Tierra Rose Care Center
4254 Weathers Street Ne, Salem, OR 97301
Tierra Rose Care Center is a nursing home in Salem, Oregon. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (503) 585-4602
- Last standard health inspection
- October 17, 2025 (1 year ago)
- Certified beds
- 76
- Residents per day, on average
- 72.2
- Ownership type
- For profit - Corporation
- Legal business name
- Legal Business Name Not Available
- Chain
- Not listed by CMS
- Takes part in
- Medicaid
Fewer health citations than the Oregon average (20 vs 34).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
2 citations
Health inspection on October 17, 2025
CMS lists this as a standard inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 10, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 10, 2025.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of August 29, 2024
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
6 citations
Health inspection on June 28, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 29, 2024.
Citation F0908. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on July 29, 2024.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on July 29, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 29, 2024.
CMS has cited this home for F0689 2 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on July 29, 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 29, 2024.
10 citations
Fire safety inspection on June 28, 2024
CMS lists this as a standard inspection.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on August 17, 2024.
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on August 17, 2024.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on August 17, 2024.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on August 17, 2024.
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on August 17, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on August 17, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 17, 2024.
CMS has cited this home for K0353 2 times since 2023.
Citation K0500. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet other general requirements that are deficient.
CMS lists it as corrected on August 17, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 17, 2024.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 17, 2024.
CMS update of May 29, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
CMS update of February 29, 2024
CMS abuse icon
CMS removed its abuse icon from this home.
12 citations
Health inspection on April 21, 2023
CMS lists this as a standard inspection.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on May 10, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on May 10, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 10, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 10, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 10, 2023.
Citation F0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS lists it as corrected on May 10, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on May 10, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on May 10, 2023.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on May 10, 2023.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on May 10, 2023.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on May 10, 2023.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on May 10, 2023.
3 citations
Fire safety inspection on April 21, 2023
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 16, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 16, 2023.
Citation K0932. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on May 16, 2023.
Questions
When was Tierra Rose Care Center last inspected?
CMS lists October 17, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Tierra Rose Care Center have?
CMS lists 20 health citations since April 21, 2023. CMS also calls these deficiencies.
Has Tierra Rose Care Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Tierra Rose Care Center?
Its CMS overall star rating is 5 of 5.
Is Tierra Rose Care Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.