Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Nursing & Retirement Home during CMS and state inspections, most recent first.
Improper Labeling and Storage of Thickened Liquids: Surveyors found opened thickened liquids in a shared nourishment kitchenette and two unit refrigerators that were not properly dated, and one opened thickened cranberry cocktail was stored unrefrigerated in an upper cabinet. Manufacturer instructions on the products required refrigeration after opening and discard within the stated time frame, and the FSD said staff were responsible for checking and labeling these items.
Unlicensed RN Assigned to Direct Resident Care: A nurse was assigned as a floor nurse and medication cart nurse providing direct resident care even though the RN license had expired. The employee file lacked clear verification of an active license, the DON confirmed the nurse was doing direct care, and the Administrator said HR was responsible for checking licenses before hire but there was no indication this was done.
Failure to use required smoking apron: A resident with moderate cognitive impairment and a documented need for a smoking apron was observed smoking without the apron while supervised by the Housekeeping Supervisor. The resident’s care plan and annual assessment identified the apron as a smoking safety intervention, but the supervisor stated the resident did not need one, while the UM later confirmed the apron should have been used and the DON noted there was no process to inform non-CNA/non-nursing staff of smoking safety changes.
Incorrect Enteral Feeding Formula Administered: A resident with a G-tube, supraglottic cancer, and severe protein malnutrition was ordered Jevity 1.5 CAL 240 ml five times daily, but an LPN administered Jevity 1.2 CAL instead. The nurse confirmed the wrong formula was given because only Jevity 1.2 CAL was available on the unit, and the RD stated the formula was not clinically appropriate for the resident’s nutritional needs.
Missing COVID-19 Vaccine Documentation for New Hires: The facility failed to maintain records showing that two newly hired staff members were educated about and offered the most recent COVID-19 vaccine. The policy required staff vaccination status to be documented, but one employee file had no vaccine-offer documentation and another employee was not even listed on the tracking spreadsheet. Interviews confirmed that the staff education and offer information was not available in the employee records.
Two residents receiving skilled Medicare Part A services did not have the SNF ABN (CMS-10055) completed and signed when their skilled coverage ended. Records showed Notices of Medicare Non-Coverage were issued, but the chart lacked the required ABN for both residents, and the SWC confirmed the notices were not given even though they should have been.
The facility failed to ensure a homelike dining experience for residents in the A and B Unit dining rooms, where meals were served directly from food trucks and eaten off serving trays, unlike the Main Dining room which had a more homelike setup with tablecloths and proper dining utensils.
A resident with severe cognitive impairment experienced a 98-day delay in audiology services after their hearing aids went missing. Despite documentation of the missing aids, the facility did not search for them, notify management or family, or offer alternative devices. Staff interviews revealed a lack of communication and action, with the issue only being addressed after the family reported it.
The facility failed to store and label medications according to professional standards, as observed in two medication carts. On Unit A, unlabeled medication cups, loose pills, and improperly labeled eye drops and inhalers were found. Nurse #1 acknowledged these issues and was unsure about cleaning responsibilities. On Unit B, similar issues with unlabeled eye drops were noted. Staff interviews revealed that the night shift nurse is responsible for cart maintenance, and the DON emphasized proper labeling and cleaning protocols.
The facility failed to follow professional standards for food safety and sanitation. Cook #1 handled ready-to-eat food with gloved hands without changing gloves between tasks, such as cooking pancakes and cracking raw eggs, contrary to the FDA Food Code and facility policy. Cook #2 wore two pairs of gloves while plating lunch, removed one pair without performing hand hygiene, and dried his hands in the walk-in freezer before putting on a new pair. The Food Service Manager acknowledged these practices were against policy.
A resident with multiple diagnoses experienced significant weight loss, and a dietitian recommended Mirtazapine as an appetite stimulant. However, the facility failed to document the review of this recommendation by the physician in a timely manner. Staff interviews revealed a lack of awareness and documentation regarding the recommendation process, and the NP's initial decision not to add another medication was not documented. The facility acknowledged the need for improved documentation systems.
A resident with Alzheimer's and severe cognitive impairment experienced a 98-day delay in receiving alternative audiology services due to the facility's failure to initiate the grievance process for missing hearing aids. Despite documentation of the hearing aids being missing for months, staff did not follow procedures to investigate or file a grievance until the family reported the issue. Key personnel were unaware of the situation, highlighting a breakdown in communication and adherence to policy.
A facility failed to follow professional standards for a resident's PICC line management. The resident, with osteomyelitis and a right great toe amputation, had specific orders for dressing changes and measurements, which were not documented or performed as required. Observations showed the dressing was not changed on specified dates, and interviews confirmed discrepancies in documentation and adherence to orders.
A resident with cognitive impairment and a history of falls experienced two falls in three months due to the facility's failure to implement and update post-fall interventions. The resident fell from a Broda chair and a wheelchair, resulting in a head bruise. Despite identifying interventions, the facility did not consistently update care plans or implement measures to prevent future falls, as observed by surveyors.
Improper Labeling and Storage of Thickened Liquids
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation by not properly labeling and dating thickened liquids in one nourishment kitchenette and two resident unit refrigerators. Surveyors observed one opened thickened cranberry cocktail carton in the shared nourishment kitchenette with no opened date identified and stored in an upper cabinet without refrigeration, even though the manufacturer’s instructions stated it could be kept up to 7 days under refrigeration after opening. In the A wing nourishment refrigerator, one opened thickened dairy beverage was not dated, and the label instructed that it be refrigerated after opening and discarded within 3 days. In the B wing nourishment refrigerator, surveyors observed three opened thickened beverage cartons that were not dated, with manufacturer instructions stating they could be kept up to 7 days under refrigeration after opening. During interview, the Food Service Director stated kitchen staff were responsible for checking the kitchenette and nourishment refrigerators and that all items should be labeled with dates showing when they were received and opened. The FSD also stated it was his expectation that undated and out-of-date items would have been discarded and that the opened thickened liquids in the kitchenette should have been refrigerated after opening.
Unlicensed RN Assigned to Direct Resident Care
Penalty
Summary
The facility failed to ensure professional staff were licensed in accordance with State law when it assigned a nurse to direct resident care without an active RN license. Review of the employee file for Nurse #5 showed the nurse was hired on [DATE], but the RN license had expired on [DATE]. The printed license verification did not include the date the information was obtained, and the job description required a current Massachusetts RN license for the position. During interviews, the Administrator stated Nurse #5 came forward during the survey week to report she did not have an active nursing license, and said Human Resources was responsible for checking licenses before hire. The Director of Nurses stated Nurse #5 was a floor nurse assigned to a medication cart and had been providing direct resident care. The employee time sheet showed Nurse #5 worked multiple shifts as a floor nurse doing direct resident care after the license had expired. A representative from the Massachusetts Bureau of Health Professions Licensure confirmed the RN license had expired and had been expired since that date. The Assistant Director of Nurses stated Nurse #5 completed her shift on the first day of survey, left the facility, and then notified the facility that she did not have an active license.
Failure to Use Required Smoking Apron
Penalty
Summary
The facility failed to implement safe smoking strategies for one resident who smoked cigarettes and had a documented need to wear a smoking apron while smoking. The resident was admitted in May 2019, and the 2/9/26 MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The annual nursing assessment dated 3/8/26 stated the resident wished to smoke cigarettes and lacked adequate judgment toward the ability to smoke safely, with an intervention to wear a smoking apron. The care plan also indicated the resident needed to wear an apron while smoking if identified on the assessment. During observation on 3/18/26 at 4:10 P.M., the resident was seen outside smoking under supervision from the Housekeeping Supervisor without a smoking apron. The resident was observed smoking with a long ash on the cigarette, attempted to flick the ash, and then continued smoking as the ash fell off to the side. During interviews, the Housekeeping Supervisor stated none of the residents who smoked required safety devices such as aprons and said this resident did not need one. Later interviews showed the resident said staff had put a smoking apron on him/her the prior night and had done so previously, but not in a long time until that smoking time. The Unit Manager stated the resident should be wearing an apron while smoking and staff should assist with putting it on, and the DON stated smoking safety changes such as an apron are added to care plans and care cards, but there was no process for informing non-CNA and non-nursing staff of such changes.
Incorrect Enteral Feeding Formula Administered
Penalty
Summary
The facility failed to ensure that Resident #10 received the enteral feeding formula ordered by the physician and based on the resident’s nutritional assessment. Resident #10 was admitted in January 2026 with diagnoses including malignant neoplasm of the supraglottis and severe protein malnutrition, and the MDS dated 1/19/26 indicated the resident was cognitively intact and received 51% or more of nutrition through a G-tube. The physician’s order specified Jevity 1.5, 240 ml five times daily via G-tube. During observation, Nurse #3 prepared and administered Jevity 1.2 CAL, 240 ml, through the resident’s G-tube on 3/18/26 and again on 3/19/26. The nurse later reviewed the order and stated the resident had been prescribed Jevity 1.5 CAL but that only Jevity 1.2 CAL was available on the unit. The Unit Manager stated enteral formula is ordered to meet residents’ nutritional needs and that the Registered Dietitian needed to be notified to adjust the feeding because of the difference in formula. The Registered Dietitian stated Jevity 1.2 CAL was not clinically appropriate for Resident #10 and could have been problematic if continued.
Missing COVID-19 Vaccine Education and Offer Documentation for New Hires
Penalty
Summary
The facility failed to ensure that new hire employee records contained documentation showing staff were educated about and offered information on obtaining the 2025-2026 COVID-19 vaccination. Review of the facility policy titled COVID-19 Vaccine Requirements Residents and Staff indicated that employees are required to be up to date with the COVID-19 vaccine, that the facility educates staff about the vaccines, offers and administers the vaccines, and documents vaccination status according to state and federal guidelines. The policy also stated that personnel declining the vaccine must include a statement certifying they received information about the risks and benefits of the COVID-19 vaccine. Review of the personnel records showed that Food Service Director #3, hired on 1/5/26, did not have documentation indicating the new employee had been offered the most recent COVID-19 vaccination. Nurse #5, hired on 2/6/26, also did not have documentation indicating the new employee had been offered the most recent COVID-19 vaccination. During interviews, the Consultant Staff Development Coordinator stated there was no information in either employee file showing they were educated or offered the COVID-19 vaccination. The Infection Control Preventionist stated vaccines were reviewed with new employees during orientation and that she kept a spreadsheet to track whether staff were educated and whether they received or declined the vaccine, but Food Service Director #3 was listed without vaccine-offer status and Nurse #5 was not on the spreadsheet. She stated she had no information on either employee and could not explain why the vaccine information was not provided.
Failure to Complete SNF ABN for Two Residents
Penalty
Summary
The facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055) was completed and signed for two residents who were receiving skilled Medicare Part A services. For Resident #10, a Notice of Medicare Non-Coverage stated that the last covered day of skilled Medicare Part A services was 1/19/26, but the medical record did not show that the SNF ABN was completed and signed by the resident and/or resident representative. During an interview, the Social Worker Consultant and MDS Nurse reviewed the record and the Social Worker Consultant stated that Resident #10 was not given the ABN notice but should have been. For Resident #52, a Notice of Medicare Non-Coverage stated that the last covered day of skilled Medicare Part A services was 12/5/25, but the medical record did not show that the SNF ABN was completed and signed by the resident and/or resident representative. During an interview, the Social Worker Consultant reviewed the documentation and stated that Resident #52 was planning to stay for long-term care and was not given the ABN notice but should have been.
Inconsistent Dining Experience Across Facility Units
Penalty
Summary
The facility failed to provide a comfortable and homelike dining experience for residents in two of the three dining rooms observed. During multiple observations, surveyors noted that the A Unit and B Unit dining rooms lacked tablecloths or placemats, and residents were served meals directly from food trucks to their tables. The meals were left on heating elements, and residents ate directly off serving trays, with meal covers and trash stacked on the tables. In contrast, the Main Dining room was set with white tablecloths, cloth napkins, flower centerpieces, and proper dining utensils, providing a more homelike atmosphere. Throughout the survey, it was consistently observed that the A Unit and B Unit dining rooms did not offer the same level of dining experience as the Main Dining room. Residents in these units were served meals in a manner that did not promote a homelike environment, with plastic water glasses and coffee cups, and televisions tuned to various programs during meal times. Additionally, some residents were seated alone, with meals placed on overbed tables, further detracting from a communal and comfortable dining experience. The Administrator was informed of these observations and acknowledged that all residents should have the same homelike dining experience. However, the report does not mention any corrective actions or plans to address the deficiency, focusing solely on the observed discrepancies in dining conditions across different units within the facility.
Failure to Provide Audiology Services for Resident
Penalty
Summary
The facility failed to ensure audiology services were offered to Resident #76, who had severe cognitive impairment and was hard of hearing, resulting in a 98-day delay in services. The resident's hearing aids went missing on September 23, 2024, and were documented as missing for the majority of the following months. Despite this, the facility did not search for the hearing aids, notify management or the family, file a grievance, offer alternative hearing devices, or arrange an audiology appointment. Interviews with staff revealed a lack of communication and action regarding the missing hearing aids. Nurse #1 and Desk Nurse #1 were aware of the missing hearing aids but did not take appropriate steps to address the issue. The Social Worker and DON were not informed until the family reported the missing hearing aids on December 30, 2024. The Administrator acknowledged that staff failed to follow the process for missing items and that education was needed to prevent similar issues in the future.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to professional standards, as observed in two medication carts. On Unit A, a surveyor found unlabeled medication cups containing Eucerin cream and normal saline, along with loose pills and a powdery substance in the cart's drawers. Additionally, several eye drops and an inhaler were in use but lacked open or discard dates. Nurse #1 acknowledged these issues, noting that single-dose medications should not be stored in the cart without a resident's name and was unsure who was responsible for cleaning the cart. On Unit B, similar issues were observed, with multiple eye drops in use but not labeled with open dates. Nurse #3 confirmed that eye drops should be labeled upon opening due to their shortened expiration dates. Interviews with staff revealed that the 11:00 P.M. - 7:00 A.M. shift nurse is responsible for cleaning and maintaining the medication carts, and the Director of Nursing stated that no medications should be stored uncovered and not labeled. The DON also mentioned that expired medications should be removed, and carts should be cleaned and stocked nightly, with housekeeping responsible for monthly thorough cleaning.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, as observed during a survey. Cook #1 was seen handling ready-to-eat food with gloved hands, which were not changed between tasks, such as cooking pancakes and cracking raw eggs. This practice was contrary to the facility's policy and the FDA Food Code, which require hand hygiene and the use of utensils to prevent cross-contamination. The Food Service Manager acknowledged that Cook #1 should have used utensils instead of gloved hands and should have performed hand hygiene between tasks. Additionally, Cook #2 was observed wearing two pairs of gloves while plating lunch plates, which is against the facility's policy. Cook #2 removed one pair of gloves after leaving the tray line to obtain supplies and continued plating without performing hand hygiene. Furthermore, Cook #2 was seen drying his hands in the walk-in freezer after removing the second pair of gloves and before putting on a new pair. The Food Service Manager confirmed that Cook #2 should not have worn two pairs of gloves, should not have dried his hands in the walk-in freezer, and should have performed hand hygiene every time he changed gloves.
Failure to Document Dietary Recommendation Review
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was admitted with multiple diagnoses, including dementia, anxiety, depression, and a history of falls. The resident experienced significant weight loss over a period of time, and the dietitian recommended the use of Mirtazapine as an appetite stimulant. However, the medical record did not indicate that this recommendation was reviewed or addressed by the physician in a timely manner. The resident continued to refuse oral supplements, accepting only ice cream and Magic Cups, and the recommendation for Mirtazapine was not documented as reviewed until two months later. Interviews with facility staff revealed a lack of awareness and documentation regarding the dietary recommendation. Nurse #1 was unaware of the recommendation process, and Desk Nurse #1 was not informed of the pending recommendation for Mirtazapine. The NP initially did not want to add another medication due to recent changes and the resident's extensive psych history, but this decision was not documented. The Director of Nurses acknowledged the need for a better system to ensure timely review and documentation of recommendations. The facility's failure to document the review and decline of the dietary recommendation contributed to the deficiency.
Failure to Initiate Grievance Process for Missing Hearing Aids
Penalty
Summary
The facility failed to initiate the grievance process for a resident whose hearing aids were missing, resulting in a significant delay in addressing the issue. The resident, who was admitted with Alzheimer's dementia and severe cognitive impairment, was hard of hearing and relied on hearing aids. Despite the hearing aids being documented as missing for several months, the facility did not initiate an investigation or file a grievance until the resident's family reported the issue. The facility's policies required staff to respond promptly to concerns about missing items and to initiate an investigation to locate them. However, the staff did not follow these procedures, as evidenced by the lack of documentation in the progress notes and the absence of a grievance filing until much later. Interviews with staff revealed a lack of awareness and adherence to the formal process for handling missing items, contributing to the prolonged period during which the resident was without hearing aids. The deficiency was further highlighted by the fact that key personnel, including the Director of Nursing and the Administrator, were not informed of the missing hearing aids until the grievance was filed. This lack of communication and failure to follow established procedures resulted in a 98-day delay in providing alternative audiology services to the resident, impacting their ability to hear and communicate effectively.
Failure to Follow PICC Line Management Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC) line. The resident, admitted with osteomyelitis, a right great toe amputation, and peripheral neuropathy, had specific physician orders for the management of the PICC line. These orders included changing the transparent dressing weekly, measuring the external catheter length and arm circumference with each dressing change, and monitoring the site for signs of infection. However, the facility did not document these measurements or perform the dressing changes as ordered. Observations revealed that the dressing was not changed on the specified dates, and there was no documentation of the required measurements. Interviews with nursing staff and the Director of Nurses (DON) confirmed the discrepancies in the documentation and the failure to follow the physician's orders. Nurse #9 acknowledged that the dressing was not changed as recorded, and the DON confirmed the lack of documentation for the catheter length and arm circumference. The DON also noted that Nurse #8 incorrectly marked the dressing as changed when it was not. These failures indicate a lack of adherence to the facility's policy and the physician's orders, compromising the standard of care for the resident.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to ensure that post-fall interventions were developed and implemented to mitigate the risk of future falls for a resident, resulting in two falls over a three-month period. The resident, who was admitted with diagnoses including muscle weakness, gait abnormalities, and dementia, experienced a fall that resulted in a head strike and bruising. The facility's policy required individualized interventions based on fall risk assessments, but these were not adequately implemented or updated following the falls. The first fall occurred when the resident attempted to stand from a Broda chair, which was not reclined as it should have been. The incident report noted that the chair's position may have contributed to the fall, but no new interventions were added to the care plan or Kardex to prevent future falls. The second fall happened when the resident fell out of a wheelchair, again with the chair not reclined, leading to bruising on the forehead. Although a new intervention was identified to recline the wheelchair after meals, it was not consistently implemented, as observed by the surveyor. Interviews with facility staff revealed gaps in the incident reporting and care plan updating processes. The Director of Nurses acknowledged that the incident report for the first fall was incomplete and that the care plan was not updated as required. Despite the facility's policy to review falls in interdisciplinary team meetings, the incomplete report and lack of intervention were not identified or addressed, indicating a failure in the facility's fall management and prevention protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 60 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Yarmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mayflower Place Nursing & Rehabilitation Center | 4.1 mi | ★★★★★ | 8 | 0 |
| Regalcare At Harwich | 5.2 mi | ★★★★★ | 7 | 0 |
| Pavilion , The | 7.3 mi | ★★★★★ | 0 | 0 |
| Cape Regency Rehabilitation & Health Care Center | 8.4 mi | ★★★★★ | 0 | 0 |
| Cape Cod Post Acute Care | 10.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Windsor Nursing & Retirement Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.