Windsor Health & Rehabilitation Center

  • MEDICARE CERTIFIED
Windsor Health & Rehabilitation Center was recognized and ceritified in 1991 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Windsor Health & Rehabilitation Center which is located in 820 Cottage Street Ne Salem, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Windsor Health & Rehabilitation Center is being offered ceritified services and products in Oregon.
Address:   820 Cottage Street Ne
       Salem, OR 97301

Phone:   (503) 399-1135

County: Marion
Federal Provider Number: 385224
Map and Directions
Participates in: Medicare And Medicaid
Certified Date: Wednesday, July 3, 1991 (33 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Evergreen Oregon Healthcare Salem, L.l.c.
Ownership Type: For Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationEmpres Healthcare Management LlcOperational/managerial Control
OrganizationEmpres Healthcare Group, Inc. Employee Stock Ownership Trust5% Or More Ownership Interest
OrganizationEmpres Healthcare Group Inc5% Or More Ownership Interest
OrganizationEmpres Financial Services LlcOperational/managerial Control
OrganizationEmpres Oregon Healthcare Llc5% Or More Ownership Interest
PersonBrenda WilsonW-2 Managing Employee
PersonDale PattersonW-2 Managing Employee
PersonCyndi PancheriW-2 Managing Employee
PersonAndrew Martini5% Or More Ownership Interest
PersonTheresa HeisW-2 Managing Employee

Provider Resides in Hospital: No
Number of Federally Certified Beds: 100
Number of Residents in Federally Certified Beds: 50 (50% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Resident
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Monday, March 17, 2014
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 21, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, March 17, 2014
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 21, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, March 17, 2014
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 21, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, March 17, 2014
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 21, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 13, 2014
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 21, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 13, 2014
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 21, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, October 4, 2013
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, November 18, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Friday, October 4, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, November 18, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Friday, October 4, 2013
Survey Type: Health
Deficiency: F0281 (Ensure services provided by the nursing facility meet professional standards of quality.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, November 18, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Friday, May 3, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, June 10, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Monday, August 13, 2012
Survey Type: Health
Deficiency: F0333 (Ensure that residents are safe from serious medication errors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 25, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 8, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 25, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 8, 2012
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 25, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 8, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 25, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 8, 2012
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 25, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 22, 2012
Survey Type: Health
Deficiency: F0333 (Ensure that residents are safe from serious medication errors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, May 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, August 12, 2011
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, August 12, 2011
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Fire Safety
Deficiency: K0073 (Restrictions on the use of highly flammable decorations.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 0
Number of Substantiated Complaints: 4
Number of Fines: 1
Number of Payment Denials: 0
Total Number of Penalties: 1
Total Amount of Fines in Dollars: USD 1,625


Date of inspection that triggered the penalty: Friday, October 4, 2013
Penalty Type: Fine
Fine Amount: 1,625
This data allows consumers to compare information about nursing homes. Information here is not an endorsement or advertisement for any nursing home and should be considered carefully. Use it with other information you gather about nursing homes facilities. Talk to your doctor or other health care provider about this.



This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (3 out of 5 stars)
Quality Rating (5 out of 5 stars)
Staffing Rating (4 out of 5 stars)
RN Staffing Rating (4 out of 5 stars)
Overall Rating (5 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
6%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
12%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
13%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
5%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
6%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
24%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
93%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
92%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
5%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
8%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
18%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
49%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
82%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
2%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
84%
84%

N/A
Data not available.

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Windsor Health & Rehabilitation Center [Federal No:385224] near 820 Cottage Street Ne, Salem OR

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