Windsor Nursing & Retirement Home Inspection Report, Violations & Safety Grade (SOUTH YARMOUTH, Massachusetts)

265 N MAIN ST, SOUTH YARMOUTH, Massachusetts 02664

Phone: 5083943514

CMS Overall:2/5

Overview & Bed Count

Certified Beds

120

Avg Residents/Day

Ownership

Non profit - Corporation

Provider Type

Medicare and Medicaid

County

Barnstable

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall2/5

Health3/5

Staffing3/5

Quality1/5

Nurse Staffing Check

Metric	This Facility	Massachusetts Avg	Difference
RN Hours per Resident per Day	0.59	0.66	-0.07
Total Nurse Hours per Resident per Day	3.82	3.94	-0.12
CMS Staffing Rating	3/5	3.1/5	-
Nursing Staff Turnover	38.4%	37.6%	-

Health Citation History

24 health citations on record

Date	Category	Description	Severity
2026-03-19	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-03-19	Administration Deficiencies	Employ staff that are licensed, certified, or registered in accordance with state laws.	E – Moderate Harm Potential
2026-03-19	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2026-03-19	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2026-03-19	Infection Control Deficiencies	Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	D – Moderate Harm Potential
2026-03-19	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	B – Minimal Harm Potential
2025-01-09	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2025-01-09	Quality of Life and Care Deficiencies	Assist a resident in gaining access to vision and hearing services.	E – Moderate Harm Potential
2025-01-09	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2025-01-09	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-01-09	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2025-01-09	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	D – Moderate Harm Potential
2025-01-09	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2025-01-09	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2023-10-12	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	G – Actual Harm
2023-10-12	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	E – Moderate Harm Potential
2023-10-12	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	E – Moderate Harm Potential
2023-10-12	Quality of Life and Care Deficiencies	Assist a resident in gaining access to vision and hearing services.	E – Moderate Harm Potential
2023-10-12	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2023-10-12	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2023-10-12	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential
2023-10-12	Administration Deficiencies	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	D – Moderate Harm Potential
2023-10-12	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	B – Minimal Harm Potential
2023-10-12	Resident Rights Deficiencies	Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	B – Minimal Harm Potential

Fire Safety Citation History

7 fire safety citations on record

Date	Category	Description	Severity
2025-01-09	Emergency Preparedness Deficiencies	Create arrangements with other facilities to receive patients.	F – Moderate Harm Potential
2025-01-09	Emergency Preparedness Deficiencies	Provide emergency officials' contact information.	F – Moderate Harm Potential
2025-01-09	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	D – Moderate Harm Potential
2025-01-09	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	D – Moderate Harm Potential
2023-10-12	Emergency Preparedness Deficiencies	Implement emergency and standby power systems.	C – Minimal Harm Potential
2023-10-12	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	C – Minimal Harm Potential
2023-10-12	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	C – Minimal Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the SOUTH YARMOUTH area at no cost.

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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.