WINDSOR HEALTH & REHABILITATION CENTER

Nursing Home Inspector

820 COTTAGE STREET NE
SALEM, OR 97301
Marion County
Phone: 503-399-1135
Provider Number: 385224
Last Inspection: 10/10/2017

About the Nursing Home

Number of Beds: 100
Number of Residents: 47
Beds Available: 53
Percent Occupancy: 47%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

100

Facility
34

County
24

OR
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

100

2017
59

2016
19

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

10/10/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Isolated : Minimal 3 11/29/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 11/29/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 11/29/2017
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 11/29/2017
 
Failed To: Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Isolated : Minimal 3 11/29/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 11/29/2017
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 11/29/2017
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 11/29/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 11/29/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 11/29/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 11/29/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 11/29/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 11/29/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 11/29/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Actual 4 11/29/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 11/29/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Widespread : Minimal 5 11/29/2017
 
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Widespread : Minimal 5 11/29/2017
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Minimal 5 11/29/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 11/29/2017
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated : Minimal 3 11/29/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 11/29/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 11/29/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 11/29/2017
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 11/29/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 11/29/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 11/29/2017
 

8/2/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Isolated : Minimal 3 9/9/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 9/9/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 9/9/2016
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 9/9/2016
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Pattern : Minimal 4 9/9/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 9/9/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/9/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 9/9/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/9/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/9/2016
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 9/9/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 9/9/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 9/9/2016
 
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Pattern : Minimal 4 9/9/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 9/9/2016
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 9/9/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Immediate 5 9/9/2016
 

6/12/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 7/15/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 7/15/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/15/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 7/15/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 7/15/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 7/15/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/15/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 4/14/2017
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 4/14/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 4/14/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/14/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 4/14/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 4/14/2017
 
Failed To: Quickly tell the resident's doctor the results of laboratory tests. Isolated : Minimal 3 4/14/2017
 

12/22/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 1/19/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 1/19/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 1/19/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 1/19/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 1/19/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 1/19/2017
 

10/4/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 11/5/2016
 

3/31/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 4/23/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 4/23/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 4/23/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/23/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 4/23/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 4/23/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 4/23/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 4/23/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 4/23/2016
 

9/9/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/13/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg OR State Avg
Number of Residents 47 55.50 53.13
Registered Nurses 0.85 0.80 0.86
Licensed Practical / Vocational Nurses 0.98 0.91 0.75
Certified Nursing Assistants 3.21 3.39 3.13
Total Staff Hours 5.04 5.10 4.75

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% OR State Avg%
of high risk long-stay residents with pressure ulcers 12 6 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 68 88 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 90 92 92
of long-stay residents experiencing one or more falls with major injury 1 2 3
of long-stay residents who have depressive symptoms 3 3 3
of long-stay residents who lose too much weight 17 9 7
of long-stay residents who received an antianxiety or hypnotic medication 21 16 15
of long-stay residents who received an antipsychotic medication 15 15 14
of long-stay residents who self-report moderate to severe pain 13 13 11
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 24 19 18
of long-stay residents whose need for help with daily activities has increased 6 12 12
of long-stay residents with a catheter inserted and left in their bladder 2 4 3
of long-stay residents with a urinary tract infection 12 5 4
of low risk long-stay residents who lose control of their bowels or bladder 68 59 51
of short-stay residents assessed and appropriately given the pneumococcal vaccine 43 78 80
of short-stay residents who had an outpatient emergency department visit 18 15 14
of short-stay residents who made improvements in function 63 71 70
of short-stay residents who newly received an antipsychotic medication 3 1 1
of short-stay residents who self-report moderate to severe pain 22 24 19
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 62 76 78
of short-stay residents who were rehospitalized after a nursing home admission 27 19 19
of short-stay residents who were successfully discharged to the community 62 68 67
of short-stay residents with pressure ulcers that are new or worsened 0 0 0