Windsor Health and Rehabilitation
820 Cottage Street Ne · Salem, OR · 97301 · 5033991135
100 certified beds For profit - Limited Liability company Chain: Evergreen Healthcare Group
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The composite number cleared 72 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 3 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 5.01 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.32 | 0.55–0.75 |
| Weekend hours / resident-day | 4.49 | ≈ weekday level |
| Nursing turnover / year | 56% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (20 in the current record)
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Potential for harm · D March 17, 2026 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected April 15, 2026 · Resident Rights
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Potential for harm · D March 17, 2026 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected April 15, 2026 · Quality of Life and Care
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Potential for harm · D February 24, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 31, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 24, 2026 · found via complaint
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected March 31, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 24, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 31, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 24, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected March 31, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 3, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 1, 2025 · Quality of Life and Care
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Potential for harm · D March 14, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected May 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 14, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected May 3, 2025 · Quality of Life and Care
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Potential for harm · D March 14, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected May 3, 2025 · Quality of Life and Care
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Potential for harm · E March 14, 2025
Observe each nurse aide's job performance and give regular training.
Corrected May 3, 2025 · Nursing and Physician Services
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Potential for harm · D March 14, 2025
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.
Corrected May 3, 2025 · Pharmacy Service
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Potential for harm · D March 14, 2025
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.
Corrected May 3, 2025 · Pharmacy Service
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Potential for harm · F March 14, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 3, 2025 · Nutrition and Dietary
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Potential for harm · D March 14, 2025
Provide and implement an infection prevention and control program.
Corrected May 3, 2025 · Infection Control
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Potential for harm · D March 14, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected May 3, 2025 · Infection Control
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Potential for harm · E November 16, 2023
Provide and implement an infection prevention and control program.
Corrected December 8, 2023 · Infection Control
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Potential for harm · D June 2, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 21, 2023 · Quality of Life and Care
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Potential for harm · D June 2, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 21, 2023 · Quality of Life and Care
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Potential for harm · D June 2, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected June 21, 2023 · Pharmacy Service
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385224 · certified since July 3, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.