Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 North Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and significant pain needs had an order for PRN oxycodone, and later two tablets were found missing from the resident’s oxycodone card and replaced with taped‑in pills that did not match the remaining tablets. During a shift‑change narcotic count, an LPN identified the non‑matching, taped‑in pills in two card slots, while another LPN acknowledged she had previously counted the narcotics without removing the card from the drawer. The facility’s investigation, as described by the RDCO, determined the substituted pills were melatonin and confirmed the oxycodone tablets were missing, but could not identify who took them or where they went, despite a policy stating that drug diversion is treated as misappropriation of resident property.
A resident with COPD and acute respiratory failure had two inhalers left on the overbed table despite no self-administration order or assessment, and staff verified the medications were at the bedside. In addition, an opened, unlabeled probiotic, an opened, unlabeled famotidine bottle, an aspart insulin pen, an open lispro vial, and an open vial of Tubersol were found without opening dates or proper labeling in medication storage areas.
Courtyard Smoking Area Not Kept Clean: The facility failed to keep the courtyard smoking area clean and sanitary, with more than 50 cigarette butts observed scattered on the ground and in the snow. An LPN verified the condition and was unsure who was responsible for cleanup, and the Administrator stated maintenance was responsible for keeping the area clean. The smoking area was identified as being used by six residents.
Inaccurate documentation and failure to report cervical collar refusals: A resident with multiple fractures and moderate cognitive impairment had an active order for a cervical collar to be worn at all times except for showers and skin checks. Staff documented the collar as in place on multiple shifts, but observation found it on the nightstand, and the DON stated the resident had been refusing to wear it since learning it was only needed for 12 weeks. There was no documented evidence of the refusals or removals, and the resident had not been seen by orthopedics since admission.
A resident with multiple chronic conditions and high fall risk was found on the floor after yelling from his room, later hospitalized with a right distal femur fracture, but the fall investigation lacked enough witness detail and was deemed inconclusive by the DON. In a separate issue, a cognitively intact resident with COPD, chronic respiratory failure, lung cancer, and nicotine dependence was observed smoking and later found with cigarettes and a lighter kept on his wheelchair, despite the facility’s smoking policy requiring staff to store smoking materials.
Oxygen tubing was not changed every 7 days for a resident with COPD, CHF, and acute respiratory failure. The resident was receiving O2 via nasal cannula, but the tubing was dated well beyond the weekly change interval. An LPN confirmed the tubing date and stated tubing should be changed weekly or sooner if soiled; the facility policy also required weekly changes and dating when opened.
The facility failed to serve meals at appropriate temperatures, affecting 64 residents. Observations showed food temperatures below FDA requirements, and residents reported receiving cold meals. The Dietary Manager confirmed a shortage of thermal pellets, impacting the ability to maintain food temperatures during transport.
A resident with severe cognitive impairment received duplicate medications due to the facility's failure to follow prescribed orders. Despite a clear transition plan from Aricept and Namenda XR to Namzaric, the resident was administered all three medications simultaneously, as confirmed by MAR and staff interviews. This was against the facility's medication administration policy.
A resident with severe cognitive impairment and Type 1 diabetes experienced a critical health decline due to the facility's failure to monitor blood glucose levels and administer insulin as ordered. Despite physician orders, the resident's blood sugar was not consistently checked, and insulin was not administered, leading to diabetic ketoacidosis, severe hypernatremia, and septic shock. The resident required emergency medical intervention and was transferred to a hospital for further treatment.
A resident with multiple complex diagnoses experienced a significant change in condition, including tremors and abnormal vital signs, which was not communicated to their representative. The facility's policy requires notification of such changes, but the resident's mother was not informed, as confirmed by staff interviews.
Misappropriation and Undetected Diversion of Resident Opioid Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when two oxycodone tablets were missing from the resident’s prescribed opioid medication card and had been replaced with non‑matching pills. The resident had multiple serious medical conditions, including acute kidney failure, end‑stage renal disease, pleural effusion, hypertensive chronic kidney disease Stage V, diabetes, COPD, peripheral vascular disease, atrial flutter, and dependence on renal dialysis, and was care planned for pain related to chronic conditions and procedures. The resident’s orders included oxycodone 5 mg, two tablets every four hours as needed for pain, which was later discontinued. During a shift‑change narcotic count, two pills in the oxycodone card (in slots #2 and #6) were found taped into place, were not uniform in color, and were not scored like the other oxycodone tablets. One LPN reported that when she had counted the narcotics at the beginning of her shift, she did not remove the medications from the cart and only visually checked them in the drawer. Witness statements documented that on a prior count, the oxycodone card had no taped‑in medications, but at a later count the two taped‑in pills were present and did not match the remaining oxycodone tablets. The Regional Director of Clinical Operations stated that the facility’s investigation determined the two taped‑in medications were melatonin and that the two oxycodone tablets were missing, with no determination of who took them or where they went. The RDCO also stated that the pharmacy was notified of the missing oxycodone and that they inquired whether the resident was due any monies, despite the medication having been discontinued. When asked why the allegation of misappropriation was unsubstantiated, the RDCO could not provide an answer. Facility policy on controlled drugs and security stated that drug diversion would be treated as misappropriation of resident property and that the Board of Nursing would be notified as appropriate for known or suspected drug diversion after review and evidence collection.
Medication Left at Bedside and Improperly Labeled Stored Medications
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for one resident who had diagnoses of COPD and acute respiratory failure. The resident had orders for Dulera inhalation and Spiriva inhalation, but there were no orders allowing self-administration and no self-medication assessment in the record. The resident’s MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. During observation, the resident was lying in bed with two inhalers, Dulera and Spiriva, placed on the overbed table next to the resident, and an LPN verified their presence there. The RDCO later verified the lack of a self-medication administration assessment. The facility also failed to store medications in a manner that preserved efficacy and proper discard time frames. During medication cart observation, an opened and unlabeled bottle of over-the-counter acidophilus used for four residents was found, along with an opened and unlabeled bottle of over-the-counter famotidine used for four other residents. An aspart insulin pen and an open vial of lispro insulin for one resident were also unlabeled as to when they were opened. In the South medication storage room, an open, unboxed, and unlabeled vial of Tubersol was observed. Staff verified the findings, and the manufacturer’s inserts stated that the insulin products should not be used after 28 days of being opened and that an opened vial of Tubersol should be discarded after 30 days.
Courtyard Smoking Area Not Kept Clean
Penalty
Summary
The facility failed to ensure the courtyard smoking area was maintained in a clean and sanitary manner free from cigarette butts. During observation on 02/10/26 at 4:25 P.M., the smoking area in the courtyard was found to have multiple cigarette butts, more than 50, scattered on the ground and in the snow. An LPN verified the observation and stated she was not sure who was responsible for cleaning up the cigarette butts. A later observation at 4:42 P.M. with the Administrator and the RDCO also verified the cigarette butts on the ground and in the snow. The Administrator stated that maintenance was responsible for ensuring the smoking area was clean. The area was identified by the facility as being used by six residents, and the facility census was 70.
Inaccurate documentation and failure to report cervical collar refusals
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation and failed to notify the physician of a resident’s refusals of a prescribed cervical collar. Resident #6 was admitted with multiple fractures, including cervical, thoracic, vertebral, clavicle, femur, and pelvis fractures, and had diagnoses that included dementia and abnormal posture. The physician ordered the cervical collar to remain in place at all times, except for showers and skin checks, and the care plan included keeping the collar in place and supporting the resident’s orthopedic follow-up and rehabilitation participation. The MDS showed the resident was moderately cognitively impaired and dependent or required substantial to maximum assistance for most ADLs. Review of the February 2026 TAR showed the cervical collar was documented as checked for placement on multiple shifts, but observation found the collar on the nightstand while the resident was in bed. During interview, the resident stated he was no longer required to wear the collar, and an LPN stated it had been discontinued a few weeks earlier. The DON stated the resident had been refusing to wear the collar since being told it would only be needed for 12 weeks, and confirmed staff documented it as in place even though he was removing it after checks. The DON also stated there was no documented evidence of refusals or removals, the resident had not been seen by orthopedics since admission, and attempts to contact the orthopedic office had not been returned, with no evidence of those contact attempts available.
Incomplete fall investigation and unsafe smoking material storage
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident with congestive heart failure, diabetes, morbid obesity, hypertension, depression, and anxiety who was assessed as being at risk for falls and required extensive assistance with activities of daily living. The resident was found on the floor after yelling from her room, complained of severe right knee pain, had very limited movement of the right leg, and was later admitted to the hospital with a right distal femur fracture. The record showed she could not explain what happened before the fall, and the facility investigation documented only limited details about the event. The investigation noted that the resident was found on her right side with her alarm sounding, barefoot, with a mattress on the floor and the bed in low position, and that she had last been toileted earlier in the evening. A witness statement from the assigned RN stated the resident had been falling asleep in her wheelchair after dinner, was asked if she wanted to lie down, refused, and was later heard yelling and found on the floor. However, there were no other witness statements or additional descriptions of the event, and the DON confirmed the investigation was inconclusive and did not contain enough detail to be considered thorough. The facility also failed to ensure safe smoking practices for a resident with COPD, chronic respiratory failure with hypoxia, lung cancer, supplemental oxygen dependence, alcohol abuse, anxiety disorder, and nicotine dependence. The resident was assessed as cognitively intact, used a wheelchair, and was identified as an independent smoker. He stated that he kept his own smoking materials, and during observation he was seen smoking in the courtyard and later had a pack of cigarettes and a lighter sitting on the left side of his wheelchair under his jacket in his room. The Administrator and RDCO were informed that the resident had his smoking materials with him, and the Administrator stated he was not supposed to have them on him.
Oxygen Tubing Not Changed Weekly
Penalty
Summary
The facility failed to ensure oxygen tubing was changed every seven days for Resident #42. Resident #42 was admitted on 12/19/25 and had diagnoses including COPD, CHF, and unspecified acute respiratory failure. The record showed no current physician order for oxygen therapy, including flow rate, method of delivery, indication for use, or monitoring parameters, and no orders for oxygen tubing management. The admission MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The care plan dated 12/31/25 identified altered cardiovascular status related to combined systolic and diastolic CHF and chronic atrial fibrillation, with an intervention to administer oxygen as ordered. Progress notes documented that the resident was on 2 liters per minute of oxygen and later receiving oxygen via nasal cannula. During an observation on 02/09/26 at 7:00 P.M., the resident was in bed with oxygen via nasal cannula, and the tubing was dated 01/24/26. An LPN verified the date on the tubing and stated oxygen tubing was to be changed every seven days and as needed if soiled. The facility policy stated nasal cannulas and tubing are changed weekly or when soiled and labeled with the date opened.
Failure to Maintain Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that foods were served at a palatable temperature, affecting 64 of the 66 residents who received meals prepared and served by the facility kitchen. Multiple resident interviews confirmed that foods were not served at the right temperatures, with some residents reporting that hot foods were served cold. An observation of the tray line revealed that the final meal trays were plated and placed on the meal cart, but by the time the meals were delivered to the dining hall, the food temperatures were below the required levels. The meatloaf was 121 degrees Fahrenheit, the peas were 112.1 degrees Fahrenheit, and the au gratin potatoes were 122.9 degrees Fahrenheit, all below the FDA requirement of 135 degrees Fahrenheit for hot foods. The cranberry juice was also not maintained at the required cold temperature. The Dietary Manager confirmed that the facility was short at least 18 thermal pellets, which are used to maintain food temperatures during transport. This shortage was known to the previous Administrator, who instructed to hold off on ordering more. The new Administrator was informed of the issue and ordered additional thermal pellets. The facility's policy on dietary operations emphasized the importance of maintaining food temperatures and limiting the time between tray preparation and meal delivery. Despite these guidelines, the facility's failure to maintain adequate food temperatures was a recurring issue, as noted in food committee meeting minutes from previous months.
Failure to Prevent Duplicate Medication Administration
Penalty
Summary
The facility failed to ensure that Resident #67's drug regimen was free from unnecessary or duplicate medications. The resident, who had severe cognitive impairment and multiple diagnoses including Alzheimer's Disease and vascular dementia, was prescribed a series of medications for dementia management. The physician's orders indicated a transition plan from Aricept and Namenda XR to Namzaric, which combines both medications. However, the Medication Administration Record (MAR) showed that the resident received Aricept, Namenda XR, and Namzaric simultaneously on several occasions, contrary to the physician's orders and the manufacturer's guidelines. Interviews with several Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed the administration of these medications in a manner that was not compliant with the prescribed orders. The facility's policy on medication administration, which requires medications to be administered only as prescribed, was not followed. This resulted in the resident receiving duplicate doses of the active ingredients found in Namzaric, which should not be taken with other medications containing the same ingredients.
Failure to Monitor and Administer Insulin Leads to Resident's Critical Condition
Penalty
Summary
The facility failed to provide adequate and necessary care to meet the total care needs of a resident, who was severely cognitively impaired and dependent on staff for activities of daily living. The facility did not consistently monitor blood glucose levels as ordered, failed to administer insulin as prescribed, and did not monitor the resident after an acute change in condition. This resulted in the resident experiencing elevated blood glucose levels, leading to diabetic ketoacidosis, severe hypernatremia, and septic shock, necessitating emergency medical intervention and transfer to a hospital. The resident was admitted with multiple diagnoses, including Type 1 diabetes mellitus and multiple sclerosis, and had a history of long-term insulin dependence. Despite having physician orders for insulin administration and blood glucose monitoring, there were multiple instances where the resident's blood sugar was not checked, and insulin was not administered as ordered. The resident's condition deteriorated, with symptoms such as clamminess, tremors, and abnormal vital signs, yet there was a lack of timely assessment and intervention by the facility staff. Interviews with facility staff revealed a lack of consistent monitoring and documentation of the resident's condition. The resident's mother reported signs of dehydration during a video chat, and the resident was later diagnosed with severe dehydration and other complications upon hospital admission. The facility's failure to adhere to physician orders and monitor the resident's condition contributed to the resident's critical health decline.
Removal Plan
- 911 was called and Resident #70 was transferred to the hospital for medical intervention due to an acute/significant change in condition. The resident did not return to the facility.
- Medical Director #20 was notified of the State agency concerns related to Resident #70.
- All licensed nurses were educated by ADON #1 and Registered Nurse (RN) #21 on the facility's policy of Notification of Change in Condition with emphasis on timely identification, ongoing monitoring and interventions provided to treat the change in condition.
- All licensed nurses were educated by ADON #1 and RN #21 on the facility policy identified as, Physician Orders with emphasis on medication administration of insulin and monitoring of blood glucose levels.
- ADON #1 educated Licensed Practical Nurse (LPN) #4 on how to contact Information Technology (IT) (for computer issues), physician orders, notification of change in condition, clinical documentation standards, blood glucose monitoring, and managing diabetic change in condition.
- The Director of Nursing (DON)/designee audited the last 14 days of residents who had physician orders for insulin administration. Any resident found to have an omission of insulin administration had their physician and family notified. All concerns were addressed, and new orders were transcribed immediately.
- The DON/designee, RDCO #7 and ADON #1 audited the last 14 days of residents who had physician orders for blood glucose monitoring and/or antidiabetic medications. Any resident found to have a blood glucose outside their parameters and not with the appropriate follow up had their physician and family notified. All concerns were addressed, and new orders were transcribed immediately.
- The DON/designee audited the last 14 days of residents' progress notes for a change in condition. Any resident identified with a change in condition and found not to have interventions provided had their physician and family notified. All concerns were addressed, and new orders were transcribed immediately.
- ADON #1 re-educated LPN #4 in person on how to contact IT, physician orders, notification of change in condition, clinical documentation standards, blood glucose monitoring, and managing diabetic change in condition.
- An Ad Hoc Quality Assurance Performance (QAPI) meeting was held with the Interim Administrator, DON, RDCO #7, ADON #1, RN #21 and Medical Director #20 to discuss the concerns involving Resident #70 and a facility corrective action plan.
- LPN #4 received a final written warning corrective action for performance/policy violation related to medication administration, notification of change in condition, and resident monitoring. Failure to document and monitor resident in change in condition.
- The DON/designee would audit for change in condition by reviewing the progress notes in the daily clinical meeting. This would be an ongoing process.
- The DON/designee would complete an audit for missed/omitted insulin/antidiabetic medications and blood glucose monitoring in the daily clinical meeting. This would be an ongoing process.
- The DON/designee would begin audits on nurses completing blood glucose checks, administering insulin as needed, and documenting the process by observing three nurses weekly for four weeks then randomly thereafter.
- The Administrator and DON would continue to monitor compliance in the monthly QAPI meetings for three months then as needed for one year.
- RDCO #7 would continue to monitor compliance during monthly visits for three months then on an as needed basis.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to timely notify a resident's representative of an acute change in condition, affecting one resident out of twelve reviewed for notification of change. The resident, who was admitted with multiple complex diagnoses including Temefactive Multiple Sclerosis, Type 1 diabetes, and severe cognitive impairment, experienced a significant change in condition on the evening of 09/06/24. The resident was noted to be cool and clammy, restless, and experiencing tremors, with abnormal vital signs including a high pulse and blood sugar level. Despite these changes, the nurse's note did not indicate that the resident's mother, who is the resident's representative, was notified of these developments. Interviews conducted during the investigation confirmed that the resident's mother was unaware of the resident's condition changes, and the registered nurse involved verified that the notification was not made. The facility's policy on Notification of Change in Condition requires informing the resident's representative of significant changes in the resident's physical, mental, or psychosocial condition. The Regional Director of Clinical Operations acknowledged that the family should have been notified of the resident's condition changes, confirming the facility's non-compliance with its policy.
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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) |
|---|---|---|---|---|
| Salem West Healthcare Center | 0 mi | ★★★★★ | 10 | 0 |
| Circle Of Care | 0.5 mi | ★★★★★ | 0 | 0 |
| Blossom Nursing And Rehab Center | 2.1 mi | ★★★★★ | 8 | 0 |
| Auburn Skilled Nursing And Rehab | 6.6 mi | ★★★★★ | 16 | 0 |
| St Mary's Alzheimer's Center | 7.3 mi | ★★★★★ | 3 | 0 |
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