Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Richfield Health Center - Salem during CMS and state inspections, most recent first.
Facility staff failed to follow provider orders by administering Tresiba insulin to a resident with diabetes on several occasions when the resident's blood sugar was below the specified threshold. This resulted in the resident experiencing severe hypoglycemia, requiring emergency intervention and hospital transfer. The DON confirmed that the medication was given inappropriately, contrary to both provider orders and facility policy.
Facility staff did not follow professional standards of practice when a resident experienced a change in respiratory status requiring oxygen and a chest x-ray. The nurse failed to document an assessment, did not record contacting the medical provider for orders, and did not enter a progress note. After a respiratory therapist noted a significant drop in oxygen saturation and started oxygen, there was no documentation of reassessment or which nurse was notified, contrary to facility policy.
Facility staff did not obtain a provider-ordered CBC and CMP for a resident who was prescribed Bumex for bilateral edema. Despite documentation of the lab order in the resident's record, there was no evidence that the tests were performed or results obtained, as confirmed by the DON during the survey.
Facility staff did not promptly implement a provider's order for lymphatic drainage massage for a resident with bilateral edema. Although the order was documented and a COTA was noted as being made aware, therapy staff were not formally notified until a care plan meeting days later. The resident was not assessed for the service until more than a week after the order, and the first massage was provided several days after that, resulting in a delay in required rehabilitative care.
A resident with full mental capacity reported being left on the toilet for 2 1/2 hours. The call Alarm History confirmed the resident's claim, showing extended call durations from the bathroom. Attempts to contact the responsible nurse were unsuccessful, and the facility's documentation did not provide further details on the incident.
A resident with multiple diagnoses experienced a significant weight loss, but the facility staff failed to notify the medical provider as required by policy. Despite the weight loss being documented, there was no evidence of communication with the medical provider, as confirmed by the DON.
A resident with severe cognitive impairment and multiple diagnoses was discharged from Medicare Part A services without receiving a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN). Although the resident's power of attorney was informed about the Notice of Non-coverage and appeal rights, the facility could not locate the required ABN notice during a survey. The issue was discussed with the Administrator and Director of Nursing, but no additional information was provided before the exit conference.
The facility staff failed to accurately complete MDS assessments for two residents. One resident's self-catheterization was not marked on the MDS, despite a provider order and the resident's confirmation. Another resident was incorrectly coded as discharged to a hospital, while records showed they were discharged home. These inaccuracies were discussed with the facility's administration.
The facility failed to implement comprehensive person-centered activity care plans for two residents, resulting in a lack of one-to-one activity programming. One resident, with Dementia and Depression, reported no engagement from activity staff, and the Activity Director confirmed no documentation of activities. Another resident, severely cognitively impaired, also lacked documented one-on-one visits, despite care plan requirements. Facility policies require such programming, but these were not followed, leading to deficiencies.
A resident's care plan was not updated to include their self-catheterization routine and prophylactic antibiotic use, despite having provider orders for these interventions. The oversight was discovered during a survey, revealing a failure to review and revise the comprehensive care plan as required.
Two residents in a facility did not receive their prescribed medications due to staff failing to follow physician's orders and facility policies. Despite the medications being available in the emergency supply, they were not administered, leading to deficiencies in care. Interviews revealed lapses in the process for checking medication availability and procuring extra doses.
The facility failed to follow up on pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident's recommendation for a gradual dose reduction was delayed by over a month, while another resident's drug regimen reviews were not reported or acted upon. The facility lacked documentation and a clear policy for Medication Drug Regimen Review.
A resident's clinical records were found to be incomplete, with missing entries in the eMAR and eTAR for prescribed treatments and medications. The resident had diagnoses including pain in the left hip and dementia, with a care plan addressing risks related to pain, skin integrity, and nutrition. The facility's policy requires complete documentation of care, but blanks were found in the records, which was discussed with the administrator and DON.
A resident over the age of 65 with multiple diagnoses, including dementia and acute kidney failure, was not offered a pneumococcal vaccine upon admission to the facility, despite facility policy and CDC guidelines. The resident's clinical record and interviews with the DON confirmed the oversight.
Failure to Hold Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
Facility staff failed to administer diabetic medication according to provider orders for one resident with Type 2 Diabetes Mellitus and Congestive Heart Failure. The resident had a physician's order for Tresiba insulin to be given at bedtime, with instructions to hold the dose if the resident's finger stick blood sugar (FSBS) was less than 200. Despite this, Tresiba was administered on multiple occasions (5/12, 5/14, 5/15, and 5/31) when the resident's FSBS was below 200, as documented in the clinical record and confirmed by the Director of Nursing. On each of these dates, the resident's blood sugar readings were significantly below the threshold specified in the order, yet the medication was still given. As a result of these medication errors, the resident was found unresponsive with a critically low blood sugar level and required emergency intervention, including administration of injectable Glucagon and transfer to a local emergency department. The facility's policy required licensed nurses to administer medications according to provider orders and to assume responsibility for correct administration and documentation. The surveyor confirmed with facility leadership that the medication was administered inappropriately on the specified dates, contrary to both the provider's orders and facility policy.
Failure to Document and Assess Change in Resident Condition
Penalty
Summary
Facility staff failed to follow professional standards of practice in assessing and documenting a resident's change in condition. Specifically, when a resident experienced a decline in respiratory status that required new medical provider orders for oxygen therapy and a chest x-ray, the nurse did not complete or document an assessment addressing the resident's condition. There was also no documentation of the nurse contacting the medical provider to obtain these orders, nor was there a progress note entered at the time the orders were received. The resident's clinical record lacked details regarding vital signs, lung sounds, and the identity of the nursing staff notified about the change in condition. Additionally, after a respiratory therapist documented a significant drop in the resident's oxygen saturation during therapy and initiated oxygen, there was no documentation of a reassessment of the resident's condition following this intervention. The facility's own policies require that all changes in a resident's medical condition, as well as responses to treatments and new symptoms, be properly recorded in the medical record. These documentation failures were confirmed through interviews, record reviews, and policy review.
Failure to Obtain Provider-Ordered Laboratory Tests
Penalty
Summary
Facility staff failed to obtain medical provider-ordered laboratory blood tests for one resident. The resident had a new order for a one-time dose of Bumex 2 mg, followed by a daily dose, due to bilateral edema in the legs and arms. Along with this medication order, the provider also ordered a complete blood count (CBC) and comprehensive metabolic panel (CMP) to be obtained on a specific date. The facility's policy requires that verbal telephone orders be documented by the nurse in both the order entry field and the resident's medical record under progress notes. A review of the resident's clinical documentation confirmed the order for the CBC and CMP, but there was no evidence in the clinical record that these laboratory tests were obtained or that results were available. The Director of Nursing confirmed that the results for the ordered laboratory tests were not found in the resident's record. This failure was discussed with facility leadership during the survey process.
Delay in Implementing Provider Order for Rehabilitative Services
Penalty
Summary
Facility staff failed to promptly implement a medical provider's order for specialized rehabilitative services for one resident. The order, documented in a nursing progress note, included a recommendation for lymphatic drainage massage due to the resident's bilateral edema in the legs and arms. Although the certified occupational therapist assistant was noted as being made aware of the order, there was no evidence that therapy staff were formally notified at the time the order was given. The resident was assessed as having intact or borderline cognition, with a BIMS score of 13 out of 15, and was able to make self understood and understand others. The Director of Therapy reported that therapy staff only became aware of the order during a care plan meeting several days after the order was written. Documentation showed that the assessment for lymphatic drainage massage did not occur until more than a week after the order, and the first massage was provided several days after the assessment. The delay in communication and implementation of the provider's order resulted in a failure to provide timely specialized rehabilitative services as required.
Resident Left on Toilet for Extended Period
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity concerning toileting needs. The resident, who was admitted with diagnoses including aftercare joint replacement, anemia, hypertension, anticoagulants, abnormal gait, and a history of pulmonary embolism, reported being left on the toilet for 2 1/2 hours. The resident was assessed as having full mental capacity, scoring 15/15 on the brief interview for mental status, and showed no signs of delirium, psychosis, or behavior affecting care. The surveyor reviewed the call Alarm History, which confirmed the resident's claim, showing a call from the bed active for 120 minutes and seven calls from the bathroom totaling 122 minutes. The nursing staff on duty during the survey were not present on the day of the incident, and attempts to contact the responsible nurse were unsuccessful. The facility's activity of daily living notes documented that the resident used the toilet once during the day shift, but did not provide further details on the incident.
Failure to Notify Medical Provider of Significant Weight Loss
Penalty
Summary
The facility staff failed to notify and consult with the medical provider following a significant weight loss for a resident. The resident, who had diagnoses including Alzheimer's Disease, Convulsions, Parkinson's Disease, Lymphedema, Essential Hypertension, and Second-Degree Atrioventricular Block, experienced a significant weight loss of 12 pounds, or 7.47%, over a 10-day period. Despite this significant change, there was no evidence found in the clinical records that the medical provider was notified of the weight loss. The surveyor reviewed the facility's policy on Weight Assessment and Intervention, which requires nursing staff to notify the dietician and physician/practitioner if a significant weight change is confirmed. However, during an interview with the Director of Nursing, it was confirmed that there was no documentation of such notification. The issue was discussed with the Administrator and DON, but no further information was provided to address the concern before the exit conference.
Failure to Provide SNF ABN Notice
Penalty
Summary
The facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) for a resident who was discharged from Medicare Part A services while still residing in the facility. This deficiency was identified during a survey that included staff interviews, clinical record reviews, and facility document reviews. The resident in question had a range of diagnoses, including Alzheimer's Disease, Convulsions, Parkinson's Disease, Lymphedema, Essential Hypertension, and Second-Degree Atrioventricular Block. The resident was noted to be severely impaired in cognitive skills for daily decision-making, with both short-term and long-term memory problems. The social services progress note indicated that the resident's power of attorney (POA) was informed via phone about the Notice of Non-coverage and appeal rights, with the effective date of skilled services ending and financial liability beginning clearly communicated. However, when the surveyor requested to view the notices provided to the resident's POA, the facility could not locate an ABN notice for the resident. The Administrator provided a copy of the Notice of Medicare Non-Coverage (NOMNC) but acknowledged the absence of the ABN notice. This issue was discussed with the Administrator and Director of Nursing, but no further information was provided before the exit conference.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to accurately complete a minimum data set (MDS) assessment for two residents, leading to deficiencies in the documentation of their care. For one resident, the staff did not mark the resident's self-catheterization on the quarterly MDS assessment, despite the resident's diagnoses of obstructive and reflux uropathy, chronic kidney disease, and diabetes. The resident confirmed during an interview that they performed self-catheterization, and the clinical record included a provider order for self-catheterization four times a day. However, the MDS assessment inaccurately indicated the resident was always continent of urine, and the box for intermittent catheterization was left unchecked. In another case, the facility staff incorrectly coded a resident's discharge location on the MDS. The resident, who had multiple diagnoses including a wedge compression fracture and cirrhosis of the liver, was documented as being discharged to a hospital, while nursing progress notes and a medical provider order indicated the resident was discharged home. The MDS Nurse later reviewed and corrected the MDS coding to reflect the accurate discharge location. These inaccuracies in MDS assessments were discussed with the facility's Administrator and Director of Nursing, but no further information was provided to the survey team before the exit conference.
Failure to Implement Person-Centered Activity Care Plans
Penalty
Summary
The facility staff failed to implement a comprehensive person-centered activity care plan for two residents, leading to deficiencies in providing one-to-one activity programming. For Resident #34, who has diagnoses including Dementia, Hemiplegia, and Depression, the care plan indicated a need for one-to-one activities in her room twice a week. However, during an interview, the resident reported that activity staff did not engage with her in her room. The Activity Director confirmed the lack of documentation for any activities or one-on-one visits with the resident, despite the care plan's requirements. Similarly, for Resident #26, who is severely cognitively impaired with Alzheimer's Disease and Vascular Dementia, the care plan required frequent one-to-one staff visits to encourage socialization. The Activity Director admitted to not maintaining records of activities or one-on-one visits for this resident as well. The care plan had not been updated to reflect any changes in the resident's needs or preferences, despite the resident's condition and the care plan's stipulations. The facility's policies on care planning and activities programming were reviewed, revealing that they require comprehensive care plans with measurable objectives and timetables to meet residents' mental and psychosocial needs. The policies also mandate one-to-one programming for residents who cannot plan their own activities. These deficiencies were discussed with the Administrator and DON, but no further information was provided to the survey team before their exit.
Failure to Update Resident Care Plan for Self-Catheterization and Antibiotic Use
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan (CCP) for one resident, identified as Resident #65, which resulted in a deficiency. Resident #65 had a history of obstructive and reflux uropathy, chronic kidney disease, and diabetes. Despite having a cognitive assessment score indicating full mental capacity, the resident's care plan did not reflect their need for self-catheterization or the administration of a prophylactic antibiotic. The resident had been self-catheterizing four times a day and was prescribed Macrobid as a prophylactic antibiotic, yet these critical aspects were omitted from the care plan. The deficiency was identified during a survey when the resident mentioned their self-catheterization routine, which was not documented in the care plan. A review of the clinical records confirmed the absence of a care plan addressing these needs. The MDS Coordinator/Registered Nurse verified the oversight, and the issue was subsequently discussed with the facility's Administrator and Director of Nursing. The lack of documentation in the care plan for these medical interventions constituted a failure to adequately review and revise the resident's CCP, as required by regulations.
Medication Administration Deficiencies
Penalty
Summary
The facility staff failed to administer medications according to physician's orders for two residents, leading to deficiencies in care. For one resident, the staff did not administer tramadol and gabapentin as prescribed. The resident, who had diagnoses including pain in the left hip and dementia, had orders for tramadol to be given four times a day and gabapentin every eight hours. However, the electronic medication administration record (eMAR) showed multiple instances where these medications were not administered, with codes indicating the medication was unavailable. Despite the medications being listed as available in the facility's emergency supply, they were not provided, and the facility's policy for procuring extra doses was not followed. Another resident, who was a new admission with anxiety disorder and chronic pain syndrome, also did not receive their prescribed medications, diazepam and oxycodone, as ordered. The eMAR indicated that these medications were unavailable, and the nurse's notes confirmed the unavailability, despite the medications being listed in the facility's emergency supply. The facility's policy for handling missing doses was not adhered to, resulting in the resident not receiving their medications as prescribed. Interviews with staff, including the Director of Nursing and a registered nurse, revealed that the process for checking medication availability and procuring extra doses was not properly executed. The facility's failure to follow physician's orders and its own policies for medication administration and procurement led to these deficiencies, impacting the care provided to the residents.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility staff failed to follow up on pharmacy recommendations for two residents, leading to deficiencies in medication management. For one resident, the facility did not act on a pharmacy recommendation for a gradual dose reduction of Ramelteon and Buspar until over a month later. The recommendation was initially made on March 20, 2024, but was not addressed until May 2, 2024, when a Nurse Practitioner noted that the current regimen was necessary. The recommendation was unsigned and unchecked, indicating a lack of timely follow-up. The medication Ramelteon was eventually discontinued on May 15, 2024. For another resident, the facility did not provide evidence that drug regimen reviews conducted on January 25, 2024, and March 19, 2024, were reported to or acted upon by the medical provider. The reviews included recommendations for dosing adjustments and gradual dose reductions, but the reports were unsigned and unchecked. The facility was unable to provide a policy for Medication Drug Regimen Review, and the Director of Nursing was unsure if such a policy existed. This lack of documentation and follow-up was discussed with the survey team, but no further information was provided before the exit conference.
Incomplete Clinical Records for a Resident
Penalty
Summary
The facility staff failed to ensure a complete and accurate clinical record for a resident, identified as Resident #93. The electronic medication administration record (eMAR) and electronic treatment administration record (eTAR) for this resident were found to be incomplete. Specifically, entries for House Supplement, Pro-Stat, and Tylenol were left blank on the eMAR for a specific date in March 2024, and entries for geri sleeves, check mattress, heel protectors, and wound vac were left blank on the eTAR for a specific date in May 2024. This deficiency was identified during a review of the resident's clinical records, which included a physician's order summary detailing various treatments and medications prescribed for the resident. Resident #93 had a face sheet listing diagnoses such as pain in the left hip and unspecified dementia. The resident's most recent minimum data set indicated both long- and short-term memory loss with severely impaired cognitive skills for daily decision-making. The comprehensive care plan for the resident included care plans addressing risks related to pain, skin integrity, and nutritional decline, among others. The facility's policy on nursing documentation requires that all observations, medications administered, and services performed be documented in the resident's clinical records. The issue of leaving blanks on the eMAR/eTAR was discussed with the facility's administrator and director of nursing, but no further information was provided before the surveyor's exit.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility staff failed to offer a pneumococcal vaccine to Resident #99 in accordance with nationally recognized standards. Resident #99, who was over the age of 65 and had not received a pneumococcal vaccine prior to admission, was not offered a pneumococcal conjugate vaccine (PCV15 or PCV20) following their admission to the facility. This oversight was identified through staff interviews, clinical record reviews, and facility document reviews. Resident #99 had a diagnosis list that included Metabolic Encephalopathy, Traumatic Subdural Hemorrhage, Dementia, Acute Kidney Failure, and Atrial Fibrillation, and was severely cognitively impaired with a BIMS score of 6 out of 15. Despite the facility's policy stating that residents or their responsible parties should be offered the pneumococcal immunization upon admission, there was no evidence found in the resident's clinical record or provided by the Director of Nursing/Infection Preventionist that the vaccine was offered to Resident #99.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Snyder Nursing Home | 3.9 mi | ★★★★★ | 5 | 0 |
| Salem Health & Rehabilitation | 5.8 mi | ★★★★★ | 9 | 0 |
| Davis And Mcdaniel Veterans Care Center | 6.3 mi | ★★★★★ | 3 | 0 |
| Brandon Oaks Nursing And Rehabilitation Center | 6.4 mi | ★★★★★ | 0 | 0 |
| Raleigh Court Health And Rehabilitation Center | 8.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Richfield Health Center - Salem.
100% money-back within 48 hours.
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.