Overview of Tierra Rose Care Center Tierra Rose Care Center is a 76-bed nonprofit skilled nursing and memory care facility at 4254 Weathers Street NE, Salem, Marion County, Oregon. Operated by CML, Inc., the community provides rehabilitation, memory care, and 24-hour staffing with private and semi-private rooms, a park-like setting with fountains and walking paths, private dining rooms, and a beauty/barber shop. CMS rates the facility 2/5 overall, 2/5 Health Inspection, 4/5 Staffing, and 2/5 Quality Measures. Nursing hours averaged 17 percent above the Oregon state benchmark.
The regulatory trajectory documents severe historical challenges followed by substantial recent recovery. Over five years, Tierra Rose logged 94 deficiencies; 18.8 annually, 181 percent above Oregon’s 6.7-deficiency benchmark.
March 28, 2022, marked a critical inflection: a complaint investigation and relicensure survey documented thirty-two deficiencies spanning resident rights, timely assessment, care planning, wound care, medication management, infection control, staffing, training, quality assurance, and resident safety. Immediate jeopardy findings for elopement and aspiration risk were identified and abated. January 11, 2023, revealed twenty-two deficiencies in resident rights, safe environment, abuse and neglect prevention, assessment accuracy, wound care, medication management, staffing, training, infection control, and quality assurance; many were corrected, others persisted. April 21, 2023, cited sixteen deficiencies in reasonable accommodations, comprehensive care planning, quality of care, nursing staffing, medication regimen review, fall prevention, physician visits, and specialized rehabilitation; several were corrected, some remained.
June 28, 2024, documented nine deficiencies in foot care, accident hazards, medication storage, food sanitation, records accuracy, equipment maintenance, and restorative services; mixed correction status. October 17, 2025, identified five deficiencies in pressure ulcer treatment, infection prevention, and medication storage and labeling, all corrected by November 10, 2025. Inspections on November 13, 2025, April 16, 2025, and December 20, 2024, found zero deficiencies.
The dramatic shift from thirty-two deficiencies in March 2022 to zero citations in November 2025 indicates major operational restructuring and sustained improvement; however, the severity and breadth of the 2022–2024 violations counsel verification of present-day systems during tour.
The facility provides rehabilitation, memory care, and 24-hour skilled nursing with above-average staffing. Nonprofit ownership structure serves Salem with park-like grounds and amenities. Private pay is required; Medicaid and Medicare are not accepted.
The facility’s recent zero-deficiency trajectory is encouraging.
Families should ask about the corrective actions and operational changes implemented following the March 2022 immediate jeopardy findings and subsequent 2023 violations.
