Windsor Health And Rehabilitation
WINDSOR HEALTH and REHABILITATION in SALEM, OR — inspection on February 24, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
her/him, and rubbed her/his head.
When she asked Staff 7 why the resident was not medicated, she
(LPN) stated she did not remember if she gave the resident medication.
Staff 7 stated she would have
done something for the resident.
Staff 7 did not make any further contact and did not provide any documentation or further explanation for this incident.On 2/24/26 at 12:15 PM, Witness 2 (Hospice Agency Care Manager) stated their notes indicated hospice staff were frustrated with medication administration not being done as ordered at the facility.
She also stated the morphine would be appropriate for shortness of breath. If the resident was breathing too hard or too quickly it could slow the breathing down and greatly benefit the resident which was why the medication was ordered. On 2/25/26 at 8:59 AM, Staff 4 (LPN/Unit Manager) indicated she remembered an issue with the resident not receiving pain medications.
Staff 7 refused to give morphine when the resident was short of breath, and it would depress the resident's breathing.
Staff 4 stated Staff 8 had informed her Resident 103 had been crying out, and Staff 7 refused to give the medication.
Staff 4 stated the medication was for pain and shortness of breath, but Staff 7 walked away from her and would not discuss the issue.
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Windsor Health and Rehabilitation 820 Cottage Street NE Salem, OR 97301
because the resident wanted to lie down.
Staff 8 said she again told Staff 6 she could not force the
nurse's station, got Resident 104 a blanket and tucked it around her/him in the wheelchair and placed
go to bed.
Staff 8 stated she overheard Staff 6 tell the resident she/he was going to sleep here and not fall. On 2/23/26 at 3:44 PM, Staff 14 (CNA) stated Resident 104 was asking to go to bed and Staff 6 did not want the resident to go to bed because she did not want to write any reports about the resident falling.
Staff 14 stated around 2:00 to 2:30AM, she finally told Staff 6 she was taking the resident to bed and did not care if she got written up. On 2/26/26 4:15 PM, Staff 6 (LPN) stated Resident 104 liked to get out of bed, and she/he fell a lot.
Staff 6 stated she did keep the resident up all night at the nurse's station.
Staff stated on 12/5/25 the resident was restless and decided to keep the resident up in her/his wheelchair.
Staff stated she got the resident a pillow, tucked a blanket snugly around the resident, leaned her/his chair back, and put coffee and magazines on a nearby table.
The resident was awake a long time and around 1:00 AM the resident was sleepy, and had staff put her/him to bed.
Staff stated on 12/6/25, she did the same thing.
Staff 6 stated staff she was being abusive to the resident and all the aides were mad about it.
Staff 6 called the on-call nurse and told her the resident had dementia and could not say what she/he wanted, but the resident did say she/he wanted to lay down.
Staff stated she was told by facility management to lie the resident down.
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Windsor Health and Rehabilitation 820 Cottage Street NE Salem, OR 97301
authorities.
interview and record review it was determined the facility failed to ensure allegations of abuse or
reporting.
This placed residents at risk for continued abuse and neglect.
Findings include:1. Resident 103 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation and respiratory failure.Resident 103's Physician Order dated 11/4/25 included to administer morphine sulfate 0.25 ml dose by mouth every hour as needed for shortness of breath and/or moderate to severe pain.On 12/12/25, the State Survey Agency received a public complaint by Witness 1 (Former Staff), which reported on 11/6/25 Staff 7 (LPN) was assigned to Resident 103's care and had refused to administer the resident's ordered pain medication even when staff members were reporting the resident was exhibiting screaming, shortness of breath, and very anxious behaviors.
Witness 1 stated she was not told about the incident when it occurred, so she was not able to report the incident.
Witness 1 stated Staff 1 (Administrator) was aware of the incident and talked to Staff 7, but was unaware if a Facility Reported Incident (FRI) was reported to the State Survey Agency. On 2/24/26 at 2:43 PM, Staff 1 (Administrator) acknowledged there was no FRI submitted to the State Survey Agency. On 2/25/26 at 8:59 AM, Staff 4 (LPN/Unit Manager) stated she was aware of an incident involving Staff 7 refusing to give Resident 103 her/his pain medication, morphine, despite being told the resident was distressed by other staff members.
Staff 4 acknowledged no FRI was reported to the State Survey Agency. 2. Resident 104 was admitted to the facility in 2025 with diagnoses including hip fracture and dementia.On 12/12/25, the State Survey Agency received a public complaint by Witness 1 (Former Staff), which reported she was notified that Staff 6 (LPN) forced Resident 104 to stay up in her/his wheelchair most of night on 12/5/25. Resident 104 was kept at the nurse's station, continuously given coffee, because Staff 6 did not want to deal with the resident falling and any potential incident reports.
Witness 1 stated she notified the Administrator of the incident and was told not to submit a FRI to the State Agency because they took care of it in-house. On 2/20/26 at 10:41 AM, Staff 2 (DNS) stated there should have been an investigation done for this incident.
Staff 2 stated that nursing staff could have a resident at the nurse's station for monitoring, but not for the entire night and not for staff convenience.On 2/24/26 at 2:43, PM Staff 1 (Administrator) acknowledged there was no FRI submitted to the State Survey Agency.
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Windsor Health and Rehabilitation 820 Cottage Street NE Salem, OR 97301
Survey Agency received a public complaint by Witness 1 (Former Staff), which reported on 11/6/25 Staff 7 (LPN) was assigned to Resident 103's care and had refused to administer the resident's ordered pain medication even when staff members were reporting the resident was exhibiting screaming, shortness of breath, and very anxious behaviors.
Witness 1 stated she was not told about the incident when it occurred, so she was not able to investigate the incident.
Witness 1 stated Staff 1 (Administrator) was aware of the incident and talked to Staff 7, but was unaware if there was an investigation completed. On 2/20/26 at 12:29 PM, Staff 1 (Administrator) Staff 1 acknowledged no investigation was completed and stated she felt the incident was handled by the facility.
Staff 1 was unable to provide any documentation to show an investigation was done and how abuse/neglect was ruled out. On 2/24/26 at 4:55 PM, Staff 7 (LPN) stated she did not remember if she gave the resident medication.
Staff 7 stated she would have to get back with an answer after she checked the medical record because she thought she must have done something for the resident.
Staff 7 did not have any further contact and did not provide any documentation or further explanation for the incident.On 2/25/26 at 8:59 AM, Staff 4 (LPN/Unit Manager) stated she was aware of an incident involving Staff 7 refusing to give Resident 103 her/his pain medication, morphine, despite being told the resident was distressed by other staff members.
Staff 4 acknowledged there was no investigation completed. 2. Resident 104 was admitted to the facility in 2025 with diagnoses including hip fracture and dementia.On 12/12/25, the State Survey Agency received a public complaint by Witness 1 (Former Staff), which reported she was notified that Staff 6 (LPN) forced Resident 104 to stay up in her/his wheelchair most of the on 12/5/25. Resident 104 was kept at the nurse's station, continuously given coffee, because Staff 6 did not want to deal with the resident falling and any potential incident reports.
Witness 1 stated she notified the Administrator of the incident. On 2/20/26 at 10:41 AM, Staff 2 (DNS) stated there should have been an investigation done for this incident.
Staff 2 stated that nursing staff could have a resident at the nurse's station for monitoring, but not for the entire night and not for staff convenience.On 2/20/26 at 12:29 PM, Staff 1 (Administrator) Staff 1 acknowledged no investigation was completed and stated she felt the incident was handled by the facility.
Staff 1 was unable to provide any documentation to show an investigation was done and how abuse/neglect was ruled out.