D68

WINDSOR NURSING & RETIREMENT HOME

Grade D 68/100 composite score

Non profit - Corporation

CMS Star Ratings

Overall
1/5
Health Insp.
2/5
Quality
1/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

120

Ownership

Non profit - Corporation

Total Fines

$15,636

Last Survey

N/A

265 N MAIN ST, SOUTH YARMOUTH, MA 02664
5083943514

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.58h
LPN
0.84h
CNA
2.33h
Total
3.75h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

FAIRVIEW EXTENDED CARE SERVICES INC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Mar 1990

100%

INTEGRITUS HEALTHCARE INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2022

100%

INTEGRITUS HEALTHCARE INC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 1990

INTEGRITUS HEALTHCARE MANAGEMENT SERVICES INC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Feb 2022

GINGRAS, MARCIE JO

IndividualCORPORATE OFFICERSince Dec 2021

JONES, WILLIAM

IndividualCORPORATE OFFICERSince Feb 1993

BREWER, SCOTT

IndividualW-2 MANAGING EMPLOYEESince Dec 2021

Penalties & Fines (2)

$15,636total fines
DateTypeDescriptionAmount
Oct 12, 2023Fine$12,386
Mar 13, 2023Fine$3,250

Health Inspection Deficiencies (42)

January 9, 2025Health8 deficiencies
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Feb 19, 2025
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 19, 2025
0685EMinimal harm, Pattern

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Corrected Feb 19, 2025
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 19, 2025
0761EMinimal harm, Pattern

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

Corrected Feb 19, 2025
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 19, 2025
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 19, 2025
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Feb 19, 2025
October 12, 2023Health10 deficiencies1 severe
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Nov 22, 2023
0585EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Nov 22, 2023
0623BNo harm, Pattern

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Nov 22, 2023
0625BNo harm, Pattern

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.

Resident Rights Deficiencies

Corrected Nov 22, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 22, 2023
0685EMinimal harm, Pattern

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Corrected Nov 22, 2023
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Nov 22, 2023
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Nov 22, 2023
0849DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Nov 22, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Nov 22, 2023
June 1, 2023Health1 deficiency
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 30, 2023
March 13, 2023Health2 deficiencies
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 22, 2023
0886FMinimal harm, Widespread

Perform COVID19 testing on residents and staff.

Infection Control Deficiencies

Corrected Mar 22, 2023
April 14, 2021Health21 deficiencies1 severe
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Jun 15, 2021
0565FMinimal harm, Widespread

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Jun 1, 2021
0585EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Jun 1, 2021
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 1, 2021
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 1, 2021
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 1, 2021
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2021
0658GActual harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2021
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Jun 1, 2021
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 1, 2021
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jun 1, 2021
0881FMinimal harm, Widespread

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Jun 1, 2021
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Jun 15, 2021
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2021
0687DMinimal harm, Isolated

Provide appropriate foot care.

Quality of Life and Care Deficiencies

Corrected Jun 1, 2021
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jun 1, 2021
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Jun 1, 2021
0758DMinimal harm, Isolated

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

Corrected Jun 1, 2021
0761EMinimal harm, Pattern

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

Corrected Jun 1, 2021
0770DMinimal harm, Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Corrected Jun 1, 2021
0838FMinimal harm, Widespread

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.

Administration Deficiencies

Corrected Jun 11, 2021

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Frequently Asked Questions

What is the CareGrader rating for WINDSOR NURSING & RETIREMENT HOME?

WINDSOR NURSING & RETIREMENT HOME in SOUTH YARMOUTH, Massachusetts has a CareGrader grade of D (Below Average), with a composite score of 68 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WINDSOR NURSING & RETIREMENT HOME?

WINDSOR NURSING & RETIREMENT HOME has an overall CMS star rating of 1 out of 5, a health inspection rating of 2/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WINDSOR NURSING & RETIREMENT HOME have?

WINDSOR NURSING & RETIREMENT HOME has 42 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has WINDSOR NURSING & RETIREMENT HOME been fined?

Yes. WINDSOR NURSING & RETIREMENT HOME has $15,636 in total fines from CMS enforcement actions across 2 penalties.

How many beds does WINDSOR NURSING & RETIREMENT HOME have?

WINDSOR NURSING & RETIREMENT HOME has 120 certified beds with approximately 88 current residents (73% occupancy). The facility is located at 265 N MAIN ST, SOUTH YARMOUTH, Massachusetts 02664. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.