familiarity with the QA/QAPI process on the hospital side but noted that LTC-specific discussions were absent. The Chief Executive Officer (CEO) indicated that the responsibility for implementing a QAPI/QA program lay with the Administrator/Executive Director and admitted to starting from scratch, as there was no knowledge of a previous program.
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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 | 0 mi | ★★★★★ | 4 | 0 |
| Salem Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Hickory Manor | 19.7 mi | ★★★★★ | 0 | 0 |
| Aurora Health And Rehabilitation | 22.6 mi | ★★★★★ | 10 | 0 |
| Rolla Presbyterian Manor | 22.9 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 July 2026) and official state health department websites.