Windsor Nursing & Retirement Home
265 N MAIN ST
SOUTH YARMOUTH, MA, 02664
4135443329
CCN: 225349
1
Overall2
Health3
Staffing1
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
OIG Federal Exclusion Matches (2)
This facility's name matches one or more entities on the OIG List of Excluded Individuals/Entities (LEIE). Excluded parties are prohibited from participation in Medicare and Medicaid programs.
INCOMRX SYSTEMS, INC
1128a1
Excluded 1991-11-21
WINTER HILL NURSING HOME
1128a1
Excluded 1988-07-25
Ownership
| Name | Role | % |
|---|---|---|
| FAIRVIEW EXTENDED CARE SERVICES INC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| INTEGRITUS HEALTHCARE INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% |
| GINGRAS, MARCIE JO | CORPORATE OFFICER | NOT APPLICABLE |
| JONES, WILLIAM | CORPORATE OFFICER | NOT APPLICABLE |
| INTEGRITUS HEALTHCARE MANAGEMENT SERVICES INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| INTEGRITUS HEALTHCARE INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| BREWER, SCOTT | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
Penalties (1)
| Date | Type | Amount |
|---|---|---|
| 2023-10-12 | Fine | $12K |
Health Deficiencies (42)
2025-01-09 · Health
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
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.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F585 · Resident Rights Deficiencies
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.
E
F584 · Resident Rights Deficiencies
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.
2023-10-12 · Health
D
F849 · Administration Deficiencies
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.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
G
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
E
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
B
F625 · Resident Rights Deficiencies
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.
B
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
E
F585 · Resident Rights Deficiencies
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.
E
F565 · Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
2023-06-01 · Health
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
2023-03-13 · Health
F
F886 · Infection Control Deficiencies
Perform COVID19 testing on residents and staff.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2021-04-14 · Health
F
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F838 · Administration Deficiencies
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.
D
F770 · Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
E
F761 · Pharmacy Service Deficiencies
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.
D
F758 · Pharmacy Service Deficiencies
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.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F687 · Quality of Life and Care Deficiencies
Provide appropriate foot care.
G
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
E
F585 · Resident Rights Deficiencies
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.
F
F565 · Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.93
RN Hrs/Resident/Day0.54
0.61
LPN Hrs/Resident/Day0.81
0.88
CNA Hrs/Resident/Day2.33
2.44
PT Hrs/Resident/Day0.12
0.08
Data as of 2026-03-01