Cycle 1
Health 2025-03-14 · Fire 2025-03-14
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Salem, OR
Windsor Health & Rehabilitation Center
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
820 Cottage Street Ne, Salem, OR
(503) 399-1135
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1991-07-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.27
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.60
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.23
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.69
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
5.27
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
737
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0190
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.91
Baseline 41.86% · Performance 51.79% · Measure score 2.91 · Achievement 2.91 · Improvement 0
Adjusted total nurse staffing
10
Baseline 4.92 hours · Performance 6.32 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 7.18% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 1 · Denominator 31 · Adjusted rate 2.18% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 67 |
| Staff flu vaccination coverage | 29.11% |
42%
12.9 pts worse
|
Numerator 23 · Denominator 79 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.76% |
25.2%
20.4 pts worse
|
Numerator 1 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.2% |
95.5%
14.3 pts worse
|
93.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.8% · Q2 70.0% · Q3 83.9% · Q4 93.1% · 4Q avg 81.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
95.2%
1.9 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
2.4%
1.9 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.3% · Q3 3.2% · Q4 3.4% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
4.7%
0.8 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 4.2% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.0%
1.7 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 11.1% · Q3 3.6% · Q4 4.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
12.5%
4.5 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.9% · Q3 10.0% · Q4 6.9% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
14.7%
5.8 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.2% · Q3 16.0% · Q4 0.0% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.0% |
24.1%
1.9 pts worse
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
15.8%
0.7 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 14.8% · Q3 6.9% · Q4 21.4% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.7%
1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.0%
0.8 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 3.4% · Q4 4.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
22.2%
5.8 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 22.6% · Q3 26.8% · Q4 42.9% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.5%
1.2 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.5% · Q3 3.4% · Q4 7.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.6% |
85.4%
28.8 pts worse
|
81.7%
25.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 42.3% · Q3 71.7% · Q4 90.9% · 4Q avg 56.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
15.1%
0.6 pts better
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 14.7% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.1% |
81.2%
27.1 pts worse
|
79.7%
25.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.8% |
21.6%
9.2 pts worse
|
23.9%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.8% · Observed 32.4% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-02 · Fire 2023-06-02
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-14
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-14
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-03
F · Potential for more than minimal harm
2025-03-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-11
D · Potential for more than minimal harm
2023-06-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-03-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-03
E · Potential for more than minimal harm
2025-03-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-03
D · Potential for more than minimal harm
2025-03-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-03
D · Potential for more than minimal harm
2025-03-14
F690 · Quality of Life and Care Deficiencies
Health
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 2025-05-03
D · Potential for more than minimal harm
2025-03-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-03
D · Potential for more than minimal harm
2025-03-14
F758 · Pharmacy Service Deficiencies
Health
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 2025-05-03
D · Potential for more than minimal harm
2025-03-14
F761 · Pharmacy Service Deficiencies
Health
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 2025-05-03
D · Potential for more than minimal harm
2025-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-03
D · Potential for more than minimal harm
2025-03-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-03
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-06-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-06-21
Penalties and ownership
What sits behind the stars
Ownership
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Cabaneros, Cecille
Operational/Managerial Control · Individual
Cepeda, Mylene
Operational/Managerial Control · Individual
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Henning, Tracey
Operational/Managerial Control · Individual
Morris, Christopher
Operational/Managerial Control · Individual
Odenthal, Jason
Operational/Managerial Control · Individual
Oregon SNF Consulting LLC (De)
Operational/Managerial Control · Organization
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Perlman, Harold
Operational/Managerial Control · Individual
Spielman, Shimon
Operational/Managerial Control · Individual
Windsor SNF Operations LLC
Operational/Managerial Control · Organization
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Tierra Rose Care Center
Salem, OR
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Keizer Nursing And Rehabilitation
Keizer, OR
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Avamere Court at Keizer
Keizer, OR
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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