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Windsor Nursing & Retirement Home

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About Windsor Nursing & Retirement Home

General Information

Legal Business NameSouth Yarmouth Management Systems Inc
Ownership TypeNon Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 1, 1989 (27 years)
Capacity120
Residents105
Percent Occupied88%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Windsor Nursing & Retirement Home

Windsor Nursing & Retirement Home
was reviewed by Medicare to have a rating of 3 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Massachusetts Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

October 26, 2015 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
CManyPotential for Minimal HarmFire Safety InspectionExits that are accessible at all times.
CManyPotential for Minimal HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
CManyPotential for Minimal HarmFire Safety InspectionExit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
BSomePotential for Minimal HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.

October 20, 2015 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionGive or get x-rays and other tests in a timely manner to meet the needs of residents.
DFewPotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionLet residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.

December 12, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.

November 20, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.

April 28, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,365 fine
GFewActual HarmComplaintProvide care by qualified persons according to each resident's written plan of care.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Windsor Nursing & Retirement Home require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 5min
2hr 20min
ReportedExpected
CNA
50min
40min
ReportedExpected
LPN
45min
1hr 5min
ReportedExpected
RN
3hr 40min
4hr
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
97.1%
97.1%
96.7%
Q1 2015Q2 2015Q3 2015MA
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
100.0%
100.0%
94.3%
Q1 2015Q2 2015Q3 2015MA
Assessed and Appropriately Given the Pneumococcal Vaccine
48.9%
47.8%
45.2%
52.5%
Q1 2015Q2 2015Q3 2015MA
Low Risk Residents Who Lose Control of Their Bowel or Bladder
27.7%
23.4%
22.2%
19.3%
Q1 2015Q2 2015Q3 2015MA
Received an Antipsychotic Medication
16.2%
23.9%
12.1%
15.0%
Q1 2015Q2 2015Q3 2015MA
Need for Help with ADLs has Increased
8.3%
8.2%
11.0%
5.7%
Q1 2015Q2 2015Q3 2015MA
Self Report Moderate to Severe Pain
5.3%
7.8%
7.1%
6.7%
Q1 2015Q2 2015Q3 2015MA
Lose Too Much Weight
6.8%
6.6%
9.1%
4.8%
Q1 2015Q2 2015Q3 2015MA
High Risk Residents With Pressure Ulcers
6.4%
11.6%
6.0%
3.5%
Q1 2015Q2 2015Q3 2015MA
Have Depressive Symptoms
14.6%
8.9%
4.7%
4.6%
Q1 2015Q2 2015Q3 2015MA
With a Urinary Tract Infection
0.0%
0.0%
1.1%
3.0%
Q1 2015Q2 2015Q3 2015MA
Experiencing One or More Falls with Major Injury
0.0%
0.0%
0.0%
2.6%
Q1 2015Q2 2015Q3 2015MA
With a Catheter Inserted and Left in Their Bladder
2.1%
1.1%
1.1%
1.2%
Q1 2015Q2 2015Q3 2015MA
Were Physically Restrained

Quality Measures for Short Stay Residents

100.0%
98.5%
96.2%
82.4%
Q1 2015Q2 2015Q3 2015MA
Assessed and Appropriately Given the Pneumococcal Vaccine
95.0%
87.7%
87.7%
85.2%
Q1 2015Q2 2015Q3 2015MA
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
23.5%
14.0%
13.6%
17.5%
Q1 2015Q2 2015Q3 2015MA
Self Report Moderate to Severe Pain
4.2%
2.4%
2.2%
1.7%
Q1 2015Q2 2015Q3 2015MA
Newly Received an Antipsychotic Medication
1.2%
0.0%
1.4%
1.2%
Q1 2015Q2 2015Q3 2015MA
With Pressure Ulcers That Are New or Worsened