Map showing the location of WINDSOR NURSING & RETIREMENT HOME in SOUTH YARMOUTH, Massachusetts
265 N MAIN ST, SOUTH YARMOUTH, MA, 02664

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • MassachusettsLowest tier among peers338 rated homes · average 3.0★
  • Barnstable CountyLowest tier among peers15 rated homes · average 2.5★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.9 vs MA avg
  • StaffingCan add or remove a star3★+0.1 vs MA avg
  • Quality measuresCan add or remove a star1★−2.3 vs MA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 18% of peersMA avg2.9★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 39% of peersMA avg2.9★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersMA avg3.3★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.93hrsAbove 70% of peersMA avg3.86Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.61hrsAbove 53% of peersMA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better49%Above only 23% of peersMA avg39%RN turnover47%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$15,636Above only 37% of peersMA avg$39,993Fines · denials2 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
42citations
5inspection dates
2actual harm (G–I)
0immediate jeopardy (J–L)
Jan 9, 2025most recent

Citations by monthApr 2021 – Jan 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jan 9, 20258 citationsCycle 1worst E · no actual harm
  1. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareE · patternCorrected Feb 19, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 19, 2025
  3. F761Ensure 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.Pharmacy ServiceE · patternCorrected Feb 19, 2025
  4. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 19, 2025
  5. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Feb 19, 2025
  6. F585Honor 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.Resident RightsD · isolatedCorrected Feb 19, 2025
  7. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Feb 19, 2025
  8. F584Honor 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.Resident RightsE · patternCorrected Feb 19, 2025
Oct 12, 202310 citationsCycle 2worst G · actual harm$12,386
  1. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Nov 22, 2023
  2. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Nov 22, 2023
  3. 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.Resident RightsB · patternCorrected Nov 22, 2023
  4. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Nov 22, 2023
  5. F585Honor 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.Resident RightsE · patternCorrected Nov 22, 2023
  6. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsB · patternCorrected Nov 22, 2023
  7. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Nov 22, 2023
  8. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareE · patternCorrected Nov 22, 2023
  9. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Nov 22, 2023
  10. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Nov 22, 2023
Jun 1, 20231 citationCycle 3worst D · no actual harm
  1. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 30, 2023
Mar 13, 20232 citationsCycle 3worst F · no actual harm$3,250
  1. F886Perform COVID19 testing on residents and staff.Infection ControlF · widespreadCorrected Mar 22, 2023
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 22, 2023
Apr 14, 202121 citationsCycle 3worst G · actual harm
  1. F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected Jun 1, 2021
  2. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jun 15, 2021
  3. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Jun 15, 2021
  4. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsF · widespreadCorrected Jun 1, 2021
  5. F585Honor 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.Resident RightsE · patternCorrected Jun 1, 2021
  6. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 1, 2021
  7. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 1, 2021
  8. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 1, 2021
  9. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jun 1, 2021
  10. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jun 1, 2021
  11. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningG · isolatedCorrected Jun 1, 2021
  12. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Jun 1, 2021
  13. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jun 1, 2021
  14. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 1, 2021
  15. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 1, 2021
  16. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jun 1, 2021
  17. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Jun 1, 2021
  18. F761Ensure 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.Pharmacy ServiceE · patternCorrected Jun 1, 2021
  19. F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationD · isolatedCorrected Jun 1, 2021
  20. F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationF · widespreadCorrected Jun 11, 2021
  21. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jun 1, 2021

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.93hrsAbove 70% of peers+0.07 vs MA avg
  • Registered nursesRN hours only0.61hrsAbove 53% of peers−0.04 vs MA avg
  • Licensed practical nursesLPN hours0.88hrs
  • Nurse aidesCNA hours2.44hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.41hrs
  • Massachusetts average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better49%Above only 23% of peersMA avg 39%
  • RN turnoverRegistered nurses only47%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy120 certified beds · ~88 residents a day73%Above only 23% of peersMA avg 81%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $15,636In fines
  • 2Fines
  • 0Payment denials
  • $39,993MA avg in fines
Above only 37% of peersFewer fines than 37% of rated homes in Massachusetts

Actions on record

  1. Oct 12, 2023Civil money penalty$12,386
  2. Mar 13, 2023Civil money penalty$3,250

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Integritus Healthcare15 facilities in the chain2.7★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Fairview Extended Care Services INC
Indirect owners (5%+)
  • Integritus Healthcare INC
Operational or managerial control
  • Integritus Healthcare INC
  • Integritus Healthcare Management Services INC
Corporate officers
  • Marcie Jo Gingras
  • William Jones
Managing employees
  • Scott Brewer

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 225349 · 265 N MAIN ST, SOUTH YARMOUTH, MA, 02664.
  • Percentiles compare this facility with every rated nursing home in Massachusetts and Barnstable County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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