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 Seville Care Center during CMS and state inspections, most recent first.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident's money, totaling $1700, was stolen after being locked in a medication room cabinet by an LPN. Camera footage showed only the DON accessed the cabinet before the money was found missing. The DON later admitted to taking the money after initially denying involvement, causing emotional distress to the resident.
Staff failed to notify physicians after two residents experienced repeated abnormal blood pressure readings and withheld antihypertensive medications as ordered. Despite clear expectations and documentation of low BP, there was no evidence of physician notification, even after family concerns were raised. Interviews confirmed that staff were expected to notify and document physician contact in such situations, but this did not occur.
A resident with cognitive impairment and multiple psychiatric diagnoses was subjected to verbal and emotional abuse when an LPN yelled at the resident to "shut up" multiple times in close proximity to the resident's face. The incident was witnessed by a CNA and confirmed through interviews and documentation, in violation of the facility's abuse prevention policy.
The facility failed to update its abuse and neglect policy to meet the required reporting time frames. The policy did not include the requirement to report alleged violations within two hours if they involve abuse or result in serious bodily injury. Interviews revealed that the DON was aware of the two-hour requirement but unsure of the policy details, and the administrator had not reviewed the policy.
The facility failed to meet professional standards in medication management and fall protocols. A resident did not receive a timely refill of pain medication, leading to discomfort. Another resident's medication and tube feeding administration were not properly documented. Additionally, neurological checks were not completed for residents with unwitnessed falls, as required by policy.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, from July to December 2024. The RN staff schedule showed multiple days without adequate coverage, and interviews revealed a lack of awareness and understanding of the regulation by the DON and administrator.
A resident developed a new pressure ulcer on the right buttock, but facility staff failed to complete proper weekly skin assessments and did not notify the physician to obtain a treatment order. The resident's care plan indicated a risk for skin integrity impairment, but the weekly assessments lacked complete wound documentation. Interviews revealed that nurses did not assess the wound or obtain treatment orders, despite the facility's policy requiring such actions.
The facility failed to ensure the activities program was directed by a qualified professional. The current Activity Director, hired in May 2024, did not have the required certification and was not enrolled in any courses to obtain it. The DON was unaware of the certification requirement, while the Administrator believed another part-time staff member's certification would suffice.
Facility staff failed to ensure privacy for two residents during perineal care. In one case, staff did not pull the privacy curtain between a resident and their awake roommate. In another, staff did not close window blinds, allowing a clear view from outside. Staff acknowledged these oversights, and interviews with facility leaders confirmed the expectation to maintain privacy during care.
Facility staff failed to update the care plan for a resident with Alzheimer's who frequently wandered into other rooms. Despite assessments indicating disorientation and a history of wandering, the care plan lacked guidance for managing these behaviors. Interviews revealed staff were unclear about the care plan's contents, and the MDS Coordinator admitted the plan should have been updated when the wandering began.
A resident, assessed as capable of smoking independently, had their smoking privileges revoked following a behavioral incident, despite the facility's policy not clearly supporting such action. The resident, who is cognitively intact and undergoing cancer treatment, expressed increased anxiety due to the change. Interviews revealed a misunderstanding of the policy's application by the facility's DON and administrator.
Facility staff failed to notify the physician when a resident expressed feelings of self-harm, despite the resident's history of depression and manic depression. The staff only contacted the resident's guardian and performed 15-minute checks, neglecting the facility's protocol to inform the physician.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Misappropriation of Resident Funds by DON
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's money when the Director of Nursing (DON) stole $1700.00 from a cognitively intact resident. Upon admission, the resident provided a resealable plastic bag containing the money to an LPN, who then locked it in a cabinet in the medication room. Camera footage confirmed that the LPN secured the bag in the cabinet and that the DON was the only staff member to access the cabinet before the money was discovered missing. The DON removed an item from the cabinet, looked at the camera, and left the medication room. No other staff accessed the cabinet during this period. The resident later requested the money, but staff were unable to locate it. The resident reported emotional distress due to the loss, as the money was intended for gifts for grandchildren. During the investigation, the DON initially denied knowledge of the money but later admitted to taking it when interviewed by the police. The facility's policy defines misappropriation as the wrongful use of a resident's belongings or money without consent, and the DON's actions directly violated this policy.
Failure to Notify Physician of Abnormal Blood Pressure Readings
Penalty
Summary
Facility staff failed to notify the physicians of two residents after documenting multiple abnormal blood pressure (BP) readings below the threshold specified in the residents' physician orders. Both residents had diagnoses including hypertension and were prescribed antihypertensive medications with explicit instructions to hold the medication if BP readings fell below 100/60 mmHg. Despite repeated low BP readings and withheld medication administrations, there was no documentation that the physicians were informed of these abnormal findings or the medication holds. For one resident with moderate cognitive impairment and a history of hypertension, staff recorded several instances of low BP readings and withheld doses of Hydralazine as ordered. The resident's family expressed concern about the consistently low BP and requested a physician appointment, but there was no evidence that the physician was notified or that the concern was escalated. The physician later confirmed that he was not informed of the abnormal BP readings and would have expected notification to reassess and adjust treatment as necessary. A second resident, cognitively intact with heart failure and hypertension, also experienced multiple days of low BP readings resulting in held doses of antihypertensive medications. Again, there was no documentation of physician notification regarding these abnormal readings or medication holds. Interviews with staff, including the DON, LPN, and CMT, confirmed the expectation to notify the physician and document such notifications, but this was not done in these cases. The physician reiterated the expectation for notification to allow for timely intervention.
Failure to Protect Resident from Verbal and Emotional Abuse by LPN
Penalty
Summary
Facility staff failed to protect a resident from verbal and emotional abuse when an LPN yelled at the resident to "shut up" multiple times, with the LPN's face in close proximity to the resident. This incident was witnessed by a CNA, who reported that the LPN entered the resident's room while the resident was screaming and proceeded to yell at the resident, stating, "Shut up! Shut up! Shut up! I'm not dealing with this tonight!" The resident was assessed as having cognitive impairment, including diagnoses of dementia, anxiety disorder, depression, bipolar disorder, psychotic disorder, and schizophrenia. The resident's care plan indicated the need for staff to monitor for non-verbal signs of pain or distress, use brief and consistent communication, and provide a safe environment. The facility's policy prohibits any form of abuse, including verbal and emotional abuse, and defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. During interviews, the administrator confirmed that the resident appeared physically distraught when discussing the incident. The LPN denied yelling at the resident but admitted to being short with staff that night. Documentation and staff statements consistently described the LPN's behavior as verbally abusive toward the resident.
Failure to Update Abuse and Neglect Reporting Policy
Penalty
Summary
The facility staff failed to develop an abuse and neglect policy that met the required time frame for reporting allegations of abuse or neglect. The facility's policy, revised in 2012, stated that any alleged violations must be reported immediately to the designated state agency, with 'immediately' defined as no more than 24 hours after the incident is discovered. However, the policy did not include the requirement to report all alleged violations within two hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not involve abuse and do not result in serious bodily injury. During interviews, the Director of Nursing acknowledged awareness of the two-hour reporting requirement but was unsure of the policy details, while the administrator admitted to not having reviewed the policy provided by the new owners.
Deficiencies in Medication Management and Fall Protocols
Penalty
Summary
The facility staff failed to ensure professional standards of practice were met in several instances, leading to deficiencies in resident care. One resident, who was cognitively intact and on a scheduled pain regimen, did not receive a timely refill of their prescribed pain medication, Buprenorphine. The staff did not order the refill in accordance with the facility's policy, resulting in the resident going without the medication for several days. During this period, the resident experienced discomfort and was not provided with an adequate substitute, despite the availability of an emergency medication kit. Another deficiency involved the failure to document the administration of medications and tube feedings for a resident who was dependent on tube feeding and had multiple diagnoses, including stroke and traumatic brain injury. The resident's Medication Administration Record (MAR) showed multiple instances where medications and feedings were not documented as administered. Interviews with staff revealed that there was no system in place to double-check for missing documentation, leading to gaps in the MAR. Additionally, the facility staff did not complete and document neurological checks for residents who experienced unwitnessed falls, as required by the facility's policy. Three residents, each with varying levels of cognitive and physical impairments, had unwitnessed falls, yet their electronic medical records lacked documentation of the necessary neurological assessments. Interviews with staff indicated a lack of consistent adherence to the policy, with some staff making case-by-case decisions rather than following the established protocol for all unwitnessed falls.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by regulations. The facility's RN staff schedule for the months of July through December 2024 showed multiple days where there was no RN coverage for the required duration. Specifically, there were numerous instances across these months where the facility did not have an RN present for eight consecutive hours, impacting the continuity of care for the residents. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness and understanding of the regulation. The DON was unaware of any current days without the required RN coverage since starting at the facility in November. The administrator acknowledged awareness of the regulation but noted challenges in meeting it, particularly due to nurses taking time off over weekends without adequate coverage. This deficiency highlights the facility's failure to ensure consistent RN presence, which is crucial for maintaining oversight and continuity of care.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility staff failed to properly complete weekly skin assessments and notify the physician to obtain a treatment order for a resident who developed a new facility-acquired pressure ulcer on the right buttock. The facility's policy requires treatment to heal existing pressure ulcers and prevent new ones, but this was not adhered to. The resident's care plan indicated a potential for skin integrity impairment and a previous Stage two pressure ulcer on the left buttock, which had resolved. However, the weekly skin assessments did not include complete wound assessments, measurements, or descriptions of the wound. The resident's Physician's Order Sheet and Treatment Administration Record lacked documentation of a physician's ordered wound treatment for the buttock area. Nurses' notes also did not contain documentation regarding the resident's pressure ulcer. During interviews, the resident reported having an open area that was not being treated, and an LPN was unaware of the need for treatment. The wound care physician later assessed the wound as a Stage three pressure injury with specific measurements and characteristics. Interviews with facility staff revealed that nurses were responsible for performing weekly skin assessments and obtaining treatment orders for new wounds. However, the LPN admitted to noticing the new wound but did not assess it or obtain an order due to being busy. The RN acknowledged not measuring or assessing the wound during weekly assessments and failing to verify treatment orders. The Director of Nursing and the administrator emphasized the importance of accurate documentation and obtaining treatment orders, but these expectations were not met in this case.
Unqualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The facility's policies did not include a policy regarding the qualifications for the Activity Director position. The job description for the Activities Designee indicated that the Activity Director must receive certification within six months of hire. However, the current Activity Director, hired on 05/17/24, did not have the required certification and was not enrolled in any courses to obtain it. Interviews revealed that the Director of Nursing was unaware of the certification requirement and the Administrator was aware of the lack of certification but believed that another part-time staff member's certification would suffice.
Failure to Ensure Resident Privacy During Perineal Care
Penalty
Summary
Facility staff failed to protect the privacy of two residents during perineal care, as observed in two separate incidents. In the first incident, two staff members, a Certified Nursing Assistant (CNA) and a Nursing Assistant (NA), provided perineal care to a resident without pulling the privacy curtain between the resident and their roommate, who was awake and facing the resident. Both staff members acknowledged the oversight during interviews, with one stating they were nervous and forgot to pull the curtain, while the other did not prompt their colleague to do so. In the second incident, the same CNA, along with another CNA, provided perineal care to a different resident without lowering and closing the window blinds, allowing a clear view from the outside. This oversight was repeated in a subsequent observation with the same CNA and NA. Both staff members admitted during interviews that they failed to consider the need to close the blinds for privacy. Interviews with a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the facility administrator confirmed that staff are expected to ensure privacy by using privacy curtains and closing window blinds during such care.
Failure to Update Care Plan for Wandering Resident
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for a resident who was cognitively impaired and had a history of wandering. Despite being assessed as disoriented and having a diagnosis of Alzheimer's Disease, the resident's care plan, dated July 18, 2024, did not include guidance for when the resident wandered into other residents' rooms or potentially unsafe areas. Observations and interviews revealed that the resident frequently propelled themselves in a wheelchair throughout the facility, requiring frequent redirection, yet the care plan was not updated to address these behaviors. Interviews with facility staff, including a CNA, a CMT, and the MDS Coordinator, indicated a lack of awareness and clarity regarding the resident's care plan concerning wandering. The MDS Coordinator acknowledged the responsibility to update care plans with any changes in care, noting that the resident's care plan should have been updated when the wandering behavior began approximately six months prior. The facility's policy did not provide specific guidance on updating care plans when changes in resident care were observed, contributing to the oversight.
Resident's Smoking Privileges Revoked Due to Behavioral Incident
Penalty
Summary
The facility staff failed to honor a resident's right to self-determination and a dignified existence by not allowing the resident, who was assessed to smoke independently, to smoke a cigarette as a consequence for their behavior. The facility's smoking policy allowed for residents to smoke independently if assessed as capable, but also included a disclaimer that residents displaying undesirable behaviors would lose their smoking opportunity. However, the policy did not provide clear guidance on transitioning residents to supervised smoking if they exhibited such behaviors. The resident in question was cognitively intact and had been assessed as capable of smoking independently. Despite this, the resident's independent smoking privileges were revoked following an incident where the resident became upset and displayed disruptive behavior when unable to access their cigarettes. The Director of Nursing (DON) informed the resident that their behavior violated the smoking policy, resulting in the revocation of their independent smoking privileges. The resident expressed distress over this decision, citing increased anxiety and discomfort due to the change in smoking arrangements. Interviews with the DON and the facility administrator revealed a misunderstanding of the policy's application, with the administrator acknowledging that the resident's privileges should not have been changed based on the policy as written. The resident's care plan did not include directives to remove smoking privileges or transition to supervised smoking based on behavior, highlighting a gap between policy and practice.
Failure to Notify Physician of Resident's Self-Harm Statement
Penalty
Summary
Facility staff failed to notify the physician in a timely manner for a resident who expressed feelings of self-harm. The resident, who was cognitively intact and had a history of depression and manic depression, reported feeling depressed and expressed a desire to self-harm. Despite the facility's policy requiring staff to notify the attending physician and family in such cases, the staff only contacted the resident's guardian and the Director of Nursing (DON). The guardian declined a room change for the resident, believing it would not help the resident learn to resolve conflicts. The staff documented performing 15-minute checks on the resident but did not notify the physician of the resident's statement of self-harm, as required by the facility's protocol. Interviews with the resident, the resident's guardian, and various staff members revealed a lack of awareness and adherence to the facility's protocol for handling statements of self-harm. The resident confirmed making the statement about a week prior, and the guardian acknowledged being contacted by the facility but believed the resident's behavior was attention-seeking. The Registered Nurse (RN) interviewed was unaware of the protocol for notifying the physician, and both the Administrator and DON confirmed that the physician should have been notified. The physician and Psychiatric Nurse Practitioner (NP) also stated that they would expect to be contacted in such situations to ensure the resident's safety. However, the staff failed to follow through with this critical step, leading to a deficiency in the facility's handling of the resident's mental health needs.
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Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — 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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salem Memorial District Hospital | 0 mi | ★★★★★ | 3 | 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.