Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Salemtowne during CMS and state inspections, most recent first.
A resident receiving hospice and end-of-life care with severe cognitive impairment and total dependence for ADLs had an order for morphine 20 mg/ml, 0.25 ml q4h PRN for pain and shortness of breath. After a family member reported apparent pain, a medication aide assessed the resident as restless, retrieved the morphine, and administered 2.5 ml instead of the ordered 0.25 ml, documenting this on the narcotic record. Routine narcotic shift-change counts did not detect the error, and it was discovered two days later when a nurse compared the ordered dose to the previously documented administration. Subsequent assessments by hospice nursing, the DON, and an NP found the resident resting comfortably with warm, dry skin, normal chest rise, and no signs of respiratory distress, while also noting a gradual decline consistent with end-of-life status.
Surveyors found an Insulin Lispro KwikPen on a medication cart that was past the manufacturer’s 28-day discard date and lacked any label identifying the resident or room number. An RN on the unit confirmed the pen had been opened well beyond the allowed timeframe and acknowledged that nurses using the cart were responsible for checking and removing expired medications. In interviews, the interim DON stated that assigned nurses and the third shift were responsible for routine cart checks and that insulin pens should carry a pharmacy label with the resident’s name and room number, while the Administrator stated that nursing staff must follow manufacturer guidelines and audit medication carts and rooms during their shifts.
Staff failed to follow the facility's infection control policy by using alcohol-based hand sanitizer instead of washing hands with soap and water after caring for a resident with C. difficile infection. Despite clear policy requirements and signage, several staff members were unaware that hand sanitizer is ineffective against C. difficile spores and did not perform proper hand hygiene after resident care.
The facility failed to maintain sanitary conditions in its central and Garden/Mill kitchens. Staff were observed handling food without covering facial hair, and improperly cleaned pans were found in the central kitchen. In the Garden/Mill kitchen, the sanitizing solution for utensils was ineffective, as testing showed no sanitizing agent present.
Significant Morphine Dosing Error for Hospice Resident
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a medication aide administered an incorrect dose of morphine. The resident had a history of multiple strokes, was severely cognitively impaired, dependent on staff for all ADLs, and was receiving hospice and end-of-life care. A physician’s order directed morphine 20 mg/ml, 0.25 ml every 4 hours as needed for pain and shortness of breath. On the date of the incident, after a family member reported the resident appeared to be in pain or discomfort, the medication aide assessed the resident as restless, retrieved the morphine from the medication cart, and reported that she checked the bottle label and directions before pouring and administering 2.5 ml instead of the ordered 0.25 ml. She documented administration of 2.5 ml on the narcotic record, leaving 27.50 ml remaining in the 30 ml bottle. The error was not recognized at the time of administration and was not detected during routine narcotic shift-change counts, which involved two staff members reviewing the beginning amount, amount given, and amount remaining. The discrepancy was only identified two days later when a nurse prepared to administer a subsequent dose and compared the ordered 0.25 ml to the previously documented 2.5 ml dose. Interviews with the hospice nurse, DON, and nurse practitioner indicated that following the incorrect dose, the resident was repeatedly observed resting comfortably, with stable or acceptable clinical observations such as warm, dry skin, normal chest rise, and no noted discoloration of lips or fingertips. The nurse practitioner and hospice nurse both described the resident as gradually declining over the prior week in the context of end-of-life care, and the nurse practitioner stated that although the resident received a much higher dose of morphine than ordered, it did not affect his outcome and he later passed away peacefully.
Expired and Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications when an Insulin Lispro KwikPen on the Mill Place medication cart was found to be both expired and unlabeled. Manufacturer guidance from 2023 specified that the Insulin Lispro KwikPen must be discarded 28 days after opening, yet the pen observed on 12/10/25 had been opened on 10/16/25 and remained available for use. The pen had no label and did not display any information identifying the resident’s name or room number. Nurse #4, who was present during the observation, confirmed that the insulin should have been discarded 28 days after opening and acknowledged that all nurses using the cart were responsible for checking and removing expired medications. In a follow-up interview, Nurse #4 identified the unlabeled insulin pen as belonging to Resident #36 and stated that both the KwikPen and its storage box should have been labeled with the resident’s name and room number. The interim DON reported that nurses assigned to the medication cart were responsible for identifying and removing expired medications and that the third shift (11 p.m. to 7 a.m.) was designated to check one cart per week. The interim DON also stated that the KwikPen should have a pharmacy label with the resident’s name and room number. The Administrator stated that nursing staff must follow the manufacturer’s guidelines and audit both the medication cart and the medication room during their shifts.
Failure to Follow Hand Hygiene Protocol for C. difficile Infection
Penalty
Summary
The facility failed to follow its infection control policy regarding hand hygiene for residents with Clostridium difficile (C. difficile) infection. Specifically, two nursing assistants and a medication aide used alcohol-based hand sanitizer instead of washing their hands with soap and water after providing care to a resident with an active C. difficile infection. The facility's policy, as well as the enteric precaution signage, required staff to wash hands with soap and water because alcohol-based hand sanitizers are not effective against C. difficile spores. Interviews revealed that the staff members were unaware of this requirement and routinely used hand sanitizer after care, regardless of whether there was contact with stool. The deficiency was observed through record review and interviews with staff and a family member, who also reported never seeing staff wash their hands with soap and water after care. The resident involved had been admitted with a diagnosis of C. difficile and was on enteric precautions, including orders for personal protective equipment and specific antibiotic therapy. Despite the presence of appropriate signage and availability of PPE, staff did not adhere to the hand hygiene protocol outlined in the facility's infection control policy. The Director of Nursing confirmed that staff were expected to wash hands with soap and water after caring for residents with C. difficile, and that this was a facility policy. However, the interviewed staff, including agency personnel, were not aware that alcohol-based hand sanitizer was insufficient for C. difficile infection control.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in both the central kitchen and one of its satellite kitchens, specifically the Garden/Mill kitchen. During a follow-up tour, it was observed that the dietary cook and the facility's Chef were handling food without covering their facial hair, which was approximately half an inch to one inch in length. This was noted both in the central kitchen while transferring baked chicken to transport containers and in the Garden/Mill satellite kitchen during food preparation. Additionally, the central kitchen's storage rack for clean pots and pans was found to have eight stainless-steel pans with dried, dark brown debris on the inside, indicating they were not properly cleaned before being stacked for use. In the Garden/Mill satellite kitchen, the sanitizing process was compromised as pots, pans, and utensils were immersed in a clear liquid that was supposed to contain a sanitizing agent. However, upon testing, it was revealed that there was no sanitizing agent present in the solution, as indicated by the sanitizing testing strip not changing color.
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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 Winston-salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mill Creek Center For Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 1 | 0 |
| Brookridge Retirement Community | 2.1 mi | ★★★★★ | 1 | 0 |
| Arbor Acres United Methodist Retirement Community | 3.8 mi | ★★★★★ | 2 | 0 |
| Willow Valley Center For Nursing And Rehabilitatio | 4.6 mi | ★★★★★ | 10 | 1 |
| Oak Forest Health And Rehabilitation | 4.7 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.