01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-19 | 6 | 2026-03-19 | 0 |
| Cycle 2 | 2025-01-09 | 8 | 2025-01-09 | 4 |
| Cycle 3 | 2023-10-12 | 10 | 2023-10-12 | 3 |
CMS CCN 2253492026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Windsor Nursing & Retirement Home
265 N Main St · South Yarmouth, MA 02664 · Barnstable County
Certified beds120CMS provider file
Recent citation rows31current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
31 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-19 · HEALTHF0582Severity B · pattern; potential for minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: No revisit needed · 2026-04-282026-03-19 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-19 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-19 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-19 · HEALTHF0839Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Correction field: Deficient, Provider has date of correction · 2026-04-282026-03-19 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-282025-01-09 · FIREE0025Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Create arrangements with other facilities to receive patients.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · FIREE0031Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide emergency officials' contact information.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-09 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · HEALTHF0685Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-09 · FIREK0911Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Correction field: Deficient, Provider has date of correction · 2025-01-242025-01-09 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-02-192023-10-12 · FIREE0041Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has plan of correction · 2023-11-132023-10-12 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2023-11-222023-10-12 · HEALTHF0585Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-11-222023-10-12 · HEALTHF0623Severity B · pattern; potential for minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-11-222023-10-12 · HEALTHF0625Severity B · pattern; potential for minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-11-222023-10-12 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-11-2203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-10-12 | Fine | $12,386 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FAIRVIEW EXTENDED CARE SERVICES INCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/29/1990
- INTEGRITUS HEALTHCARE INCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 02/01/2022
- BREWER, SCOTTIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 12/22/2021
- GINGRAS, MARCIE JOIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/13/2021
- JONES, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/01/1993
- INTEGRITUS HEALTHCARE INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/26/1990
- INTEGRITUS HEALTHCARE MANAGEMENT SERVICES INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.91per resident day
RN hours0.63per resident day
Weekend nurse hours3.34per resident day
Staff turnover37.7%CMS reported field
06 / LOCAL RECORDS
Open the Massachusetts ledger →Other published facilities nearby
No second facility in the same city met the directory rule.