Above average — CMS composite of the measures below.
The next survey window likely opens around September 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 Tierra Rose Care Center during CMS and state inspections, most recent first.
Failure to Reposition Resident With Coccyx Wound: A resident with dementia and high risk for skin breakdown had a care plan for regular turning and repositioning and a coccyx MASD wound order, but was repeatedly observed lying flat without offloading or pressure-relieving devices. Staff gave conflicting accounts about whether the resident was on a turning program, and wound care later found the coccyx wound open, non-blanchable, and painful during treatment.
Infection control procedures were not followed when staff cared for a resident with confirmed COVID-19 and during meal service. A CNA entered the resident’s room without an N95 respirator and eye protection, another CNA stored and reused a face shield inside the room without disinfecting it, and a staff member handled trash then delivered coffee without hand hygiene. Staff leadership confirmed staff were expected to use N95s and eye protection in COVID-19 rooms and to complete hand hygiene as needed.
The facility failed to maintain proper food storage and cleanliness in the walk-in refrigerator, freezer, and resident refrigerator. Expired and undated food items, including moldy fruits and an opened bag of omelets, were found. Additionally, the walk-in refrigerator had a liquid spill under defrosting raw meat, and the freezer floor was dirty. These issues were acknowledged by the Dietary Manager, Administrator, and Assistant DNS.
The facility did not maintain the walk-in freezer in a safe condition, as evidenced by long ice crystals forming on a pipe. Despite attempts by two repair companies, the issue persisted, and the Plant Manager had to manually break the ice crystals weekly. This practice was documented in a maintenance log since September 2023.
A resident with heart failure and weakness was observed with long, thick toenails despite a care plan requiring regular nail care. The care plan specified that nails should be checked, trimmed, and cleaned on bath days. A CNA stated that nail care was to be provided weekly, with the nurse responsible for notifying staff of residents needing care. An LPN confirmed the resident's toenails were long and thick.
The facility failed to properly store and label medications and biologicals, as observed during a review. An opened multi-dose vial of Tubersol was found without a date, risking inaccurate tuberculosis testing. Additionally, a medication cart contained unmarked white pills labeled only as 'Loratadine,' which were improperly stored. An LPN and the Assistant DNS acknowledged these deficiencies.
A facility failed to maintain complete and accurate records for a resident with arthritis and mobility issues. The resident's care plan incorrectly included a Restorative Aid Therapy program, which was not provided, and was intended for another resident. Staff confirmed the error, and the resident reported not receiving the therapy services since admission.
The facility failed to implement and update fall prevention measures for three residents, leading to inadequate supervision and increased fall risk. A resident with dementia and a history of falls did not have the required bilateral fall mats, while another resident with heart failure had mats placed incorrectly. Additionally, a resident with a history of falls was observed without the necessary fall mats, highlighting a lack of adherence to care plans.
Failure to Reposition Resident With Coccyx Wound
Penalty
Summary
The facility failed to implement interventions to promote wound healing for a resident with dementia who was assessed as not cognitively intact and at high risk for developing sores. The resident had a care plan for turning and repositioning in bed two to three times per shift and as necessary, and a physician order dated 10/5/25 identified a MASD wound on the coccyx. However, from 10/13/25 through 10/16/25, the resident was observed on eleven occasions lying flat on the back with no offloading or other pressure-relieving devices present. Staff interviews showed inconsistent understanding of the resident’s repositioning status and needs. One RN stated the wound was healed and closed, while later wound care on 10/17/25 showed the coccyx wound was open with a pink wound bed and non-blanchable area, and the resident verbalized pain during care. A CNA stated the resident was bed bound, had limited ROM, and was not on a turning/repositioning program, while another CNA and an RN gave different descriptions of the turning schedule and whether the resident was on such a program. The LPN Resident Care Manager stated the resident was bed bound, depended on staff to reposition, and required repositioning every one to two hours with pillow support, while the Assistant DNS stated there was no specific program requiring pillow support when repositioning residents.
Infection Control Failures With PPE and Hand Hygiene
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed failures in hand hygiene and PPE use. The report states that the facility did not follow infection control procedures for 1 of 1 facility reviewed for infection control, and that this placed residents at risk for exposure to infection and cross contamination. The CDC's 6/24/24 Infection Control Guidance: SARS-CoV-2 was referenced as requiring staff caring for residents with confirmed COVID-19 to wear an N95 respirator and a barrier face covering. A resident admitted on 9/2/25 with Parkinson's disease tested positive for COVID-19 on 10/14/25 at 10:23 AM. That same day, a CNA entered the resident's room wearing a gown, gloves, and surgical mask, but without eye protection and an N95 respirator. The CNA stated the resident was on transmission-based precautions for COVID-19 and said he used contact precautions without eye protection because he did not provide direct care. On 10/15/25, another CNA entered the room to deliver a meal tray, doffed PPE at the doorway, and hung a face shield on the wall inside the room without disinfecting it. A third CNA stated a face shield was stored inside the room of a resident with COVID-19 and was used when providing care. In a separate observation, a staff member placed his hands inside a garbage bag to dispose of trash and then prepared and delivered a cup of coffee to a resident without completing hand hygiene; he later acknowledged he had not performed the needed hand hygiene.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and cleanliness in both the walk-in refrigerator and freezer, as well as the resident refrigerator in the therapy gym. During an inspection, an opened half-gallon of heavy whipping cream with an expired use-by date was found in the walk-in refrigerator, along with a red and brown liquid on the floor beneath a rack holding defrosting raw meat. In the walk-in freezer, an opened and undated bag of pre-made egg and cheese omelets was discovered, along with food crumbs and dirt clumps on the floor. Additionally, the resident refrigerator contained an expired bottle of sriracha mustard, undated moldy strawberries and blueberries, and a styrofoam container of chocolate pudding past its use-by date. These findings were acknowledged by the Dietary Manager, Administrator, and Assistant DNS, with the Assistant DNS noting that food should be labeled and discarded after three days or by the use-by date.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, specifically the walk-in freezer. During an observation, long vertical ice crystals approximately 15 inches in length were found attached to a pipe connected to the freezer's temperature unit. The Dietary Manager acknowledged the issue and stated that two repair companies had attempted to fix the freezer but were unsuccessful. The Plant Manager was responsible for breaking the ice crystals weekly as they accumulated rapidly, and a maintenance log confirmed that this practice had been ongoing since September 2023.
Inadequate Foot Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 66, who was admitted in 2024 with diagnoses including heart failure and weakness. The resident's care plan, dated 5/7/24, required staff to check, trim, and clean nails on bath days and as necessary, and to report any changes to the nurse. On 6/25/24, Resident 66 was observed wearing sandals with thick toenails extending past the end of the toes. Despite having a bath on 6/26/24, the resident's toenails remained long and thick. Staff 4, a CNA, stated that nail care was to be provided weekly, with the nurse responsible for informing CNA staff of residents needing nail care. Staff 5, an LPN, confirmed the observation of the resident's long and thick toenails.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed during a review of the medication storage area. The facility's policy required that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer, and that medications not be transferred between containers. During the inspection, a refrigerator was found to contain an opened multi-dose vial of Tubersol without a date on the box or vial, which was verified by an LPN and a CMA. This lack of labeling could lead to inaccurate tuberculosis testing. Additionally, a medication cart was found to contain a small cup with multiple round white pills without markings, labeled only with the word 'Loratadine.' An LPN acknowledged that the pills were improperly stored and indicated they needed to be discarded. The Assistant DNS confirmed that both the vial of Tubersol and the cup of white pills were not labeled and stored appropriately, which could result in improper medication administration and reduced efficacy of medication.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate, specifically for a resident admitted with diagnoses including arthritis, gait and mobility abnormalities, and muscle weakness. The resident's comprehensive care plan indicated a need for a restorative nursing program with range of motion exercises for the lower extremities. However, there were no active orders for Physical Therapy, Occupational Therapy, or Restorative Aid Therapy. The resident reported not receiving any therapy services since admission, and staff confirmed the absence of a Restorative Aid Therapy program. The care plan mistakenly included a Restorative Aid Therapy intervention intended for a different resident, as acknowledged by the Assistant DNS.
Failure to Implement and Update Fall Prevention Measures
Penalty
Summary
The facility failed to follow care planned interventions and revise care plans to prevent falls for three residents. Resident 64, who was admitted with diagnoses including stroke and dementia, had a care plan indicating a fall mat on the left side of the bed. However, after a non-injury fall on the right side, no new interventions were implemented, and the care plan was not updated to include bilateral fall mats. Observations showed that staff did not consistently place the required fall mats, leaving the resident at risk. Resident 66, admitted with heart failure and weakness, was supposed to have a fall mat on the right side of the bed according to the care plan. However, observations revealed the mat was placed on the left side, contrary to the care plan. Similarly, Resident 1, with a history of falls, was care planned for bilateral fall mats but was observed with only one mat on the right side, and later, no mats at all. Staff acknowledged these discrepancies, indicating a failure to adhere to and update care plans as necessary.
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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) |
|---|---|---|---|---|
| Windsor Health And Rehabilitation | 2.4 mi | ★★★★★ | 6 | 0 |
| Keizer Nursing And Rehabilitation | 3.3 mi | ★★★★★ | 3 | 0 |
| Salem Transitional Care | 4.4 mi | ★★★★★ | 2 | 0 |
| Avamere Court At Keizer | 4.5 mi | ★★★★★ | 19 | 0 |
| Avamere Transitional Care At Sunnyside | 4.8 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.