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Health Inspection

Windsor Nursing & Retirement Home

January 9, 2025 · South Yarmouth, MA · 265 N Main St
Citations 1
CMS Rating 2/5
Beds 120
Provider ID 225349
Healthcare Facility
Windsor Nursing & Retirement Home
South Yarmouth, MA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)  ·  24 pages
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Windsor Nursing & Retirement Home in SOUTH YARMOUTH, MA — inspection on January 9, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF685
Minimal harm or 41106 Few practice for one Resident (#197), out of a total sample of 19 residents. Specifically, the facility failed to follow affected

Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Advisory Ruling Number 9324, dated as revised July 10, 2002, indicated:

-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations.

-Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.

Review of the facility's policy titled Vascular Access Device (VAD) Insertion Care and Removal, dated 7/1/2018, indicated but was not limited to the following:

-Central vascular access device (CVAD): Dressing changes

-CVADs require a sterile transparent semipermeable membrane dressing and shall be changed with a practitioner order:

a.

Upon admission or 24-hour post-insertion;

b.

Every seven days;

c. As needed (PRN) if compromised.

-PICC Lines require measurements which include:

a.

Total catheter length:

i.

Upon admission or insertion;

ii.

Obtained from insertion nurse or discharge facility.

225349

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225349 B.

Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing & Retirement Home 265 N Main St South Yarmouth, MA 02664

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SOUTH YARMOUTH, MA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Windsor Nursing & Retirement Home or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.