Windsor Nursing & Retirement Home
Open-data reference.
Windsor Nursing & Retirement Home is a non profit - corporation facility in SOUTH YARMOUTH, MA with 120 certified beds and a 1-star overall CMS rating. The facility has 42 deficiency records on file. Total penalties: $12K.
265 N MAIN ST, SOUTH YARMOUTH, MA 02664
Phone: 4135443329
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 225349
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 88
- In Hospital
- No
- County
- Barnstable
- Last Inspection
- Jan 9, 2025
Staffing Data
- RN Hours
- 0.61 (nat'l avg: 0.68)
- LPN Hours
- 0.88
- CNA Hours
- 2.44
- Total Nursing Hours
- 3.93 (nat'l avg: 3.89)
- PT Hours
- 0.08
- Nursing Turnover
- 49.4%
- RN Turnover
- 47.1%
What the CMS Record Reveals About Windsor Nursing & Retirement Home
Windsor Nursing & Retirement Home operates 120 certified beds in SOUTH YARMOUTH, MA with approximately 88 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (3★), and quality measures (1★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 42 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $12K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.93 total nursing hours per resident day (national average 3.89), with RN coverage at 0.61 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Windsor Nursing & Retirement Home falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 49.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (42 most recent)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 19, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 19, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 19, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 19, 2025
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 19, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 19, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Feb 19, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Feb 19, 2025
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.
Category: Administration Deficiencies
Corrected: Nov 22, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 22, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 22, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 22, 2023
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 22, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 22, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Nov 22, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Nov 22, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Nov 22, 2023
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Nov 22, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 30, 2023
Perform COVID19 testing on residents and staff.
Category: Infection Control Deficiencies
Corrected: Mar 22, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 22, 2023
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Jun 1, 2021
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 1, 2021
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Category: Administration Deficiencies
Corrected: Jun 11, 2021
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Jun 1, 2021
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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 1, 2021
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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 1, 2021
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 1, 2021
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 1, 2021
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 1, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 1, 2021
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 1, 2021
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 1, 2021
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 1, 2021
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 1, 2021
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 1, 2021
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 1, 2021
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 1, 2021
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.
Category: Resident Rights Deficiencies
Corrected: Jun 1, 2021
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Jun 1, 2021
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jun 15, 2021
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Jun 15, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.0% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.6% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.9% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 16.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 97.8% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 89.5% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 24.4% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 18.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 80.7% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 80.4% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.7% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 10.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 19.6% | Yes |
Penalty History 1 penalties totaling $12K
| Date | Type | Amount |
|---|---|---|
| Oct 12, 2023 | Fine | $12K |
| Mar 13, 2023 | Fine | $3K |
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Frequently Asked Questions
What is the overall CMS rating for Windsor Nursing & Retirement Home?
What are the staffing levels at Windsor Nursing & Retirement Home?
How many beds does Windsor Nursing & Retirement Home have?
Does Windsor Nursing & Retirement Home have any deficiencies on record?
Has Windsor Nursing & Retirement Home received any fines or penalties?
Who owns Windsor Nursing & Retirement Home?
When was Windsor Nursing & Retirement Home last inspected?
What quality measures are tracked for Windsor Nursing & Retirement Home?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.