Deficiency Records for Villa at Windsor Park
Updated as of June 01, 2019
This is not the most recent data for Villa at Windsor Park. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 | 2019-04-11 | 2019-05-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-11 | 2019-05-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-11 | 2019-05-02 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-04-11 | 2019-05-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2019-04-11 | 2019-04-30 | 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 | 2019-04-11 | 2019-04-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-11 | 2019-04-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-10 | 2019-04-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-10 | 2019-04-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-10 | 2019-04-25 | 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 | 2019-04-10 | 2019-04-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-04-10 | 2019-04-25 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-04-10 | 2019-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-10 | 2019-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-10 | 2019-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-05 | 2019-03-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-12-18 | 2019-01-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-28 | 2018-03-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-28 | 2018-03-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-02-28 | 2018-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-28 | 2018-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-28 | 2018-03-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-02 | 2018-03-14 | 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 | 2018-03-02 | 2018-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-02 | 2018-03-14 | 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 | 2018-02-28 | 2018-03-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-02-28 | 2018-03-01 | 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 | 2018-02-28 | 2018-03-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-02-28 | 2018-02-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-28 | 2018-02-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2017-12-22 | 2018-01-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-22 | 2018-01-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2017-12-22 | 2018-01-09 | Y |
| Implement 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 ne | Health | 2017-12-22 | 2018-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-04 | 2017-05-16 | Y |
| Provide timely notification to the resident before transfer or discharge. | Health | 2017-03-30 | 2017-04-19 | Y |
| Tell 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. | Health | 2017-03-30 | 2017-04-19 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-03-30 | 2017-04-19 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-30 | 2017-04-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-01-19 | 2017-03-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-01-19 | 2017-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-01-19 | 2017-02-20 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-02-02 | 2017-02-17 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-02-02 | 2017-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-02-02 | 2017-02-17 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-02-02 | 2017-02-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-19 | 2017-02-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-01-19 | 2017-02-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-01-19 | 2017-02-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-01-19 | 2017-02-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-01-19 | 2017-02-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-01-19 | 2017-02-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-01-19 | 2017-02-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-01-19 | 2017-02-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-01-19 | 2017-02-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-01-19 | 2017-02-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-01-19 | 2017-02-05 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-01-20 | 2017-02-03 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-01-20 | 2017-02-03 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-20 | 2017-02-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-01-20 | 2017-02-03 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2017-01-20 | 2017-02-03 | N |
| Upon the death of a resident, convey the resident?s personal funds and an accounting of those funds to the appropriate party. | Health | 2017-01-20 | 2017-02-03 | Y |
| 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 | 2017-01-19 | 2017-01-29 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-12 | 2017-01-24 | Y |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-01-19 | 2017-01-20 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-08-23 | 2016-09-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-08-23 | 2016-09-02 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-08-23 | 2016-09-02 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-06-15 | 2016-06-20 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-06-15 | 2016-06-20 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-06-15 | 2016-06-20 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-06-15 | 2016-06-20 | Y |
