South Yarmouth, MA

Windsor Nursing & Retirement Home

1-star overall rating with 2-star inspections with $12,386 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

265 N Main St, South Yarmouth, MA

(413) 544-3329

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

88

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Integritus Healthcare

Operator or chain grouping

Approved since

1989-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

15 facilities

Chain averages 3 overall / 3 health / 3 staffing / 2 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.61

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.44

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.93

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.49

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.41

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.34

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.58

CMS adjusted RN staffing hours

Adjusted total hours

3.75

CMS adjusted total nurse staffing hours

Case-mix index

1.43

Higher values indicate more complex resident acuity

RN turnover

47%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,020

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.31

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 20.05% · Performance 23.04% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

4.79

Baseline 6.51% · Performance 6.40% · Measure score 4.79 · Achievement 4.79 · Improvement 0.24

Total nurse turnover

0

Baseline 48.72% · Performance 71.11% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.53

Baseline 3.48 hours · Performance 3.80 hours · Measure score 2.53 · Achievement 2.53 · Improvement 0.88

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 8.67%
10.72%
2.1 pts better
No Different than the National Rate · Eligible stays 175 · Observed rate 5.14% · Lower 95% interval 5.83%
Discharge to community 48.16%
50.57%
2.4 pts worse
No Different than the National Rate · Eligible stays 149 · Observed rate 43.62% · Lower 95% interval 40%
Medicare spending per beneficiary 0.89
1.02
0.1 pts better
Drug regimen review with follow-up 85.47%
95.27%
9.8 pts worse
Numerator 100 · Denominator 117
Falls with major injury 0.85%
0.77%
0.1 pts worse
Numerator 1 · Denominator 117
Discharge self-care score 29.51%
53.69%
24.2 pts worse
Numerator 18 · Denominator 61
Discharge mobility score 32.79%
50.94%
18.1 pts worse
Numerator 20 · Denominator 61
Pressure ulcers or injuries, new or worsened 3.42%
2.29%
1.1 pts worse
Numerator 4 · Denominator 117 · Adjusted rate 4.59%
Healthcare-associated infections requiring hospitalization 6.4%
7.12%
0.7 pts better
No Different than the National Rate · Eligible stays 106 · Observed rate 4.72% · Lower 95% interval 4.22%
Staff COVID-19 vaccination coverage 2.91%
8.2%
5.3 pts worse
Numerator 3 · Denominator 103
Staff flu vaccination coverage 50.62%
42%
8.6 pts better
Numerator 41 · Denominator 81
Discharge function score 22.95%
56.45%
33.5 pts worse
Numerator 14 · Denominator 61
Transfer of health information to provider 98%
95.95%
2 pts better
Numerator 49 · Denominator 50
Transfer of health information to patient 97.67%
96.28%
1.4 pts better
Numerator 42 · Denominator 43
Resident COVID-19 vaccinations up to date 42.03%
25.2%
16.8 pts better
Numerator 29 · Denominator 69

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.9
1.9
About the same
1.9
About the same
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.0
1.5
0.5 pts worse
1.8
0.2 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 97.8%
92.2%
5.6 pts better
93.4%
4.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 97.4% · Q4 95.1% · 4Q avg 97.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 80.7%
94.8%
14.1 pts worse
95.5%
14.8 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.7%
Percentage of long-stay residents experiencing one or more falls with major injury 2.8%
3.5%
0.7 pts better
3.3%
0.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.6% · Q4 3.7% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 16.8%
12.0%
4.8 pts worse
11.4%
5.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.8% · Q3 31.5% · Q4 24.7% · 4Q avg 16.8%
Percentage of long-stay residents who lose too much weight 6.0%
5.2%
0.8 pts worse
5.4%
0.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.3% · Q3 9.3% · Q4 5.6% · 4Q avg 6.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 18.2%
19.2%
1 pts better
19.6%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 21.8% · Q3 18.4% · Q4 18.7% · 4Q avg 18.2%
Percentage of long-stay residents who received an antipsychotic medication 19.6%
22.5%
2.9 pts better
16.7%
2.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 16.3% · Q3 18.3% · Q4 19.4% · 4Q avg 19.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 24.4%
17.7%
6.7 pts worse
16.3%
8.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 17.0% · Q3 16.4% · Q4 31.7% · 4Q avg 24.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 20.8%
17.6%
3.2 pts worse
14.9%
5.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 20.3% · Q3 20.6% · Q4 17.4% · 4Q avg 20.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.6%
1.0%
0.4 pts better
1.0%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.9%
2.0%
0.1 pts better
1.7%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 2.6% · Q4 2.6% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 10.2%
21.7%
11.5 pts better
19.8%
9.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.0% · Q3 12.7% · Q4 11.2% · 4Q avg 10.2%
Percentage of long-stay residents with pressure ulcers 4.7%
4.6%
0.1 pts worse
5.1%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.4% · Q3 5.7% · Q4 4.1% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 89.5%
77.1%
12.4 pts better
81.7%
7.8 pts better
Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 92.7% · Q3 90.0% · Q4 86.9% · 4Q avg 89.5%
Percentage of short-stay residents who had an outpatient emergency department visit 11.3%
11.8%
0.5 pts better
12.0%
0.7 pts better
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 12.0% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.5%
1.3%
0.8 pts better
1.6%
1.1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 80.4%
77.7%
2.7 pts better
79.7%
0.7 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 29.6%
25.8%
3.8 pts worse
23.9%
5.7 pts worse
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 32.4% · Expected 26.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-09 · Fire 2025-01-09

8 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2023-10-12 · Fire 2023-10-12

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2021-04-14 · Fire 2021-04-14

24 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-09

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2025-02-19

F · Potential for more than minimal harm 2025-01-09

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2025-02-03

D · Potential for more than minimal harm 2025-01-09

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2025-01-24

D · Potential for more than minimal harm 2025-01-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-02-19

C · Minimal harm 2023-10-12

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-11-13

C · Minimal harm 2023-10-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-11-13

C · Minimal harm 2023-10-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-13

E · Potential for more than minimal harm 2021-04-14

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2021-05-31

E · Potential for more than minimal harm 2021-04-14

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-05-31

E · Potential for more than minimal harm 2021-04-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-05-31

C · Minimal harm 2021-04-14

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2021-05-31

C · Minimal harm 2021-04-14

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2021-05-31

C · Minimal harm 2021-04-14

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-05-31

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-01-09

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-02-19

E · Potential for more than minimal harm 2025-01-09

F685 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-19

E · Potential for more than minimal harm 2025-01-09

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-02-19

E · Potential for more than minimal harm 2025-01-09

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-02-19

E · Potential for more than minimal harm 2025-01-09

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-02-19

D · Potential for more than minimal harm 2025-01-09

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2025-02-19

D · Potential for more than minimal harm 2025-01-09

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-02-19

D · Potential for more than minimal harm 2025-01-09

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-19

G · Actual harm 2023-10-12

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-22

E · Potential for more than minimal harm 2023-10-12

F565 · Resident Rights Deficiencies

Health

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

Corrected 2023-11-22

E · Potential for more than minimal harm 2023-10-12

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2023-11-22

E · Potential for more than minimal harm 2023-10-12

F685 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-10-12

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-10-12

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-10-12

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-10-12

F849 · Administration Deficiencies

Health

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.

Corrected 2023-11-22

B · Minimal harm 2023-10-12

F623 · Resident Rights Deficiencies

Health

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

Corrected 2023-11-22

B · Minimal harm 2023-10-12

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-06-01

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-06-30

F · Potential for more than minimal harm 2023-03-13

F886 · Infection Control Deficiencies

Health

Perform COVID19 testing on residents and staff.

Corrected 2023-03-22

D · Potential for more than minimal harm 2023-03-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-22

G · Actual harm 2021-04-14

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2021-06-01

F · Potential for more than minimal harm 2021-04-14

F565 · Resident Rights Deficiencies

Health

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

Corrected 2021-06-01

F · Potential for more than minimal harm 2021-04-14

F838 · Administration Deficiencies

Health

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.

Corrected 2021-06-11

F · Potential for more than minimal harm 2021-04-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-06-01

F · Potential for more than minimal harm 2021-04-14

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2021-06-01

E · Potential for more than minimal harm 2021-04-14

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2021-06-01

E · Potential for more than minimal harm 2021-04-14

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-06-01

E · Potential for more than minimal harm 2021-04-14

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2021-06-01

E · Potential for more than minimal harm 2021-04-14

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F552 · Resident Rights Deficiencies

Health

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

Corrected 2021-06-15

D · Potential for more than minimal harm 2021-04-14

F554 · Resident Rights Deficiencies

Health

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

Corrected 2021-06-15

D · Potential for more than minimal harm 2021-04-14

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2021-06-01

D · Potential for more than minimal harm 2021-04-14

F770 · Administration Deficiencies

Health

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

Corrected 2021-06-01

Penalties and ownership

What sits behind the stars

$12,386 2023-10-12

Fine

Fine · fine $12,386

Fine

Ownership

Fairview Extended Care Services Inc

5% Or Greater Direct Ownership Interest · Organization

100% 4 facilities 1990-03-29
Integritus Healthcare Inc

5% Or Greater Indirect Ownership Interest · Organization

100% 14 facilities 2022-02-01
Brewer, Scott

W-2 Managing Employee · Individual

0% 1 facilities 2021-12-22
Gingras, Marcie Jo

Corporate Officer · Individual

0% 15 facilities 2021-12-13
Integritus Healthcare Inc

Operational/Managerial Control · Organization

0% 14 facilities 1990-03-26
Integritus Healthcare Management Services Inc

Operational/Managerial Control · Organization

0% 14 facilities 2022-02-01
Jones, William

Corporate Officer · Individual

0% 15 facilities 1993-02-01

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