Windsor Nursing & Retirement Home

Windsor Nursing & Retirement Home was recognized and ceritified in 1989 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Windsor Nursing & Retirement Home which is located in 265 N Main St South Yarmouth, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Windsor Nursing & Retirement Home is being offered ceritified services and products in Massachusetts.
Address:   265 N Main St
       South Yarmouth, MA 02664

Phone:   (508) 394-3514

County: Barnstable
Federal Provider Number: 225349
Participates in: Medicare And Medicaid
Certified Date: Saturday, July 1, 1989 (35 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: South Yarmouth Management Systems Inc
Ownership Type: Non Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationBhs Management Services IncOperational/managerial Control
OrganizationBerkshire Healthcare System IncOperational/managerial Control
OrganizationFairview Extended Care Services Inc5% Or More Ownership Interest
PersonDavid PhelpsDirector/officer
PersonLynn MurphyDirector/officer
PersonMitchell MarshW-2 Managing Employee
PersonWilliam JonesDirector/officer

Provider Resides in Hospital: No
Number of Federally Certified Beds: 120
Number of Residents in Federally Certified Beds: 103 (86% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Resident
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Monday, April 28, 2014
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, June 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, October 16, 2013
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Friday, November 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 16, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Friday, November 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0518 (Train all employees on what to do in an emergency, and carry out unannounced staff drills.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0466 (Have enough backup water supply for essential areas of the nursing home.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0242 (Ensure residents have the right to have a choice over activities, their schedules, and health care a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0176 (Allow residents to self-administer drugs if determined safe.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0252 (Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal be)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 23, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 5, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, July 25, 2012
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 15, 2011
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Friday, July 15, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 26, 2011
Survey Type: Health
Deficiency: F0281 (Ensure services provided by the nursing facility meet professional standards of quality.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 10, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 26, 2011
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 10, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 26, 2011
Survey Type: Health
Deficiency: F0456 (Keep all essential equipment working safely.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 10, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 26, 2011
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 10, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 26, 2011
Survey Type: Health
Deficiency: F0334 (Develop policies and procedures for influenza and pneumococcal immunizations.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 10, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 1
Number of Substantiated Complaints: 0
Number of Fines: 1
Number of Payment Denials: 0
Total Number of Penalties: 1
Total Amount of Fines in Dollars: USD 1,365


Date of inspection that triggered the penalty: Monday, April 28, 2014
Penalty Type: Fine
Fine Amount: 1,365
This data allows consumers to compare information about nursing homes. Information here is not an endorsement or advertisement for any nursing home and should be considered carefully. Use it with other information you gather about nursing homes facilities. Talk to your doctor or other health care provider about this.



This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (1 out of 5 stars)
Quality Rating (3 out of 5 stars)
Staffing Rating (4 out of 5 stars)
RN Staffing Rating (5 out of 5 stars)
Overall Rating (2 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
5%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
5%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
2%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
14%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
2%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
5%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
18%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
96%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
96%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
4%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
6%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
21%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
52%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
85%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
2%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
88%
84%

N/A
Data not available.

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Windsor Nursing & Retirement Home [Federal No:225349] near 265 N Main St, South Yarmouth MA

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