Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WINDSOR HEALTH AND REHABILITATION
SALEM, OR · 100 certified beds · Last Life Safety survey March 14, 2025
CMS Certification Number 385224 · first certified July 1991
Ownership
Operated by EVERGREEN HEALTHCARE GROUP · For profit - Limited Liability company
- Ownership changed August 31, 2023 (change of ownership)to WINDSOR HEALTH & REHABILITATION CENTER from EVERGREEN OREGON HEALTHCARE SALEM, L.L.C.
Position within OR
7 citations — more than 17% of the 128 certified nursing homes in OR. Compared within OR rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 0.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to July 2026), and past the point by which nine in ten OR facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in OR are typically surveyed 15–17 months after the last one (median 16), measured over 188 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
2 of the 7 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in OR, and nationally. Surveyors differ markedly between states, so the OR figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in OR | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 2, 2023 | 1 |
| November 16, 2023 | 0 |
| March 14, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2025-03-14 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-03-14 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2025-03-14 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-03-14 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2025-03-14 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-03-14 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2023-06-02 |
What the citations cover
- Miscellaneous Deficiencies 3
- Emergency Preparedness Deficiencies 2
- Smoke Deficiencies 2
| Category | Citations |
|---|---|
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Smoke Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 14, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 11, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 3, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (April 11, 2025) |
June 2, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 21, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.