SOUTH YARMOUTH, MA - A federal inspection at Windsor Nursing & Retirement Home in January 2025 documented multiple care deficiencies affecting resident safety and quality of life, including failures in IV line management, delayed hearing aid replacement, inadequate fall prevention, and food safety lapses.
Critical IV Line Management Failures
Inspectors identified serious deficiencies in the facility's management of a peripherally inserted central catheter (PICC line) for a resident receiving treatment for a bone infection. PICC lines are sophisticated medical devices—thin, flexible tubes inserted into an upper arm vein and threaded to a large vein near the heart. These devices require meticulous care to prevent life-threatening complications.
The facility's own policy mandated specific protocols: dressing changes every seven days, measurement of the external catheter length at each change, and monitoring of upper arm circumference to detect potential complications. For the resident in question, admitted in December 2024 for osteomyelitis of the right foot, these critical safety measures were systematically ignored.
When surveyors observed the resident on January 2, 2025, the PICC line dressing was dated December 25, 2024—eight days overdue for changing. More concerning, dried blood was visible around the insertion site. Review of treatment records revealed a pattern of incomplete care: dressing changes on December 18 and December 25 lacked any documentation of catheter length or arm circumference measurements. On January 1, a nurse signed off that the dressing had been changed, yet the dressing observed two days later still showed the December 25 date.
PICC line complications can escalate rapidly. Infections at the insertion site can introduce bacteria directly into the bloodstream, potentially causing sepsis—a life-threatening condition. Changes in catheter length may indicate the line has migrated from its proper position, risking improper medication delivery or vessel damage. Increased arm circumference can signal deep vein thrombosis, a dangerous blood clot that can travel to the lungs.
The Massachusetts Board of Registration in Nursing explicitly requires licensed nurses to implement physician orders consistent with current standards of care and establish infrastructure to minimize errors. The facility's Director of Nurses acknowledged that nurses should have been recording catheter measurements on treatment records with each dressing change. When questioned about the discrepancy between the nurse's documentation and the actual unchanged dressing, the director confirmed that one nurse admitted she "did not get to" the dressing change on January 1 but marked it complete anyway—a falsification of medical records that compromises patient safety monitoring.
Three-Month Delay in Hearing Aid Services
A resident with Alzheimer's dementia and severe cognitive impairment went without hearing aids for 98 days after staff noted them missing in September 2024, representing a fundamental failure to maintain quality of life for a vulnerable individual.
Hearing loss in dementia patients compounds cognitive difficulties and increases isolation, confusion, and behavioral symptoms. The ability to hear and communicate directly affects a person's capacity to express needs, participate in activities, and maintain connections with others. For this resident, who scored 3 out of 15 on cognitive testing indicating severe impairment, hearing aids were essential assistive devices.
Documentation on the medication administration record painted a troubling picture. After staff documented the hearing aids as "put in" daily from September 1 through September 22, they were suddenly noted as missing on September 23. Over the following months, the hearing aids were documented as "missing," "misplaced," or "not available" on 64 of the next 102 days. Yet the facility took no documented action.
According to facility policy, staff should respond promptly to missing items, initiate investigations, and review results with residents or responsible parties. The consulting services policy specifically stated that audiology services should be offered to ensure the highest practicable level of functioning. None of this occurred. No search was documented. Management was not notified. The family was not contacted. No grievance was filed. Most critically, no alternative hearing assistance was offered.
The facility only filed a grievance on December 30, 2024—three months after the hearing aids disappeared—and only after the resident's family reported them missing. During the inspection, staff acknowledged the hearing aids had been missing "for a few months" and that "alternate services should have been offered sooner." The social worker stated an audiology appointment "should have been made" when staff first noted the devices missing in September, but was "unsure why the process was not followed."
Throughout this period, surveyors observed the resident experiencing significant communication difficulties, expressing frustration at the inability to hear. Staff needed to speak loudly and slowly, with frequent repetitions. This daily struggle continued unnecessarily for over three months due to systemic failures in the facility's response protocols.
Inadequate Fall Prevention Following Injury
The facility failed to implement effective fall prevention measures for a resident with dementia and mobility impairment, resulting in two falls from a specialized wheelchair within four months, the second causing head trauma with visible bruising.
The resident's care plan identified multiple fall risk factors: changes in mobility and gait, confusion and forgetfulness, and unsafe behaviors. The individual had been assessed at admission in October 2022 with a documented history of falls and unsteady transfers. Despite this high-risk profile, the facility's response to the first fall proved inadequate to prevent recurrence.
On June 1, 2024, staff found the resident sitting on the floor in front of the Broda chair—a specialized wheelchair designed to recline for safety. The incident report identified that the chair back was at a 90-degree angle and may have contributed to the fall. Investigators proposed a new intervention: reclining the wheelchair back shortly after meals. However, this intervention was crossed out on the incident report with a note stating it "would not necessarily have prevented fall." Crucially, no alternative intervention was added to the care plan.
Four months later, on September 20, 2024, the resident fell again from the wheelchair in the dayroom. This time, the individual sustained bruising to the right forehead requiring ice pack application and neurological monitoring. The incident report identified the same contributing factor: the wheelchair was not reclined. Only after this second fall—and resulting injury—did staff update the care plan with the intervention to recline the wheelchair after meals.
Even after implementing this intervention, compliance remained inconsistent. Surveyors observed the resident sitting in the Broda chair with the back upright (not reclined) on January 6 after being in the activity room, and again on January 7 following lunch in the dayroom.
Fall prevention in nursing homes requires comprehensive assessment of individual risk factors and consistent implementation of tailored interventions. When a fall occurs despite existing precautions, facilities must conduct thorough root cause analysis to identify what failed and what additional measures are needed. The facility's policy required exactly this process, yet the interdisciplinary team failed to identify that the June incident report was incomplete and no intervention had been implemented.
Additional Issues Identified
Medication Storage and Handling Violations: Inspectors documented unsanitary conditions in medication carts on two units, including loose pills scattered in drawers with crusted yellowish substances and powder. Unlabeled medication cups containing prepared substances sat uncovered in carts. Multiple eye drop bottles and inhalers in active use lacked required opening dates, making it impossible to determine if they had exceeded safe use timeframes. Single-dose prescription medications without resident names were stored improperly. These conditions create risks for medication errors and contamination.
Food Safety Breaches: Kitchen staff handling ready-to-eat foods violated fundamental food safety principles during meal preparation. One cook was observed wearing the same pair of gloves while handling cooked pancakes, toast, and bacon, then leaving to crack raw eggs on a griddle, then returning to plate breakfast foods—all without changing gloves or performing hand hygiene. Another cook wore two pairs of gloves simultaneously, removed them after handling equipment, and attempted to dry wet hands by holding them up to a freezer fan before donning new gloves without proper handwashing. These practices risk cross-contamination and foodborne illness transmission to a vulnerable population.
Medical Record Documentation Deficiency: For a resident experiencing severe malnutrition with weight loss from 155.8 pounds to 112.8 pounds over three months, the facility's dietitian recommended in October 2024 that the physician consider prescribing Mirtazapine as an appetite stimulant. This recommendation was not addressed in the medical record until December 2024—a two-month delay. The nurse practitioner stated she initially declined to add another medication given recent changes and the resident's psychiatric history, but acknowledged she could not recall documenting this decision and "should have." This gap in documentation prevented the care team from understanding the status of clinical recommendations for a resident with life-threatening weight loss.
The deficiencies identified at Windsor Nursing & Retirement Home reflect systemic breakdowns in clinical oversight, staff training, and quality assurance processes. Proper IV line care, timely provision of assistive devices, evidence-based fall prevention, medication safety, food sanitation, and accurate medical documentation represent fundamental standards of nursing home care. When these standards fail, residents face increased risks of infection, injury, isolation, and compromised health outcomes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Nursing & Retirement Home from 2025-01-09 including all violations, facility responses, and corrective action plans.
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