Deficiency Records for Villa at Windsor Park
Updated as of January 01, 2022
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? |
|---|---|---|---|---|
| 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 | 2021-06-11 | 2021-07-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-11 | 2021-07-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-11 | 2021-07-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-11 | 2021-07-05 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-11 | 2021-07-05 | 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 | 2021-06-11 | 2021-07-05 | 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 | 2021-06-11 | 2021-07-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-11 | 2021-07-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-11 | 2021-07-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-11 | 2021-07-05 | N |
| 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 necessary and PRN use is limited. | Health | 2021-06-11 | 2021-07-05 | 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 | 2021-06-11 | 2021-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-11 | 2021-07-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-11 | 2021-07-05 | 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 | 2021-06-17 | 2021-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-17 | 2021-07-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-17 | 2021-06-28 | 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 | 2021-06-17 | 2021-06-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-17 | 2021-06-22 | N |
| Have an externally vented heating system. | Fire Safety | 2021-06-17 | 2021-06-22 | N |
| 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-02-22 | 2021-03-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-04 | 2020-08-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-16 | 2020-07-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-13 | 2020-03-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-07 | 2020-02-28 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-07 | 2020-02-28 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2020-02-07 | 2020-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-07 | 2020-02-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-07 | 2020-02-28 | 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 | 2020-02-07 | 2020-02-28 | 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 | 2020-02-07 | 2020-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-07 | 2020-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-07 | 2020-02-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-02-07 | 2020-02-28 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-02-13 | 2020-02-28 | 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 | 2020-02-13 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-04 | 2019-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-28 | 2019-07-19 | 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 | 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 an enclosure around a vertical opening shaft. | 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 |
