Public Record
Windsor Nursing & Retirement Home
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 120
- Avg. residents per day
- 87.8
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 54
- Inspections on file
- 8
- Last inspection
- 2025-01-09
*CMS
*CMS
*CMS
Citations
54 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0911Generalpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0585Generalpotential for harm
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.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0685Generalpotential for harm
Assist a resident in gaining access to vision and hearing services.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0031Generalpotential for harm
Provide emergency officials' contact information.
- 0025Generalpotential for harm
Create arrangements with other facilities to receive patients.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0584Generalpotential for harm
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.
- 0623Generalno actual harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0585Generalpotential for harm
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.
- 0625Generalno actual harm
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.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0685Generalpotential for harm
Assist a resident in gaining access to vision and hearing services.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0849Generalpotential for harm
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.
- 0041Generalno actual harm
Implement emergency and standby power systems.
- 0712Generalno actual harm
Have simulated fire drills held at unexpected times.
- 0918Generalno actual harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0886Generalpotential for harm
Perform COVID19 testing on residents and staff.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0758Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0770Generalpotential for harm
Provide timely, quality laboratory services/tests to meet the needs of residents.
- 0838Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0658Seriousactual harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0687Generalpotential for harm
Provide appropriate foot care.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0030Generalno actual harm
List the names and contact information of those in the facility.
- 0039Generalno actual harm
Conduct testing and exercise requirements.
- 0041Generalpotential for harm
Implement emergency and standby power systems.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0585Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
FAQ
Questions and answers
- What is Windsor Nursing & Retirement Home?
- Windsor Nursing & Retirement Home is a Medicare- and Medicaid-certified nursing home in South Yarmouth, MA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 225349.
- What is the CMS rating for Windsor Nursing & Retirement Home?
- Windsor Nursing & Retirement Home has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Windsor Nursing & Retirement Home have?
- Windsor Nursing & Retirement Home is certified for 120 beds. It serves an average of 87.8 residents per day.
- How many citations does Windsor Nursing & Retirement Home have?
- Windsor Nursing & Retirement Home has 54 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Windsor Nursing & Retirement Home last inspected?
- Windsor Nursing & Retirement Home was last inspected on January 9, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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