CCN 225349

Windsor Nursing & Retirement Home

265 N MAIN ST, South Yarmouth, MA 02664 · Barnstable County

Phone: (508) 394-3514
Ownership: Non profit - Corporation
Certified beds: 120
Residents per day: 88.6
Health citations: 24
Penalties: 1
Fines: 1 · $12,386
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 2 · short-stay 1.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 2.42; 2.25; 2.32
LPN/LVN: 0.86; 0.95; 0.86
Registered nurse: 0.63; 0.65; 0.69
Total nurse staff: 3.91; 3.86; 3.86
Weekend total: 3.34; 3.48; 3.42
Weekend RN: 0.28; 0.45; 0.48

Adjusted total nurse hours: 3.78. Adjusted RN hours: 0.61. Case-mix total: 3.96. Case-mix index: 1.448.

Total nursing staff turnover: 37.7%. RN turnover: 26.7%. Administrators who left: 0.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 1 fine totaling $12,386, and 0 payment denials.

Date	Type	Amount or days
October 12, 2023	Fine	$12,386

Cycle 1 standard survey: March 19, 2026. Health deficiencies counted in cycle 1: 6. Cycle 1 total health score: 28.

Cycle 2 standard survey: January 9, 2025. Cycle 2/3 health deficiencies: 8. Total weighted health survey score: 34.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 24 citations for this home, including 0 at immediate jeopardy and 1 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

March 19, 2026

6 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 28, 2026
F839	Employ staff that are licensed, certified, or registered in accordance with state laws. Administration Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 28, 2026
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 28, 2026
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 28, 2026
F887	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. Infection Control Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 28, 2026
F582	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Standard survey · Cycle 1	B: pattern, no actual harm, with potential for minimal harm	No revisit needed · April 28, 2026

January 9, 2025

8 citations

Tag	What CMS cited	Scope and severity	Status
F584	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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025
F685	Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025
F761	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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025
F842	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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025
F585	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025
F658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 19, 2025

October 12, 2023

10 citations

Tag	What CMS cited	Scope and severity	Status
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · November 22, 2023
F565	Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F585	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 · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F685	Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F656	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 · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F698	Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F849	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 · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F623	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 · Standard survey · Cycle 3	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · November 22, 2023
F625	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 · Standard survey · Cycle 3	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · November 22, 2023

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Chain name in the file: Integritus Healthcare (14 facilities). Chain average overall rating: 2.9.
Legal business name: South Yarmouth Management Systems INC.
First approved for Medicare and Medicaid services: July 1, 1989.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Windsor Nursing & Retirement Home?

Windsor Nursing & Retirement Home has an overall rating of 2 out of 5. The health inspection rating is 3, staffing is 4, and the quality measure rating is 1.

How many health citations does CMS list for Windsor Nursing & Retirement Home?

The Health Deficiencies file lists 24 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 1 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Windsor Nursing & Retirement Home?

CMS reports 3.91 total nurse hours per resident per day, including 0.63 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

October 12, 2023

10 citations

Tag	What CMS cited	Scope and severity	Status
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · November 22, 2023
F565	Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F585	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 · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F685	Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F656	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 · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F698	Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F849	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 · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 22, 2023
F623	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 · Standard survey · Cycle 3	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · November 22, 2023
F625	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 · Standard survey · Cycle 3	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · November 22, 2023