Tierra Rose Care Center
4254 Weathers Street Ne, Salem, OR 97301 · Marion County · (503) 585-4602
76 certified beds, about 71 residents a day · For profit - Corporation · Medicaid since 1980
Certified for Medicaid
Overall
5 of 5
Health inspections
5 of 5
Staffing
4 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 38E075 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on October 17, 2025, inspectors cited 2 health deficiencies (the Oregon average is 9.2, the national average 9.2).
None of its 20 health citations since April 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.15 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.40 of those hours.
30.6% of nursing staff left within the year CMS measured (Oregon average 47.4%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1204/23
606/24
210/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
3E
0F
Potential for minimal harm
0A
0B
0C
October 17, 2025Standard inspection · 2 citations
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement interventions to promote wound healing for 1 of 2 sampled residents (#5) reviewed for pressure ulcers. This placed the residents at risk for worsening pressure ulcers.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow infection control procedures for hand hygiene and PPE use for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infection and cross contamination.
June 28, 2024Standard inspection, Complaint inspection · 6 citations
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure food was stored appropriately and discarded in a timely manner, and failed to maintain a clean freezer for 1 of 1 kitchen and 1 of 1 resident refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness.
- E Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment in a safe operating condition for 1 of 1 kitchen reviewed for kitchen services.
- D Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 3 sampled residents (#66) reviewed for ADLs. This placed residents at risk for lack of nail care and skin impairments.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow care planned interventions and revise care plans to prevent falls for 3 of 6 sampled residents (#s 1, 64 and 66) reviewed for falls and during a random observation. This placed residents at risk for injury from falls.
- D 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 medication carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for inaccurate tuberculosis testing, decreased vaccine efficacy, improper medication administration, and reduced efficacy of medication.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 1 sampled resident (#7) reviewed for therapy services. This placed residents at risk for inaccurate medical records and unassessed needs.
April 21, 2023Standard inspection · 12 citations
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to attain and maintain the highest practicable well-being for 3 of 3 halls (100, 200, 300) reviewed for staffing. This placed residents at risk for unmet needs.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received reasonable accommodation of needs for 1 of 1 sampled resident (#62) reviewed for accommodation of needs. This placed residents at risk for being dependent on bed mobility and repositioning in bed.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident centered care plan was developed for 1 of 1 sampled resident (#17) reviewed for hospice. This placed residents at risk for lack of care planning.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 5 and 63) reviewed of medications. This placed residents at risk for worsening medical conditions.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure fall safey interventions were in place for 1 of 2 sampled residents (#9) reviewed for accidents. This placed residents at risk for falls.
- D Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wrote2. Resident 17 was admitted to the facility in 2022 with diagnoses including heart disease. A review of Resident 17's clinical record on 4/20/23 revealed the last documented physician visit occurred in 11/2022. No evidence was found to indicate physician visits occurred every 60 days. On 4/20/23 at 3:43 PM Staff 2 (Assistant DNS) acknowledged there was no evidence to indicate Resident 17 had a physician visit every 60 days. Based on interview and record review it was determined the facility failed to ensure physician visits occurred at least every 60 days for 2 of 7 sampled residents (#s 17 and 65) reviewed for medications. This placed residents at risk for unmet care needs.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow pharmacy recommendations for 2 of 5 sampled residents (#s 17 and 65) reviewed for medications. This placed residents at risk for adverse medication side effects.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure gradual dose reductions (GDRs) were attempted for residents on psychotropic medications for 1 of 5 sampled residents (#62) reviewed for unnecessary psychotropic medications. This placed residents at risk for side effects of unnecessary medications.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide adequate meal portions and honoring preferences timely for 2 of 6 sampled residents (#s 43 and 63) reviewed for food. This place residents at risk for weight loss and lessened quality of life.
- D Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide meals at a palatable temperature for 2 of 6 sampled residents (#s 43 and 63) reviewed for food. This placed residents at risk for receiving unpalatable food.
- D Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on interview and record review it was determined the facility failed to honor meal preferences for 1 of 6 sampled residents (#54) reviwed for food. This placed residents at risk for lessened quality of life.
- D Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide rehabilitation services for 2 of 4 sampled residents (#s 10 and 63) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life.
Fire safety inspections
13 fire safety citations on file: 10 on June 28, 2024, 3 on April 21, 2023.
Every fire safety citation13 citations
- F Conduct risk assessment and an All-Hazards approach.
- F Develop Emergency Preparedness policies and procedures.
- F Conduct testing and exercise requirements.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Install a fire alarm system that can be heard throughout the facility.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Meet other general requirements that are deficient.
- F Have simulated fire drills held at unexpected times.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Inspect, test, and maintain automatic sprinkler systems.
- D Ensure proper usage of power strips and extension cords.
- D Meet other general requirements.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.15 | 5.03 | 3.86 |
| Registered nurses | 0.40 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.64 | 4.51 | 3.42 |
| Nurse aides | 3.88 | ||
| Licensed practical nurses | 0.87 | ||
| Nursing staff turnover (share who left in a year) | 30.6% | 47.4% | 45.8% |
| Registered nurse turnover | 16.7% | 51.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.72 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.36 on weekdays and 4.64 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.15 in April to June 2025 to 5.15 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.15 | 0.40 | 5.36 | 4.64 | 0.4% | 0 of 90 | 71 |
| Oct to Dec 2025 | 4.93 | 0.29 | 5.11 | 4.48 | 0.4% | 0 of 92 | 72 |
| Jul to Sep 2025 | 5.13 | 0.40 | 5.36 | 4.57 | 0.5% | 0 of 92 | 71 |
| Apr to Jun 2025 | 5.15 | 0.40 | 5.40 | 4.52 | 0.6% | 0 of 91 | 72 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.8 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.5 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.9 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.4 | 2.4 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 14.6 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.5 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.7 | 13.9 | 15.4 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 6 problems in this area, most recently on October 17, 2025: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 4 problems in this area, most recently on June 28, 2024: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on June 28, 2024: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 2 problems in this area, most recently on June 28, 2024: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
Other nursing homes nearby
- Windsor Health and Rehabilitation Salem, 2.4 mi · 1 of 5 stars · 36 citations
- Keizer Nursing and Rehabilitation Keizer, 3.3 mi · 3 of 5 stars · 33 citations
- Salem Transitional Care Salem, 4.4 mi · 2 of 5 stars · 35 citations
- Avamere Court at Keizer Keizer, 4.5 mi · 4 of 5 stars · 18 citations
- Avamere Transitional Care at Sunnyside Salem, 4.8 mi · 2 of 5 stars · 52 citations
- Mt Angel Health and Rehabilitation Mount Angel, 12 mi · 4 of 5 stars · 22 citations
- Independence Health and Rehabilitation Independence, 13 mi · 2 of 5 stars · 31 citations
- French Prairie Nursing & Rehabilitation Center Woodburn, 14.8 mi · 1 of 5 stars · 62 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Tierra Rose Care Center's Medicare star rating?
- CMS rates Tierra Rose Care Center 5 out of 5 stars overall, with 5 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Tierra Rose Care Center get at its last inspection?
- 2 health deficiencies at the standard inspection on October 17, 2025. The Oregon average is 9.2.
- Has Tierra Rose Care Center been fined?
- CMS lists no fines in the last three years.
- Does Tierra Rose Care Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Tierra Rose Care Center?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.