Salem Transitional Care: Resident Left Alone 70 Min - OR
The incident happened on the evening of October 31, 2025, at Salem Transitional Care, a nursing and rehabilitation facility on Boone Road SE. Federal inspectors documented the case during a complaint inspection completed January 29, 2026.
The resident, identified in inspection records as Resident 4, had been admitted to the facility in October 2025 with sepsis, lobar pneumonia, and acute respiratory failure with hypoxia. She was cognitively intact, with a near-perfect score on a standardized cognition assessment. She could not move her wheelchair on her own or transfer herself into bed without help.
A nursing care note from that evening recorded that staff assisted Resident 4 back to her room after dinner. The staff member then left to find a second person for the transfer, which her care plan required. Nobody came back for over an hour.
The CNA assigned to Resident 4 that shift, Staff 13, told inspectors she had also been assigned to the dining room that evening and could not leave while residents were still eating. She said she asked another CNA to help Resident 4 get back to her room. She later found Resident 4 sitting alone in her wheelchair, still waiting.
Resident 4 told inspectors on January 29 that she had been left alone for approximately one hour and ten minutes. She said she experienced pain during that time, had no call light within reach, had no phone she could access, and could not move the wheelchair herself or get into bed on her own.
A Risk Management Report completed that same night by Staff 12, a licensed practical nurse, confirmed the account. The report documented that Resident 4 had been left alone in her wheelchair in her room for over an hour while awaiting transfer assistance.
The resident's family member, identified as Witness 4, filed the complaint that triggered the inspection. On January 26, 2026, she told inspectors her family member had been left alone in the wheelchair for an extended period waiting to be transferred to bed.
When inspectors interviewed facility leadership on January 28, four of them acknowledged the failure. Staff 1, identified as the Assistant Administrator in Training, Staff 2, the Field Lead for Oregon and Cascadia, Staff 3, the Chief Nursing Officer, and Staff 4, the Assistant Chief Nursing Officer, all confirmed that Resident 4 should have received more timely transfer assistance.
The inspection cited the facility for failing to provide transfer assistance to Resident 4, with a finding of minimal harm or potential for actual harm affecting a small number of sampled residents.
What the report does not resolve is what the hour and ten minutes felt like for a woman who had just been hospitalized with respiratory failure, who could not reach a call button, who was in pain, and who had no way to summon help or move herself to bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salem Transitional Care from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
SALEM TRANSITIONAL CARE in SALEM, OR was cited for violations during a health inspection on January 29, 2026.
The incident happened on the evening of October 31, 2025, at Salem Transitional Care, a nursing and rehabilitation facility on Boone Road SE.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.