Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Salemhaven during CMS and state inspections, most recent first.
Improper Date Labeling of Refrigerated Thickened Beverages and Shakes: Surveyors found multiple thickened beverages and Mighty Shakes in the kitchen and 3 kitchenette refrigerators without required open, use-by, or thaw dates. The Dietary Mgr confirmed the items should have been labeled per manufacturer instructions and facility policy, but they were not.
Physician orders were not followed for a resident receiving labetalol for HTN. The MAR showed multiple doses given when SBP was below the ordered parameter of greater than 160, and the IP and MD confirmed the medication was administered outside the ordered limits. Facility policy required meds to be given in accordance with written prescriber orders and documented as withheld when not administered.
Two residents with indwelling urinary catheters had PRN irrigation orders that did not specify when irrigation should be done or how much NS to use. For one resident, no urine output was documented overnight, and the provider was not notified. The DON and MD confirmed the orders were incomplete, and the MD confirmed he/she was not notified of the no-output event.
Unlabeled Opened Multidose Tuberculin Vials: Surveyors found opened vials of tuberculin in 2 medication refrigerators without an opened date or open expiration date. An LPN and the Infection Preventionist confirmed the findings. The facility policy required multidose vials to be labeled with the date opened, and the manufacturer stated an entered vial of TUBERSOL should be discarded after 30 days.
Infection prevention and control program not reviewed annually and droplet precautions were not followed for three residents during a respiratory outbreak. A resident with pneumonia, a resident with an upper respiratory infection on antibiotics, and another resident on droplet precautions all had staff or contracted personnel enter rooms without the required PPE, despite signage calling for N95, gown, gloves, and face shield use. The IP confirmed the outbreak-related precautions, and the Administrator confirmed the IPC plan had not been reviewed since June 2024.
Failure to Implement Staff COVID-19 Immunization Policy: The facility failed to follow its COVID-19 vaccination policy for staff. The IP stated the facility did not offer the COVID-19 vaccine to employees or track declinations, and there was no staff immunization policy in place. A staff member’s record showed the last COVID-19 vaccine was in 2021, and the staff member said they could not recall being offered the vaccine or asked to sign a declination. The IPC plan addressed other vaccines and flu shots but did not include staff COVID-19 vaccination.
Resident Council grievances were not documented as addressed or followed up. Residents reported cold meals, food not matching orders, missing items, and long waits to use the bathroom, but meeting minutes did not show any response or follow-up at later meetings. All eight residents in attendance said the facility did not tell them what actions, if any, had been taken, and the AD confirmed the concerns were not shared with Dept Heads. The Administrator also confirmed missing council minutes for several months.
The facility failed to follow infection control protocols, including improper hand hygiene and glove use during medication administration, incorrect disposal of medical waste, and inadequate cleaning of medical equipment. Additionally, Enhanced Barrier Precautions were not implemented for residents with open wounds or indwelling devices, as required by facility policies and CDC guidelines.
The facility failed to report alleged neglect involving two residents to the SSA within the required timeframe. One resident's call bell was ignored for 45 minutes, and they were treated dismissively by staff. Another resident experienced incontinence due to ignored calls and was told to manage care independently. These incidents were not reported as per facility policy.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of two residents' hospital transfers. Despite the facility's policy requiring such notifications, the Director of Social Services confirmed that notices were not sent. This oversight was identified during a review of the residents' transfer/discharge forms.
The facility failed to ensure accurate MDS assessments for four residents. Two residents had incorrect coding regarding bed rail use, which was intended for mobility assistance. Another resident's discharge was inaccurately coded as unplanned, despite being a planned transfer. Additionally, a resident's use of bed rails was incorrectly coded as a restraint, although it was for mobility assistance. These discrepancies were confirmed by staff interviews.
The facility did not conduct annual performance reviews for two LNAs. One LNA, employed since June 2022, and another, employed since July 2023, had no documented evaluations. This was confirmed by the DON.
Improper Date Labeling of Refrigerated Thickened Beverages and Shakes
Penalty
Summary
The facility failed to store and serve food in accordance with professional food safety standards in 1 of 1 kitchen and 3 of 3 kitchenettes observed. Surveyors observed multiple refrigerated ready-to-eat items without required date markings, including thickened apple juice, thickened cranberry juice cocktail, thickened orange juice, hydrolyte thickened water with a hint of lemon, and thickened dairy beverage in the walk-in refrigerator, all with no open or use-by date. In the 2nd floor Unit kitchenette refrigerator, two Vital Cuisine Mighty Shakes were observed with no thawed date or use-by date. Additional observations in the 2nd floor Skilled Nursing Unit kitchenette refrigerator found eight Vital Mighty Shakes with no thawed date or use-by date and one carton of thickened apple juice with no open or use-by date. In the 3rd floor Unit kitchenette refrigerator, four Vital Cuisine Mighty Shakes were observed with no thawed date or use-by date. The Dietary Manager confirmed that the thickened beverages and shakes should have been labeled with an open and use date based on the manufacturer's instructions. Manufacturer guidance reviewed by surveyors stated that Vital Cuisine Mighty Shakes should be used within 14 days after thawing, Thick & Easy thickened orange juice, apple juice, cranberry juice, and hydrolyte lemon water should be discarded if not used within 10 days of opening, and Thick & Easy thickened dairy beverage should be discarded if not used within 4 days of opening. The facility policy also stated that Mighty Shakes are to be labeled with an expiration date 14 days after removal from the freezer.
Physician Orders Not Followed for BP Medication
Penalty
Summary
The facility failed to ensure that physician orders were followed for Resident #84 when administering labetalol HCL 100 mg by mouth every 6 hours for hypertension. The order specified to give the medication only if systolic blood pressure was greater than 160 and to hold it if apical pulse was less than 60. Review of the August 2025 MAR showed multiple administrations of the medication when the recorded systolic blood pressure was below the ordered threshold, including readings of 121, 137, 134, 128, 139, 141, 152, 142, 143, and 145. During interview, the Infection Preventionist confirmed that the MAR check indicated the medication had been administered outside the ordered parameters. The physician also stated that the medication would not be expected to be given outside the parameters in the order. The facility policy titled Medication Administration (General Guidelines), dated 1/25, stated that medications are to be administered in accordance with written prescriber orders and that if a regularly scheduled dose is withheld, the nurse shall document that the dose was withheld and enter an explanatory note.
Incomplete catheter irrigation orders and failure to report no urine output
Penalty
Summary
The facility failed to ensure appropriate catheter care for 2 residents with indwelling urinary catheters. One resident had a physician order to irrigate a Foley/suprapubic catheter with normal saline PRN, but the order did not specify when irrigation should be performed or how much normal saline to use. The same issue was identified for a second resident, whose order also directed irrigation of a Foley/suprapubic catheter with normal saline PRN without clear indications or volume instructions. The DON confirmed that the irrigation orders for both residents did not have clear indications for when to perform catheter irrigation, and the physician confirmed that the orders were incomplete. For one resident, the medical record showed no urine output documented overnight, and there was no documentation that the provider was notified when no urine output was reported. The unit manager confirmed that the provider was not notified about the lack of urine output. The physician also confirmed that he/she was not notified that the resident had no urine output during the overnight period. The facility policy reviewed stated that PRN medication orders must specify the condition for use and that a designated nurse reviews the order summary for necessary corrections.
Unlabeled Opened Multidose Tuberculin Vials
Penalty
Summary
The facility failed to properly label opened multidose injectable medication in 2 of 3 medication refrigerators observed. In the third floor medication room refrigerator, surveyors observed an open vial of Tuberculin Purified Protein Derivative that did not have an opened date or open expiration date. In the Infection Preventionist Office refrigerator, surveyors observed one opened vial of Tuberculin solution that was also undated. Staff E, an LPN, and Staff D, the Infection Preventionist, both confirmed the findings during interview. Manufacturer instructions for Tuberculin Purified Protein Derivative stated that a vial of TUBERSOL entered and in use for 30 days should be discarded and should not be used after the expiration date. The facility policy on medications and medication labels stated that multidose vials shall be labeled to assure product integrity and that nursing staff should document the date opened on multidose vials on the auxiliary label.
Infection Prevention Program Not Reviewed Annually and Droplet Precautions Not Followed
Penalty
Summary
The facility failed to conduct an annual review of its infection prevention and control program and failed to implement policies and procedures for Transmission Based Precautions for 3 of 4 residents observed on precautions, including Resident #17, Resident #56, and Resident #68. Staff J, an LPN, stated there was an upper respiratory virus outbreak and identified those residents as being on contact precautions. Staff D, the Infection Preventionist, confirmed that the rooms were on droplet precautions recommended by the health department due to a respiratory outbreak and stated that symptomatic residents should remain on droplet precautions until they completed antibiotics or were symptom free for 24 hours. Staff D also stated that staff entering rooms on droplet precautions should wear an N95 mask, gloves, gowns, and a face shield. Resident #68 had pneumonia and was on droplet precautions per the care plan. In the room, the posted signage indicated that an N95, gloves, gown, and face shield were required, but a contracted dermatologist entered wearing only a surgical mask and gown. Resident #17 had droplet precaution signage posted, but a hospice social worker was seated in the room without PPE. Resident #56 was receiving antibiotic therapy for an upper respiratory infection and was placed on droplet precautions; a LNA entered the room with a meal tray and assisted with meal setup while wearing only a surgical mask. The facility's Infection Prevention and Control Plan stated that the risk assessment is done at least annually and that Transmission-Based Precautions will be followed by all employees, and the isolation precautions policy required staff to use the specified PPE for droplet precautions. Staff F, the Administrator, confirmed that the Infection Prevention and Control Plan had not been reviewed since June 2024.
Failure to Implement Staff COVID-19 Immunization Policy
Penalty
Summary
The facility failed to implement its policies and procedures on COVID-19 immunization for 1 of 1 staff reviewed, identified as Staff M. Review of the facility’s COVID-19 Vaccination policy showed that the facility was to educate residents and staff, offer the COVID-19 vaccine, and maintain documentation of vaccination status, including education, the offer of the vaccine or information on obtaining it, and the staff member’s COVID-19 vaccine status. However, interview with the Infection Preventionist revealed that the facility did not offer COVID-19 vaccinations to employees or track or obtain declinations, and stated there was no policy for staff COVID-19 immunization. Record review showed Staff M’s immunization report card listed the last COVID-19 vaccination as 12/13/21. During interview, Staff M stated they could not recall when the facility had last offered the COVID-19 vaccine and confirmed they had not been asked to sign a declination documenting education and refusal. Review of the facility’s Infection Prevention and Control Plan 2024 showed it addressed some vaccinations and employee influenza vaccination, but did not address COVID-19 vaccinations for staff. The Administrator confirmed that the plan had not been reviewed since June 2024.
Resident Council grievances were not documented as addressed or followed up
Penalty
Summary
The facility failed to demonstrate its response and rationale to resident council grievances and failed to maintain evidence showing follow-up on concerns raised during Resident Council Meetings. Review of the meeting minutes showed that on 5/13/25 residents reported that food was not hot and that a blanket and two afghans were missing. On 6/9/25 residents reported cold meals, food not matching what was ordered, and long waits to use the bathroom. On 7/24/25 residents again reported waiting too long to use the bathroom, missing items, and food being served cold, delivered late, and not what was ordered. Further review found no documentation that these concerns were responded to or followed up on at the next Resident Council Meeting. There were no Resident Council Meeting minutes available for February, March, or April 2025. During the Resident Council Meeting interview, all eight members in attendance stated the facility did not inform them of any actions taken regarding concerns discussed at prior meetings. Staff H, the Activity Director, confirmed the concerns were not responded to and stated the June and July concerns were not shared with Department Heads. Staff F, the Administrator, confirmed the concerns were not documented as followed up on and confirmed that Resident Council was not held in February and March 2025 and that April 2025 minutes could not be found.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines, as evidenced by multiple observations of improper hand hygiene and glove use during medication administration. Staff O, an LPN, was observed administering insulin, eye drops, and nasal spray to a resident without changing gloves or performing hand hygiene between procedures. This was confirmed by both the staff member and the infection preventionist, who acknowledged the breach in protocol. The facility's policies and CDC guidelines clearly outline the necessity of hand hygiene and glove changes between patient contacts and procedures, which were not followed in this instance. Another deficiency was noted with the improper disposal of medical waste and inadequate cleaning of medical equipment. Staff P, another LPN, was observed disposing of a used lancet needle in a regular trash bin instead of a sharps container and failed to properly disinfect a glucometer after use. The infection preventionist confirmed that the glucometer should have been cleaned with bleach wipes according to the manufacturer's instructions, and the lancet needle should have been disposed of in a sharps container, as per OSHA guidelines. Additional deficiencies were identified in the implementation of Enhanced Barrier Precautions (EBP) for residents with open wounds or indwelling medical devices. Several residents, including those with pressure ulcers and PICC lines, were not placed on EBP as required. Staff members were either unaware of the need for EBP or failed to implement it correctly, as evidenced by the lack of PPE and improper gown use during high-contact care activities. These lapses were confirmed through interviews with staff and a review of the facility's policies and CDC guidelines.
Failure to Timely Report Alleged Neglect
Penalty
Summary
The facility failed to report alleged violations of neglect to the State Survey Agency (SSA) within the required timeframe for two residents. Resident #79 reported an incident where their call bell was not answered for 45 minutes, and when staff finally responded, they were dismissive, telling the resident to wait their turn. Additionally, the resident reported that a Licensed Nursing Assistant (LNA) entered their room before breakfast and abruptly pulled the blankets off, instructing them to get up. These allegations were documented in the facility's grievance log but were not reported to the SSA as required. Similarly, Resident #20 alleged neglect when their call bell was ignored, resulting in incontinence. When the LNA eventually responded, they told the resident to manage their toileting and incontinence care independently. An interview with Resident #20 confirmed the grievance, and a subsequent interview with Staff A verified that these allegations were not reported to the SSA. The facility's policy mandates immediate reporting of such allegations, or within two hours if they do not result in serious bodily injury, which was not adhered to in these cases.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to send a copy of the notice of Transfer/Discharge to a representative of the Office of the State Long-Term Care Ombudsman for two residents who were hospitalized. Resident #30 was transferred to the hospital for a higher level of care, and upon review of their Notice of Transfer/Discharge form, there was no evidence that it was sent to the Ombudsman. Similarly, Resident #57 was hospitalized, and their Notice of Transfer/Discharge form also lacked evidence of being sent to the Ombudsman. An interview with the Director of Social Services confirmed that the facility does not send copies of the transfer/discharge notices to the Ombudsman. This is contrary to the facility's policy, which requires that a copy of the notice be faxed or mailed to the Ombudsman. The policy, dated January 17, 2019, outlines the procedure for transfers to hospitals, including the responsibility of the Social Services representative to follow up on written notifications.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status for four residents. For Resident #12, the MDS indicated daily use of bed rails, which was confirmed by the resident and supported by a physician's order for bed rails to assist with mobility due to muscle weakness and a cerebrovascular accident. Similarly, Resident #34's MDS was incorrectly coded for bed rail use, which was intended to assist with bed mobility and transfers, as confirmed by the MDS Coordinator. Resident #90's discharge was inaccurately coded as unplanned in the MDS, despite social services notes and interviews confirming it was a planned transfer to a memory care unit. Additionally, Resident #5's MDS inaccurately coded the use of bilateral bed rails as a restraint, although they were used for mobility assistance, as confirmed by the resident, physician orders, and care plan. These discrepancies were confirmed through interviews with staff, including the MDS Coordinator and Unit Manager.
Failure to Conduct Annual Performance Reviews for LNAs
Penalty
Summary
The facility failed to complete a performance review at least once every 12 months for two of the four Licensed Nurse Assistants (LNAs) reviewed. Staff I, who started employment on June 3, 2022, had no evidence of a performance evaluation completed. Similarly, Staff J, who began employment on July 25, 2023, also lacked evidence of a performance evaluation. These findings were confirmed during an interview with the Director of Nurses.
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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) |
|---|---|---|---|---|
| Warde Health Center | 3.3 mi | ★★★★★ | 2 | 0 |
| Cedar View Rehabilitation And Healthcare Center | 4 mi | ★★★★★ | 5 | 0 |
| Nevins Nursing & Rehabilitation Center | 4.1 mi | ★★★★★ | 13 | 0 |
| Whittier Bradford Transitional Care Unit | 4.9 mi | ★★★★★ | 0 | 0 |
| Berkeley Retirement Home,the | 4.9 mi | — | 0 | 0 |
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