Windsor Health and Rehabilitation

Name: Windsor Health and Rehabilitation
Address: 820 COTTAGE STREET NE, Salem, OR, 97301, US
Telephone: 5033991135

820 Cottage Street NE, Salem, OR 97301 · Marion County · 100 certified beds · avg 48 residents/day · certified since Jul 3, 1991

Part of chain: EVERGREEN HEALTHCARE GROUP (44 facilities, chain avg rating 2.5★)

3/5

Health inspection rating (on-site)

Serious findings on record

$20,910

Fines, last 3 years

5.48

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (20)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Mar 17, 2026	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Mar 17, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Feb 24, 2026	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 24, 2026	D · Potential for harm, one-off	The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint
Feb 24, 2026	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Feb 24, 2026	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jul 3, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 14, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 14, 2025	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
Mar 14, 2025	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 14, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Mar 14, 2025	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Mar 14, 2025	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Mar 14, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 14, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 14, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Nov 16, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 2, 2023	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 2, 2023	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jun 2, 2023	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (1 → 9).

Year	Citations	Worst severity that year
2023	4	E
2025	10	F
2026	6	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $20,910.

Date	Type	Amount / length
Jul 13, 2026	Fine	$20,910

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Oregon avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.48	5.42	3.95	top 39% in Oregon; top 7% in the U.S.
Registered Nurse hours	0.42	0.78	0.69	bottom 10% in Oregon; bottom 26% in the U.S.
Weekend total nurse staffing	4.87	4.85	3.50	top 42% in Oregon; top 7% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.38	0.48	0.48	top 48% in Oregon; bottom 49% in the U.S.
Total nursing staff turnover (%)	51.4	47.4	45.8	bottom 35% in Oregon; bottom 33% in the U.S.
RN turnover (%)	85.7	51.6	42.9	bottom 7% in Oregon; bottom 3% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.07, RN 0.39, weekend 4.51. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
CH Pacific Northwest Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Herzka, Yisroel	Individual	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Pacific Northwest SNF Operations Holdings (or) LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	08/31/2023
Pacific Northwest SNF Operations Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Windsor SNF Operations LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Witzcorp Global LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Yenowitz, Yitzchok	Individual	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Cabaneros, Cecille	Individual	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Cabaneros, Cecille	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023
Cepeda, Mylene	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/31/2023
Cepeda, Mylene	Individual	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Cepeda, Mylene	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023
CH Pacific Northwest Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/31/2023
Couve Financial Services LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Couve Financial Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/13/2025
Couve Healthcare Consulting LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Couve Healthcare Consulting LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/04/2025
Henning, Tracey	Individual	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Henning, Tracey	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023
Herzka, Yisroel	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"How do you assess and manage residents' pain, especially for those who have trouble communicating?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"Under what circumstances, if any, would a resident ever be kept in their room or separated from others?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Tierra Rose Care Center	2.5 mi	Salem, OR	★★★★★	5/5
Keizer Nursing and Rehabilitation	2.7 mi	Keizer, OR	★★★☆☆	3/5
Avamere Court at Keizer	3.7 mi	Keizer, OR	★★★★☆	4/5
Avamere Transitional Care at Sunnyside	3.9 mi	Salem, OR	★★☆☆☆	2/5
Salem Transitional Care	4.8 mi	Salem, OR	★★☆☆☆	2/5
Independence Health and Rehabilitation	11.0 mi	Independence, OR	★★☆☆☆	2/5
Mt Angel Health and Rehabilitation	13.9 mi	Mount Angel, OR	★★★★☆	4/5
Dallas Retirement Village Health Center	14.2 mi	Dallas, OR	★★★★☆	4/5
French Prairie Nursing & Rehabilitation Center	15.7 mi	Woodburn, OR	★☆☆☆☆	1/5	SFF
Evan Terrace Post Acute	19.9 mi	McMinnville, OR	★☆☆☆☆	1/5

Compare this facility with the 3 closest →

All facilities in Salem →

Facility data as of CMS processing date 2026-08-01. CCN 385224.

The Care File

Visit checklist — Windsor Health and Rehabilitation

820 Cottage Street NE, Salem, OR 97301 · 5033991135

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $20,910

Questions for the administrator:

☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "Under what circumstances, if any, would a resident ever be kept in their room or separated from others?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 385224 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)