01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-14 | 15 | 2025-03-14 | 6 |
| Cycle 2 | 2023-11-16 | 2 | 2023-11-16 | 0 |
| Cycle 3 | 2023-06-02 | 3 | 2023-06-02 | 1 |
CMS CCN 3852242026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Windsor Health And Rehabilitation
820 Cottage Street Ne · Salem, OR 97301 · Marion County
Certified beds100CMS provider file
Recent citation rows27current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
27 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-17 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2026-04-15 · complaint2026-03-17 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-04-15 · complaint2026-02-24 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2026-03-31 · complaint2026-02-24 · HEALTHF0603Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Correction field: Deficient, Provider has date of correction · 2026-03-31 · complaint2026-02-24 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2026-03-31 · complaint2026-02-24 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2026-03-31 · complaint2025-07-03 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-08-01 · complaint2025-03-14 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-14 · FIREE0020Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-14 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0694Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-14 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-05-032025-03-14 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-14 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-04-112023-11-16 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-12-082023-06-02 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2023-06-2103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-07-13 | Fine | $20,910 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS (OR) LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/31/2023
- CH PACIFIC NORTHWEST HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/31/2023
- PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/31/2023
- WINDSOR SNF OPERATIONS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/31/2023
- WITZCORP GLOBAL LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/31/2023
- HERZKA, YISROELIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/31/2023
- YENOWITZ, YITZCHOKIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/31/2023
- CEPEDA, MYLENEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/31/2023
- ODENTHAL, JASONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/31/2023
- COUVE FINANCIAL SERVICES LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- COUVE HEALTHCARE CONSULTING LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- OREGON SNF CONSULTING LLC (DE)Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- PACIFIC NORTHWEST OPCO MANAGEMENT LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- WINDSOR SNF OPERATIONS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- CABANEROS, CECILLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- CEPEDA, MYLENEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- HENNING, TRACEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
- MORRIS, CHRISTOPHERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/31/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.07per resident day
RN hours0.39per resident day
Weekend nurse hours4.51per resident day
Staff turnover51.4%CMS reported field