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.
About this community
Tierra Rose Care Center is administered by Colleen Rees.
Inspection History
In Oregon, the Department of Human Services, Aging and People with Disabilities performs unannounced surveys and regular inspections to ensure resident safety in all care settings.
Inspection Scorecard
This scorecard compares key inspection, deficiency, and complaint metrics at this facility against the Oregon state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Since 2021 vs. Oregon state average
• Total deficiencies (135% above)
• Deficiencies per year (135% above)
• Deficiencies per inspection (66% above) 0 Better No metrics in this bucket.
Deficiencies
|
This Facility | OR Average | vs. OR Avg |
|---|---|---|---|
|
Total deficiencies
|
73 | 31 | This facility has 135% more total deficiencies than a typical Oregon nursing home (73 vs. OR avg 31).↑ 135% worse |
|
Deficiencies per year
|
14.6 | 6.2 | This facility has 135% more deficiencies per year than a typical Oregon nursing home (14.6 vs. OR avg 6.2).↑ 135% worse |
|
Deficiencies per inspection
|
7.3 | 4.4 | This facility has 66% more deficiencies per inspection than a typical Oregon nursing home (7.3 vs. OR avg 4.4).↑ 66% worse |
Inspections
|
This Facility | OR Average | vs. OR Avg |
|---|---|---|---|
|
Total inspections
|
10 | 7 | This facility has had 43% more total inspections than the Oregon average (10 vs. OR avg 7). More inspections can mean more regulatory scrutiny rather than worse care.↑ 43% more |
Inspection Reports Summary
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
- The most recent inspection on November 13, 2025 found no deficiencies during the complaint and re-licensure survey.
- The October 17, 2025 inspection cited five deficiencies including pressure ulcer treatment, infection control, and medication storage, all corrected by November 10, 2025.
- The facility had multiple prior inspections with numerous deficiencies in care planning, staffing, medication management, and resident safety, including immediate jeopardy findings in March 2022.
Penalties and fines
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
Places of interest near Tierra Rose Care Center
2.0 miles from city center
Estimated distance in miles from Salem's city center to Tierra Rose Care Center's address, calculated via Google Maps.
Calculate Travel Distance to Tierra Rose Care Center
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The information below is reported by the Oregon Department of Human Services, Aging and People with Disabilities.
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| Avamere Court at Keizer |
NH
AL
IL
RESC
RC
SNF
|
Keizer | 69 | 75.1% | +2% | 4.47 | -56% | -15% | $0 | 18 | 6.0 | - | 52 | - | 76 | Ari Cbc LLC | $12.9MFiscal year ending 12/2023 | $6.3MFiscal year ending 12/2023 | 48.8%Fiscal year ending 12/2023 | 385233 | ||||
| Avamere Transitional Care at Sunnyside |
NH
RC
SNF
|
Salem (Morningside) | 88 | 87.0% | +18% | 6.05 | -47% | +15% | $0 | 53 | 7.6 | - | 77 | - | 78 | Amanda Ingraham | $12.1MFiscal year ending 12/2023 | $5.6MFiscal year ending 12/2023 | 46.6%Fiscal year ending 12/2023 | 385189 | ||||
| Salem Transitional Care |
NH
SNF
|
Se Salem | 80 | 80.4% | +9% | 5.00 | -15% | -5% | $22.5k | 29 | 3.6 | 2 | 64 | - | 77 | Tyler Bolin | $14.4MFiscal year ending 12/2023 | $5.9MFiscal year ending 12/2023 | 40.5%Fiscal year ending 12/2023 | 385234 | ||||
| Windsor Health and Rehabilitation |
NH
RC
SNF
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Salem | 108 | 90.1% | +7% |
3.86
Facility
3.86
CT AVG
3.97
Rank
#26 / 67
| -46% | -3% |
$19.4k
Facility
$19.4k
CT AVG
$43.8k
Rank
#52 / 69
|
42
Facility
42
CT AVG
32.0
Rank
#56 / 69
|
10.5
Facility
10.5
CT AVG
5.8
Rank
#69 / 69
| 2 | 97 | - | 85 | Windsor Health And Rehabilitation Center LLC |
$10.1MFiscal year ending 12/2023
Facility
$10.1MFiscal year ending 12/2023
CT AVG
$19.0M
Rank
#51 / 72
|
$5.2MFiscal year ending 12/2023
Facility
$5.2MFiscal year ending 12/2023
CT AVG
$7.2M
Rank
#63 / 72
|
51.6%Fiscal year ending 12/2023
Facility
51.6%Fiscal year ending 12/2023
CT AVG
42.4%
Rank
#50 / 72
| 75011 |
Financial Assistance for
Nursing Home in Oregon
Tierra Rose Care Center is located in NE Salem, Oregon.
Here are the financial assistance programs available to residents in Oregon.
Frequently Asked Questions about Tierra Rose Care Center
Who is the owner of Tierra Rose Care Center?
Tierra Rose Care Center is legally operated by Cml, Inc., and administered by Colleen Rees.
Is Tierra Rose Care Center in a walkable area?
Tierra Rose Care Center has a walk score of 50. Moderately walkable. Some errands can be accomplished on foot, with a mix of nearby amenities.
Are pets allowed at Tierra Rose Care Center?
No, Tierra Rose Care Center has a no-pet policy.
What is the best email address for Tierra Rose Care Center?
The team at Tierra Rose Care Center can be reached at crees@tierrarose.com.
Does Tierra Rose Care Center operate as a for-profit or non-profit?
Tierra Rose Care Center is registered as a non-profit in OR.
Who is the administrator of Tierra Rose Care Center?
Colleen Rees is the administrator of Tierra Rose Care Center.
How many beds does Tierra Rose Care Center have?
Tierra Rose Care Center has 76 beds.
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