A list of the most recent deficiencies for Villa at Windsor Park. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-18 | 2024-05-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-19 | 2024-02-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-19 | 2024-02-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-01-19 | 2024-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-19 | 2024-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-19 | 2024-02-06 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-19 | 2024-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-19 | 2024-02-06 | N |
| Ensure 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. | Health | 2024-01-19 | 2024-02-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-19 | 2024-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-19 | 2024-02-06 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-01-19 | 2024-02-06 | N |
| Dispose of garbage and refuse properly. | Health | 2024-01-19 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-19 | 2024-02-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-19 | 2024-02-06 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-01-19 | 2024-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-19 | 2024-02-06 | Y |
| Use approved construction type or materials. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-18 | 2024-02-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-21 | 2023-12-08 | Y |
| 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. | Health | 2023-11-21 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-21 | 2023-12-08 | Y |
| Ensure 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. | Health | 2023-11-21 | 2023-12-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-21 | 2023-12-08 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-10-06 | 2023-10-07 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-10-06 | 2023-10-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-25 | 2023-08-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-25 | 2023-08-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-25 | 2023-08-17 | Y |
| Keep all essential equipment working safely. | Health | 2023-07-25 | 2023-08-17 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-06-23 | 2023-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-02 | 2023-03-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-02 | 2023-03-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-02-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-23 | 2023-01-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-23 | 2023-01-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-13 | 2023-01-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-13 | 2023-01-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-13 | 2023-01-27 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-01-13 | 2023-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-13 | 2023-01-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-13 | 2023-01-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-13 | 2023-01-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-13 | 2023-01-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-01-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-13 | 2023-01-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-13 | 2023-01-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-13 | 2023-01-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-13 | 2023-01-27 | N |
| Ensure 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. | Health | 2023-01-13 | 2023-01-27 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-01-13 | 2023-01-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-13 | 2023-01-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-13 | 2023-01-27 | N |
| Dispose of garbage and refuse properly. | Health | 2023-01-13 | 2023-01-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-13 | 2023-01-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-13 | 2023-01-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-13 | 2023-01-27 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-13 | 2023-01-27 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-13 | 2023-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-18 | 2023-01-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-18 | 2023-01-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-18 | 2023-01-20 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-01-18 | 2023-01-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-18 | 2023-01-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-16 | 2022-11-20 | Y |
| Ensure 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. | Health | 2022-11-16 | 2022-11-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-11 | 2022-03-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-11 | 2022-03-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-11 | 2022-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-03-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-11 | 2022-03-31 | N |
| Ensure 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. | Health | 2022-03-11 | 2022-03-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-11 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-03-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-15 | 2022-03-31 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-10 | 2022-03-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-30 | 2021-10-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-30 | 2021-10-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-30 | 2021-10-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-30 | 2021-10-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-30 | 2021-10-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-30 | 2021-10-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-30 | 2021-10-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-30 | 2021-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-30 | 2021-10-21 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-09-30 | 2021-10-21 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-08-31 | 2021-09-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-31 | 2021-09-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-15 | 2021-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-15 | 2021-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-05 | 2021-03-19 | Y |
