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Tierra Rose Care Center
4254 Weathers Street NE, Salem, OR 97301 (opens Google Maps) · Marion County · (503) 585-4602· 76 certified beds · avg 71 residents/day · certified since Apr 1, 1980 · Medicaid only — not Medicare certified
Certified for Medicaid only. It cannot bill Medicare, so a short post-hospital rehabilitation stay would not be covered the usual way here. Who pays for nursing home care →
5/5
Health inspection rating (on-site)
inspected Oct 17, 2025
0
Serious findings on record
$0
Fines, last 3 years
5.31
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
New to these records? How to read an inspection report →
Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
Inspection findings in the public record
Showing the latest 3 of 20 inspection findings. Open the full record below to read every finding.
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. F-0686
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. F-0880
The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. F-0812
View all 20 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Oct 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Oct 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Jun 28, 2024 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Jun 28, 2024 | E · Potential for more than minimal harm, pattern | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint · F-0908 |
| Jun 28, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · F-0687 |
| Jun 28, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Jun 28, 2024 | D · Potential for more than minimal harm, isolated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Jun 28, 2024 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Apr 21, 2023 | E · Potential for more than minimal harm, pattern | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · F-0725 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · F-0712 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · F-0758 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · F-0803 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · F-0806 |
| Apr 21, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · F-0825 |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 2).
All citationsSerious citations (G–L)
2023
All citations: 12
Serious citations (G–L): 0
2024
All citations: 6
Serious citations (G–L): 0
2025
All citations: 2
Serious citations (G–L): 0
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 12 | 0 | E |
| 2024 | 6 | 0 | E |
| 2025 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
Nurse staffing (from payroll records, adjusted for how much care residents need)
What these staffing numbers mean →
This facilityOregon averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 5.31
Oregon average: 5.42
U.S. average: 3.95
Registered Nurse hours
This facility: 0.41
Oregon average: 0.78
U.S. average: 0.69
Weekend total nurse staffing
This facility: 4.77
Oregon average: 4.85
U.S. average: 3.50
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.31 | 5.42 | 3.95 | bottom 47% in Oregon; top 9% in the U.S. |
| Registered Nurse hours | 0.41 | 0.78 | 0.69 | bottom 8% in Oregon; bottom 24% in the U.S. |
| Weekend total nurse staffing | 4.77 | 4.85 | 3.50 | bottom 46% in Oregon; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.12 | 0.48 | 0.48 | bottom 2% in Oregon; bottom 3% in the U.S. |
| Total nursing staff turnover (%) | 30.6 | 47.4 | 45.8 | top 9% in Oregon; top 15% in the U.S. |
| RN turnover (%) | 16.7 | 51.6 | 42.9 | top 4% in Oregon; top 9% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.15, RN 0.40, weekend 4.64.Comparing with Medicare Care Compare? Care Compare shows the raw figure (5.15 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 4/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Costs & payment
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Tierra Rose Care Center. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
- Request the room type, effective date and itemized daily rate in writing.
- Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
- Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Understand who pays for care · How we handle price evidence · Report an incorrect price
Who owns this facility
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
All 1 owning or managing party CMS has on file are shown — none excluded.
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
- "How is routine foot care handled here, and does a podiatrist visit regularly?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
Also worth asking anywhere
- "Your weekend nurse staffing is reported below the Oregon midpoint — how does the weekend schedule differ from a weekday?"
- "Can I see the plan of correction for the findings in your most recent state inspection?"
- "CMS reports 31% total nursing staff turnover here — who on the care team has been with you longest?"
- "Can I visit again unannounced, at a mealtime or on a weekend?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Windsor Health and Rehabilitation | 2.5 mi | Salem, OR | ★★★☆☆ | 3/5 | |
| Keizer Nursing and Rehabilitation | 3.3 mi | Keizer, OR | ★★★☆☆ | 3/5 | |
| Salem Transitional Care | 4.4 mi | Salem, OR | ★★☆☆☆ | 2/5 | |
| Avamere Court at Keizer | 4.5 mi | Keizer, OR | ★★★★☆ | 4/5 | |
| Avamere Transitional Care at Sunnyside | 4.8 mi | Salem, OR | ★★☆☆☆ | 2/5 | |
| Mt Angel Health and Rehabilitation | 12.0 mi | Mount Angel, OR | ★★★★☆ | 4/5 | |
| Independence Health and Rehabilitation | 13.0 mi | Independence, OR | ★★☆☆☆ | 2/5 | |
| French Prairie Nursing & Rehabilitation Center | 14.8 mi | Woodburn, OR | ★☆☆☆☆ | 1/5 | SFF |
| Dallas Retirement Village Health Center | 16.7 mi | Dallas, OR | ★★★★☆ | 4/5 |
Facility data as of CMS processing date 2026-08-01. CCN 38E075.