Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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 | — | 6 | 0 |
| Circle Of Care | 0.5 mi | — | 0 | 0 |
| Blossom Nursing And Rehab Center | 2.1 mi | — | 7 | 0 |
| Auburn Skilled Nursing And Rehab | 6.6 mi | — | 13 | 0 |
| St Mary's Alzheimer's Center | 7.3 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 August 2026) and official state health department websites.