B
TIERRA ROSE CARE CENTER
70/100 score
0.40 hrs RN staffing
2 deficiencies
WINDSOR HEALTH & REHABILITATION CENTER
820 COTTAGE STREET NE, SALEM, OR 97301
D
Facility Assessment
4 federal violations at this facility remain unresolved. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — elevated deficiency count.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.27 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
18
Outstanding
4
Actual harm or worse (G–L)
0
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★☆☆ (3/5)
Staffing: ★★★☆☆ (3/5)
|
|
NursingHomeGrade Score
|
35/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
18 deficiencies found. 14 corrected. None involved actual harm. — 4 still outstanding
Most recent inspection (February 24, 2026)
D
Potential harm — isolated
F0600
Status: Outstanding — Plan Filed
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026
D
Potential harm — isolated
F0603
Status: Outstanding — Plan Filed
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026
D
Potential harm — isolated
F0609
Status: Outstanding — Plan Filed
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026
D
Potential harm — isolated
F0610
Status: Outstanding — Plan Filed
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
D
Potential harm — isolated
F0883
Status: Corrected
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
E
Potential harm — pattern
F0730
Status: Corrected
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
D
Potential harm — isolated
F0758
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
D
Potential harm — isolated
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 1, 2025
D
Potential harm — isolated
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
D
Potential harm — isolated
F0694
Status: Corrected
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
D
Potential harm — isolated
F0657
Status: Corrected
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2025
Inspection cycle 2 (November 16, 2023)
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 8, 2023
Inspection cycle 3 (June 2, 2023)
D
Potential harm — isolated
F0756
Status: Corrected
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2023
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2023
D
Potential harm — isolated
F0695
Status: Corrected
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2023
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B
AVAMERE TRANSITIONAL CARE AT SUNNYSIDE
67/100 score
0.53 hrs RN staffing
8 deficiencies
C
SALEM TRANSITIONAL CARE
51/100 score
0.62 hrs RN staffing
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