Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Windsor Nursing & Retirement Home

SOUTH YARMOUTH, MA · 120 certified beds · Last Life Safety survey March 19, 2026

CMS Certification Number 225349 · first certified July 1989

Ownership

Operated by INTEGRITUS HEALTHCARE · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

7
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
3
Inspection & testing records
Of the citations on file

Position within MA

7 citations — more than 31% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 0 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens March 2027 — about 6 months from now. This facility’s last Life Safety survey was March 2026. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 7 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0584 Honor 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.

How that compares

Citations on file over three years

Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.

This facility7MA median11National median11
Citations on file over three years, compared
MeasureCitations
This facility7
Median facility in MA11
Median facility nationally11

Survey history

Citations at each Life Safety survey
32023-1042025-0102026-03
Citations at each Life Safety survey
Survey dateCitations
October 12, 20233
January 9, 20254
March 19, 20260

Most-cited tags

Most-cited tags at this facility
K-09182K-07121E-00311E-00411K-09111E-00251
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.22025-01-09
K-0712Have simulated fire drills held at unexpected times.12023-10-12
E-0031Provide emergency officials' contact information.12025-01-09
E-0041Implement emergency and standby power systems.12023-10-12
K-0911Meet requirements for the installation and maintenance of electrical systems.12025-01-09
E-0025Create arrangements with other facilities to receive patients.12025-01-09

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 3
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Miscellaneous Deficiencies 1
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies3
Gas, Vacuum, and Electrical Systems Deficiencies3
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 9, 2025 — 4 citations

Citations issued on January 9, 2025
TagWhat the surveyor checksStatus
E-0025Create arrangements with other facilities to receive patients.Deficient, Provider has date of correction (February 19, 2025)
E-0031Provide emergency officials' contact information.Deficient, Provider has date of correction (February 3, 2025)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (January 24, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (February 19, 2025)

October 12, 2023 — 3 citations

Citations issued on October 12, 2023
TagWhat the surveyor checksStatus
E-0041Implement emergency and standby power systems.Deficient, Provider has plan of correction (November 13, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has plan of correction (November 13, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has plan of correction (November 13, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.