Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Salem Transitional Care during CMS and state inspections, most recent first.
A facility failed to maintain a homelike dining environment when tablecloths were removed from the dining room tables. Resident council minutes showed residents preferred the tablecloths, but dietary staff said labor cuts eliminated linens and they did not expect them to return. Observations during mealtimes showed no tablecloths on any table, and residents stated the dining room was more inviting with tablecloths and that budget reasons were given for not having them. Leadership acknowledged the dining room was not a homelike environment.
Failure to Follow Contact Precautions: Staff did not consistently follow posted contact precautions for residents with CRE and C. diff. A CNA assisted a resident with a snack without gown or gloves, another CNA handled a resident’s belongings and exited without soap-and-water hand hygiene, and other staff entered rooms or exited after meal delivery without the required PPE or handwashing.
A resident admitted with Medicare Part A benefits received a Notice of Medicare Non-Coverage, but the record showed the resident stayed in the facility as private pay after Medicare coverage ended and no SNF ABN was issued. Staff confirmed the notice was given and acknowledged the SNF ABN was not provided.
A resident's admission MDS was completed after the required timeframe. The RN MDS Coordinator confirmed the assessment was not completed on time.
The facility failed to complete a Significant Change MDS within the required timeframe for a resident with diabetes and COPD who was admitted to hospice. The MDS Coordinator acknowledged that the assessment was completed after the 14-day deadline.
A resident admitted with sepsis had an open coccyx lesion and redness noted on the skin inspection, but no orders or care instructions were in the chart. The resident stated the facility was supposed to continue treating the area after hospital transfer, yet staff were unaware of any current wound, and the RNCM confirmed no care orders were in place for the identified skin concern.
Unnecessary Medication Administration and Allergy Error: A resident with a documented gabapentin allergy was mistakenly given gabapentin 300 mg and hydralazine 50 mg after a CMA entered the wrong room and administered medications intended for another resident. The resident was sent to the ER after the error was identified, and the DNS acknowledged the resident received unnecessary medications.
Hospice care coordination and care plan deficiencies were identified for a resident with DM and COPD who was receiving hospice services. The RNCM did not know what hospice information belonged in the care plan or which staff were responsible for coordinating with hospice, and the DNS acknowledged there were no designated staff members identified to communicate with hospice representatives. The resident’s care plan also did not include hospice-related information, including the Hospice Plan of Care.
Survey Findings Binder Not Updated: A resident council meeting revealed that residents were not aware of where to find the state survey inspection results. Observation of the Survey Findings Binder at the front entrance showed it did not include all 2025 survey findings and had no 2026 survey findings. The ED acknowledged the binder was not updated with the most recent survey results.
A resident admitted with sepsis, pneumonia, and acute respiratory failure, who was cognitively intact but dependent for wheelchair mobility, was assisted back to their room after dinner and left alone in a wheelchair while staff sought a second person for a two-person transfer. Staff did not return for over an hour, and the resident reported being alone for more than an hour without a call light or phone within reach, experiencing pain and being unable to transfer or move the wheelchair independently. A CNA assigned to both the resident and dining room duties stated she could not leave the dining room and had asked another CNA to assist, later finding the resident still waiting in the wheelchair, and facility leadership acknowledged the transfer assistance was not provided in a timely manner.
A resident with a right lower leg fracture and intact cognition had a STAT physician order for Lokelma to treat elevated potassium, but the facility failed to administer the medication as ordered. The missed STAT dose was identified in facility documentation, and the on-call provider was notified, after which the resident was sent to the ER. A hospital social worker confirmed the medication was not given and that the transfer was related to the missed dose. An LPN and an RN/RCM both recalled a medication error involving Lokelma, and facility leadership acknowledged the resident should have received the STAT medication.
A resident with kidney disease sustained superficial burns after being given a heat pack by a CNA without nurse approval, a protective barrier, or supervision. The resident applied the heat pack independently and kept it on for an unknown duration, resulting in blisters and skin redness that were discovered the following day.
Annual performance reviews for CNA staff were not completed as required, with some reviews missing for several years and one CNA lacking any documented review. The DNS confirmed that timely annual reviews were expected but had not been conducted for the sampled staff.
The facility did not ensure that CNAs completed the required 12 hours of annual in-service training, as evidenced by documentation showing several CNAs with incomplete or missing training hours. Facility leadership confirmed the expectation for annual training completion.
A resident with kidney failure was admitted with an external urinary catheter, but the care plan lacked documentation of the catheter and there was no physician order on the TAR. An LPN changed the catheter without reviewing a physician's order and documented the change in notes instead of the TAR, contrary to facility policy.
A resident with a history of stroke was given medications all at once by a CNA, despite the resident's clear preference and repeated requests to take medications one at a time with water or applesauce. The resident and a friend attempted to intervene, and a nurse ultimately stopped the improper administration. The resident's preference was later documented for staff.
A resident with brain cancer and stroke was given medications by a CNA who was not authorized to do so, after a CMA left the medications unattended in the room. Despite the resident's repeated refusals and protests, the CNA continued to administer the medications until other staff intervened. Facility policy and staff interviews confirmed that only licensed or certified staff may administer medications and that staff must stop if a resident refuses care.
A resident with significant medical conditions was subjected to unsafe medication administration when a CNA, not authorized to give medications, attempted to administer them after a CMA left the medications unattended in the resident's room. The resident and a friend protested, and the incident was stopped only after intervention by other staff. Staff interviews confirmed the CNA was aware she was not permitted to administer medications.
Two residents experienced deficiencies in pressure ulcer care, including lack of timely assessment, failure to update care plans, and inadequate documentation. One resident developed toe discoloration from compression socks without proper follow-up, while another developed a Stage 2 sacral wound that was not promptly identified or reported. Required protocols for wound monitoring and care plan updates were not followed.
Two residents did not receive timely pharmaceutical services when ordered medications for thrush and hypertension were repeatedly unavailable. Staff were unable to locate the medications on several occasions, and there was confusion regarding medication orders and reordering procedures. The DON expected staff to contact the pharmacy when medications were missing, but gaps in administration still occurred.
A resident was administered ibuprofen as a scheduled medication instead of as needed (PRN) due to a transcription error in the MAR. This led to multiple unnecessary doses, after which the resident experienced significant GI bleeding and was hospitalized. The error was not detected during order entry or review, and the facility's investigation confirmed the medication was given contrary to the physician's original PRN order.
A resident with dementia and a speech deficit was not treated with dignity by an LPN, who taunted the resident to yell louder and incorrectly transferred them by picking them up like a baby. The LPN admitted to becoming annoyed with the resident's behavior and used a not-so-nice tone. These actions were reported by other staff members, leading to the LPN's termination.
An LPN failed to adhere to professional standards by intimidating a resident with dementia and a stroke, who exhibited behaviors like yelling. The LPN admitted to using a harsh tone and physically scooping the resident for transfers, actions that were disrespectful and contrary to the resident's care plan.
A facility failed to report an allegation of verbal abuse involving a resident to the SSA within the required two-hour timeframe. The incident, which involved an agency nurse being rude and causing pain during a dressing change, was reported 18 days late due to leadership changes within the facility.
A facility failed to thoroughly investigate a verbal abuse allegation involving a cognitively intact resident with bilateral leg fractures and chronic pain. The incident was initially treated as a grievance, and the investigation lacked critical elements such as observations, interviews, and record reviews. Staff acknowledged the insufficiency of their investigation process, placing residents at risk for potential ongoing abuse.
Homelike Dining Environment Not Maintained
Penalty
Summary
The facility failed to provide a homelike dining environment for 1 of 1 dining rooms reviewed for resident council by not having tablecloths on the dining room tables. Resident council meeting minutes from 6/2026 showed residents liked having tablecloths in the dining room, but dietary staff responded that labor cuts had eliminated linens on tables and that they did not expect them to return soon. Random observations from 7/20/26 through 7/24/26 during mealtimes showed the dining room had no tablecloths on any table. During the 7/22/26 resident council meeting, residents stated the dining room was more inviting with tablecloths and made them want to eat meals there, and one resident said the facility did not put in the effort, which made the resident not want to come down to the dining room. Residents also stated they were told tablecloths could not be provided because of budget reasons. Staff 17 stated the tablecloths went away around the time of the transition to the new company in December 2025 or January 2026, and Staff 1 and Staff 3 stated they were unsure why the previous administrator discontinued them and acknowledged the dining room was not a homelike environment.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to implement appropriate contact precautions for 3 of 3 sampled residents reviewed for contact precautions. Resident 8 had CRE and was on contact precautions to prevent transmission of the bacteria. A contact precautions sign outside the room directed staff to perform hand hygiene, wear gloves and a gown upon entering, discard PPE upon exiting, and perform hand hygiene again, but a CNA was observed assisting the resident to eat a snack inside the room without gloves or a gown. The CNA stated she was unsure when PPE was required and thought it was only needed during ADL care, while the RNCM and IP later stated staff were to wear a gown and gloves every time they entered the room of a resident on contact precautions. Resident 23 had C. diff and was also on contact precautions. A sign outside the room directed staff to perform hand hygiene, wear gloves and a gown upon entering, and wash hands with soap and water before exiting, but a CNA was observed in the room placing belongings in a bag and picking up a water container without gloves or a gown and then exiting without washing hands with soap and water. The CNA confirmed she did not follow the required PPE and hand hygiene steps. Resident 125 also had C. diff and was on contact precautions; staff were observed exiting the room without washing hands with soap and water, and one CNA entered the room to deliver a lunch tray without a gown or gloves and without washing hands before exiting. Staff later stated they were to wear a gown and gloves every time they entered the room and wash hands with soap and water before exiting.
Failure to Issue SNF ABN After Medicare Coverage Ended
Penalty
Summary
The facility failed to provide SNF ABN notification to Resident 130, who was admitted with Medicare Part A benefits. A Notice of Medicare Non-Coverage was issued on 2/14/26 with the last Medicare-covered day listed as 2/17/26, but the medical record showed the resident remained in the facility as private pay from 2/18/26 to 2/24/26 and there was no evidence that a SNF ABN was issued. During interview, Staff 13 confirmed the Notice of Medicare Non-Coverage was issued and that Resident 130 stayed in the facility after 2/17/26 without receiving a SNF ABN. Staff 1 later acknowledged that the SNF ABN was not issued to Resident 130.
Late Completion of Admission MDS
Penalty
Summary
The facility failed to complete a comprehensive admission assessment within the required timeframe for Resident 128. Resident 128 was admitted to the facility on [DATE], and the admission MDS was completed on 7/22/26, five days after the regulatory timeframe. On 7/22/26 at 12:06 PM, Staff 7, the RN MDS Coordinator, confirmed that Resident 128's admission MDS was not completed within the regulatory timeframe.
Delayed Significant Change MDS Completion
Penalty
Summary
The facility failed to complete a Significant Change MDS within the required timeframe for Resident 2, who was admitted in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document showed the resident was admitted to hospice services on 5/24/26, but the Significant Change MDS was not completed until 6/18/26, which was 11 days after the required 14-day timeframe. On 7/22/26 at 12:27 PM, Staff 8, the MDS Coordinator, acknowledged that the Significant Change MDS completion date exceeded the required timeframe.
Failure to Initiate Treatment for Identified Coccyx Skin Lesion
Penalty
Summary
The facility failed to initiate treatment for Resident 32’s identified skin issue after admission. Resident 32 was admitted with diagnoses including sepsis, and a 7/19/26 Skin Inspection Evaluation documented an open lesion and redness to the coccyx. The medical record contained no orders or care instructions related to the coccyx skin lesion. On 7/20/26, Resident 32 stated the resident had been admitted from the hospital with a crack in the seat and that the facility was supposed to continue treating the area, but no update had been received. Staff 11, the LPN who completed the skin inspection, recalled a small skin area was identified and said she passed it along to the next shift to follow up on care, but did not recall whether it was an actual wound. Staff 14 stated she was not aware of any current wounds, and Staff 5, the RNCM, reviewed the skin inspection and stated the nurse was expected to request care orders for any identified skin concerns; Staff 5 later confirmed there were no orders in place for care and stated the nurse who identified the skin issue should have notified the provider and requested treatment.
Unnecessary Medication Administration and Allergy Error
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary medications when Resident 112, who was admitted with diagnoses including depression and diabetes and had a documented allergy to gabapentin, was given gabapentin 300 mg and hydralazine 50 mg that were not prescribed to the resident. The resident’s admission MDS showed a BIMS score of 14, indicating cognitive intactness. A public complaint alleged the resident received gabapentin and hydralazine, and the resident was sent to the hospital emergency room after the medication error was identified. A progress note documented that a CMA administered the wrong medication, including gabapentin and hydralazine, to Resident 112 and noted the resident’s gabapentin allergy. Another medication error report stated Staff 22 mistakenly entered the wrong resident room and administered the medications to Resident 112. Staff 22 later stated she was covering a hall she had never worked on before and mixed up the resident rooms. The DNS acknowledged that Resident 112 was administered gabapentin and hydralazine unnecessarily.
Hospice Care Coordination and Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure there was a designated staff member responsible for collaborating and communicating with hospice representatives, and the resident’s care plan did not include the hospice plan of care for 1 resident receiving hospice services. Resident 2 was admitted to the facility in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document showed the resident was admitted to hospice services on 5/24/26. Review of the care plan showed it did not include hospice-related information, including a Hospice Plan of Care. During interviews, Staff 6, the RNCM, stated she did not know what information needed to be on the care plan for residents receiving hospice services and did not know which staff members were responsible for collaborating and coordinating with hospice representatives for Resident 2. Staff 6 acknowledged that Hospice Plan of Care information was not included in the resident’s care plan. Staff 2, the DNS, also acknowledged the facility did not have designated staff members identified to communicate and collaborate with hospice representatives for Resident 2 and that Hospice Plan of Care information was not included in the resident’s care plan.
Survey Findings Binder Not Updated
Penalty
Summary
The facility failed to ensure the state survey inspection results contained the most recent survey results for 1 of 1 facility reviewed for resident council. During the resident council meeting on 7/22/26 at 2 PM, residents in attendance stated they were not aware of where to find the state survey inspection results in the facility. Later that day, at 4:14 PM, observation of the Survey Findings Binder at the front entrance across from the receptionist desk showed that it did not contain all of the 2025 survey findings and had no 2026 survey findings included. At 4:48 PM, Staff 1, the Executive Director, stated the administrator oversaw updating the state survey inspection result binder and acknowledged that the binder was not updated with the most recent survey results.
Failure to Provide Timely Transfer Assistance and Access to Call System
Penalty
Summary
The deficiency involves the facility’s failure to provide timely transfer assistance to a resident who required staff support for activities of daily living. The resident was admitted with sepsis, lobar pneumonia, and acute respiratory failure with hypoxia, and the admission MDS documented a BIMS score of 14, indicating the resident was cognitively intact but dependent for wheelchair mobility. A nursing care note documented that after dinner the resident was assisted back to their room and left alone in a wheelchair while staff went to obtain a second person for a two-person transfer. Staff did not return to the room for over an hour. A risk management report completed by an LPN confirmed the resident remained alone in the wheelchair in the room for over an hour awaiting transfer assistance. The resident later stated they were left alone for approximately one hour and ten minutes, did not have a call light or phone within reach, experienced pain, and were unable to transfer or move the wheelchair independently. A CNA reported being assigned both to the resident and to dining room duties and stated she could not leave the dining room while residents were still eating, so she requested another CNA to assist the resident back to the room; she later found the resident still sitting alone in the wheelchair awaiting transfer to bed. Multiple facility leaders, including the assistant administrator in training, field lead, chief nursing officer, and assistant chief nursing officer, acknowledged the resident should have received more timely transfer assistance.
Failure to Administer STAT-Ordered Lokelma for Elevated Potassium
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s STAT medication order for a resident with an elevated potassium level. The resident was admitted with a diagnosis of a right lower leg fracture and had a BIMS score of 13, indicating intact cognition. A STAT order for Lokelma, a medication used to treat high blood potassium levels, was placed on 8/1/25. According to the facility’s Risk Management report and a Progress Note dated 8/3/25, the facility did not administer the ordered STAT dose of Lokelma. As a result of the missed medication, the on-call provider was notified and the resident was sent to the emergency room on 8/3/25. During interviews, a hospital social worker stated the facility failed to administer the physician-ordered medication for the resident’s elevated potassium level and confirmed the resident was sent to the hospital related to the missed dose. An LPN reported that a medication error occurred involving the Lokelma dose and stated that an incident report should have been written, though they could not recall if one was completed. An RN/Resident Care Manager also recalled a medication error involving the Lokelma but could not remember details of the findings. Administrative and nursing leadership staff acknowledged that the resident should have received the STAT Lokelma dose as ordered.
Resident Sustains Burns Due to Improper Heat Pack Application
Penalty
Summary
A resident with kidney disease, who was cognitively intact and required partial assistance with upper body dressing, was admitted without any skin impairment. The resident had standing orders for a heat pack, but these orders were not transcribed onto the Treatment Administration Record (TAR). On one occasion, a CNA provided the resident with an insta-hot heat pack without first communicating with a nurse or ensuring a barrier was placed between the heat pack and the resident's skin. The CNA handed the heat pack directly to the resident, who then applied it herself/himself. Staff did not monitor or ensure the timely removal of the heat pack. As a result, the resident kept the heat pack on for an unknown period, leading to the development of superficial blisters and redness on the shoulder and underarm. The next morning, the resident reported itching, and upon assessment, clear and uncapped blisters were observed, with some skin sloughing noted. The incident occurred due to a lack of staff supervision, failure to follow proper procedures for heat pack application, and absence of documentation and communication regarding the intervention.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for all five sampled CNA staff members. Personnel records showed that performance reviews for these staff were either outdated by several years or missing entirely. Specifically, one CNA had no performance review on file, while the others had last received reviews between two and seven years prior to the survey. During an interview, the Director of Nursing Services confirmed that annual performance reviews were expected to be completed in a timely manner, but this had not occurred for the sampled staff.
Failure to Ensure Annual CNA In-Service Training Requirements Met
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of in-service training annually. A review of staff training records showed that four out of five randomly selected CNAs had not completed the mandated training hours within the specified timeframes. Specifically, one CNA had only 1.5 hours, another had 2.25 hours, a third had no documented training, and a fourth had 8.62 hours of training documented for the relevant annual periods. During an interview, facility leadership confirmed that CNAs were expected to complete the annual training requirement.
Failure to Provide Adequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with a history of kidney failure who was admitted with an external urinary catheter. The resident's care plan did not include documentation of the catheter, and there was no physician-ordered treatment for the catheter found on the Treatment Administration Record (TAR). A staff LPN changed the resident's catheter after it became dislodged, but did not review a physician's order prior to the procedure and documented the change in progress notes rather than on the TAR. The facility's policy required verification of a physician's order and care plan review prior to catheter care, but these steps were not followed for this resident.
Failure to Honor Resident's Medication Administration Preferences
Penalty
Summary
A resident with a history of stroke was admitted to the facility and had a specific preference for medication administration, requesting to take medications one pill at a time with water or applesauce. Despite these instructions, a former CNA administered the resident's medications all at once with a spoon, disregarding repeated requests from both the resident and a friend to stop. The friend intervened by notifying a nurse, who then stopped the improper administration. The resident's preference for medication administration was subsequently documented in the care notes and communicated to staff.
Unlicensed Staff Administers Medication Against Resident's Wishes
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), identified as Staff 30, administered medications to a resident diagnosed with brain cancer and stroke, despite not being licensed or permitted to do so according to state regulations and facility policy. The incident began when a certified medication aide (CMA), Staff 29, entered the resident's room to administer morning medications but found Staff 30 providing personal care. Instead of waiting or returning later, Staff 29 left the medications on the bedside table and exited the room. Staff 30 then attempted to administer the medications to the resident, which was outside her scope of practice. Multiple witnesses, including a friend of the resident and other staff members, observed Staff 30 administering the medications by the spoonful, despite the resident's protests and attempts to refuse, including yelling "no, no, no" and spitting the medications back into the cup. Witnesses reported that Staff 30 did not stop when told to do so by both the resident and the friend. The situation escalated until other staff intervened and removed Staff 30 from the room. Interviews with staff and review of facility policy confirmed that only licensed or certified staff are permitted to administer medications, and that staff are expected to stop any action if a resident refuses care.
Unlicensed Staff Administered Medication Against Resident's Wishes
Penalty
Summary
Facility staff failed to follow professional standards of practice for medication administration for a resident with diagnoses including brain cancer and stroke. A certified medication aide (CMA) entered the resident's room to administer morning medications but found a CNA providing personal care. The CMA left the medications on the bedside table and exited the room, contrary to facility policy and state regulations. The CNA, who was not authorized to administer medications, attempted to give the medications to the resident by the spoonful, despite the resident's verbal refusals and attempts to spit out the medication. A friend of the resident witnessed the event, intervened, and alerted staff at the nurses station. Multiple staff interviews confirmed that the CNA continued to attempt to administer the medications even after being told to stop by both the resident and the friend. The incident was only halted when additional staff, including the CMA and an LPN, entered the room and removed the CNA. Staff acknowledged that only licensed or permitted personnel are allowed to administer medications and that the actions taken were not in accordance with facility policy or professional standards.
Failure to Monitor and Update Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper monitoring and care planning for pressure injuries in two residents. One resident was readmitted with no documented skin impairment but was later found to have redness and discoloration on both great toes, likely related to compression socks. Despite this finding, there were no further assessments or measurements of the affected areas, and the care plan was not updated to reflect the new skin condition. Staff interviews revealed that the areas were not reassessed after the initial finding, and the DNS was not notified of the skin changes, contrary to facility protocol. Another resident was admitted with intact skin but developed a facility-acquired Stage 2 pressure wound to the sacrum and buttocks shortly after admission. The wound was not identified until several days after admission, and the initial wound assessment was inaccurate. The care plan was not revised to address the new wounds, and no incident report was completed as required by facility policy. The DNS acknowledged these lapses, including the failure to notify the physician, initiate an investigation, and document the wound accurately.
Failure to Provide Timely Pharmaceutical Services for Two Residents
Penalty
Summary
The facility failed to provide timely pharmaceutical services for two residents who required medication for their medical conditions. One resident, admitted with cancer, had an order for Nystatin Mouth/Throat Suspension to treat thrush, but the medication was repeatedly unavailable over several days. Progress notes indicated that staff could not locate the medication on multiple occasions, and there was confusion regarding the medication's stop date, resulting in only a small amount being sent by the pharmacy. Staff confirmed the medication was not found in the medication cart or emergency dispensary, and the usual procedure was to notify the nurse and verify if the medication had been ordered. The Director of Nursing expected staff to call the pharmacy if a medication was not available. Another resident, admitted with hypertension and heart disease, had an order for daily isosorbide mononitrate. The medication was not available on several days, as documented in the medication administration records and electronic notes. Staff confirmed the medication could not be located and were unsure if it had been reordered. The pharmacist stated that the medication was ordered and sent out as requested, but gaps in administration occurred due to the medication's unavailability within the facility.
Medication Error: Incorrect Transcription of PRN Ibuprofen Order
Penalty
Summary
The facility failed to ensure that a resident was administered ibuprofen as prescribed, resulting in a significant medication error. The physician ordered ibuprofen 600 mg by mouth every eight hours as needed (PRN) for chills or fever, but the order was incorrectly transcribed into the Medication Administration Record (MAR) as a scheduled medication to be given three times daily. This error led to the resident receiving nine scheduled doses of ibuprofen over several days, rather than only as needed. The error was not identified by the nurse who entered the order or by the second nurse who reviewed it. The resident, who had a diagnosis of obesity and was elderly, subsequently experienced a significant gastrointestinal event, including a large, dark red liquid bowel movement with clots and rectal bleeding. Laboratory results showed low hemoglobin and hematocrit levels, and the resident was transported to the hospital for evaluation and treatment. Hospital records indicated the presence of a duodenal ulcer and diverticula, with an assessment of acute blood loss anemia and suspected diverticular bleed. The facility's investigation confirmed the medication error and noted that the ibuprofen administration may have worsened the resident's condition.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the actions of Staff 3, an LPN, towards a resident with dementia and a speech deficit. The resident, who was admitted with diagnoses including dementia and a stroke, exhibited behaviors such as fidgeting, anger, frustration, and yelling. Despite these known behaviors, Staff 3 was reported to have willfully intimidated the resident by taunting them to yell louder and incorrectly transferring the resident by picking them up like a baby. These actions were observed by other staff members, who reported the incidents to facility management. Staff 3 admitted to becoming annoyed with the resident's yelling and acknowledged using a not-so-nice tone to remind the resident to be quiet. Additionally, Staff 3 stood over the resident in a manner described as dangling a treat if the resident behaved, further demonstrating a lack of respect and dignity towards the resident. The facility's Dignity Policy, which requires staff to treat residents with dignity and speak respectfully, was not adhered to in this instance, leading to the termination of Staff 3's employment.
LPN Fails to Adhere to Professional Standards of Resident Dignity
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN), identified as Staff 3, adhered to professional standards of practice concerning residents' dignity and plan of care. This deficiency was identified during an investigation into the treatment of a resident admitted with dementia and a stroke with speech deficit. The resident's care plan, revised in August 2024, noted behaviors such as fidgeting, anger, frustration, and yelling, with specific triggers and interventions outlined. However, on October 15, 2024, Staff 3 admitted to becoming annoyed with the resident's yelling and frequently reminded the resident to be quiet in a harsh tone. Additionally, Staff 3 stood over the resident while they yelled and physically scooped the resident up for transfers, actions that were deemed intimidating and disrespectful, thus failing to respect the resident's dignity and rights as per the care plan.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Survey Agency (SSA) within the required two-hour timeframe. The incident occurred on 1/18/24 when the resident, who was cognitively intact and had bilateral leg fractures and chronic pain, reported that an agency nurse was rude and disrespectful during a dressing change and did not use caution when moving the resident's fractured leg. The resident reported the incident to a Licensed Practical Nurse (LPN) who assisted in completing a grievance form and attempted to contact the agency nurse but did not receive a response. The resident and their family later reported additional concerns about the incident, including experiencing pain and feeling frightened, but the facility did not report the incident to the SSA until 2/13/24, 18 days after the initial report. During an interview on 5/17/24, facility staff acknowledged that the verbal abuse incident was not reported to the SSA in a timely manner. The delay in reporting was attributed to leadership changes within the facility, which led to a review of the grievance log and the eventual determination that the incident should have been reported. The failure to report the incident promptly placed residents at risk for potential ongoing abuse.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident who was admitted with bilateral leg fractures and chronic pain. The resident, who was cognitively intact, reported that an agency nurse was rude, disrespectful, and failed to use caution during a dressing change. Despite the resident filing grievance forms on two occasions, the facility delayed reporting the incident to the State Survey Agency by 18 days and did not conduct a comprehensive investigation. The initial investigation lacked critical elements such as observations of the resident following the allegation, interviews with potential witnesses or staff, and a thorough review of relevant records. During an interview, facility staff acknowledged that the incident was initially treated as a grievance rather than an abuse allegation. The Director of Nursing Services and other staff members admitted that their investigation process was insufficient and did not meet the required standards for handling abuse allegations. The failure to conduct a thorough investigation placed residents at risk for potential ongoing abuse.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 164 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
A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Avamere Transitional Care At Sunnyside | 2.5 mi | ★★★★★ | 0 | 0 |
| Tierra Rose Care Center | 4.4 mi | ★★★★★ | 2 | 0 |
| Windsor Health And Rehabilitation | 4.8 mi | ★★★★★ | 27 | 0 |
| Keizer Nursing And Rehabilitation | 7.2 mi | ★★★★★ | 3 | 0 |
| Avamere Court At Keizer | 8.4 mi | ★★★★★ | 0 | 0 |
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