Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa At Stamford, The during CMS and state inspections, most recent first.
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with Alzheimer's disease and severe cognitive impairment, who required maximum assistance with eating, had multiple instances of missing meal intake documentation over nearly a month. Despite facility policy and expectations for accurate recordkeeping, several breakfasts, lunches, and dinners were not recorded in the EMR, as confirmed by interviews with the dietician and DON.
A resident with a history of aggressive behaviors, including verbal and physical gestures, repeatedly directed negative actions toward another cognitively impaired resident. Despite staff awareness of these ongoing behaviors, care plans did not address the escalating conflict, resulting in a physical altercation where one resident struck the other. The lack of specific interventions and care plan updates contributed to the incident of resident-to-resident abuse.
A resident with hemiplegia/hemiparesis was involved in an abuse allegation where a family member reported a nursing assistant slapped the resident. The facility's investigation found no injuries and could not substantiate the claim. However, the social worker failed to document a follow-up visit with the resident, violating the facility's documentation policy.
The facility failed to follow dental orders for a resident needing a tooth extraction, resulting in multiple cancellations due to not discontinuing aspirin and lacking an Ativan order. Additionally, another resident with a surgical incision did not receive prescribed sulfadiazine cream treatment as ordered. Staff interviews revealed a breakdown in transcribing and administering physician orders, with the DNS acknowledging the failure to follow expected procedures.
A resident with COPD, dementia, and a psychotic disorder was found smoking in their room, but the responsible party was not notified until five days later. The facility's policy requires prompt notification of incidents, which was not followed in this case.
A resident with multiple mental health diagnoses did not receive a timely Level II PASRR screening after their short-term approval expired. The facility's social worker failed to submit the necessary screening, which was completed seven months late, despite the facility's policy requiring timely assessments for residents with short-term PASRR approvals.
The facility failed to update care plans for two residents after significant incidents. One resident, with a history of smoking, was found smoking in their room, but the care plan was not revised to include new interventions like a nicotine patch. Another resident, admitted for rehabilitation with a cervical fracture and an implanted loop recorder, did not have their care plan updated to include necessary interventions for the neck collar and surgical incision monitoring. Staff interviews revealed that care plans were not revised due to time constraints, despite facility policy requiring comprehensive care plans.
A resident with hemiplegia and other conditions did not have splints applied as per physician orders, leading to contracted limbs. Despite a care plan and orders for specific splints, observations showed they were not consistently used. Interviews with staff and the resident confirmed the inconsistency, and the facility's policy on orthotics was not followed, resulting in a deficiency in care.
A resident with a history of COPD and dementia was found smoking in their room, violating the facility's no-smoking policy. The resident accessed smoking materials brought by their spouse, highlighting lapses in supervision and documentation. Staff interviews revealed missing admission paperwork and incomplete incident reporting, contributing to the deficiency.
A facility failed to implement contact precautions for a resident with a multi-drug resistant organism (MDRO) infection, despite heavy wound drainage and treatment with intravenous antibiotics. The resident, who had lymphedema, sepsis, MRSA infection, and schizoaffective disorder, was only placed on enhanced barrier precautions (EBP). Staff interviews revealed a lack of communication and oversight in updating the resident's precautionary status, and a misunderstanding of the difference between EBP and contact precautions.
The facility did not complete annual performance evaluations for three nurse aides, as required by policy. Personnel files lacked documentation of 2023 evaluations. The DNS acknowledged the oversight, confirming it was her responsibility to ensure reviews on anniversary dates. Facility policy mandates annual written reviews by department supervisors, which were not conducted.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Incomplete Meal Intake Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for a resident with Alzheimer's disease and anxiety who was at risk for weight loss. The resident was identified as being severely cognitively impaired and required maximum assistance with eating. Review of the resident's care plan directed staff to feed the resident meals. However, meal intake documentation was missing for multiple breakfasts, lunches, and dinners over a period of nearly one month. Specifically, several dates were identified where meal intakes were not recorded in the electronic medical record. Interviews with the dietician and the DON confirmed that it was the expectation for staff to document meal intakes accurately after each meal, and that the facility's policy required records to be accurate and based on resident information. The DON was unable to provide an explanation for the missing documentation. The deficiency was identified through clinical record review, facility documentation review, policy review, and staff interviews.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with a history of behavioral issues, including verbal and physical aggression, was not adequately protected from physical abuse by another resident. The resident, who had diagnoses such as impulse disorder, intellectual disabilities, schizophrenia, and delusional disorder, frequently directed negative comments, gestures, and spitting toward another resident with severe cognitive impairment. Multiple staff members, including LPNs, a social worker, and a psychiatric APRN, confirmed that the resident regularly expressed dislike and made threatening gestures toward the other resident, who typically did not react to these provocations. On the day of the incident, staff heard yelling in the hallway and observed both residents with raised arms. An LPN witnessed the cognitively impaired resident strike the resident with behavioral issues on the cheek after the latter had reportedly hit the former first. The resident who was struck exhibited distress, repeatedly hitting their own cheek and stating they had been hit. Documentation and interviews confirmed that the resident with behavioral issues admitted to hitting the other resident first because of personal dislike. Prior to this incident, the care plans for both residents did not specifically address the ongoing negative interactions and behaviors between them. Although staff were aware of the frequent verbal and non-verbal aggression, interventions to keep the residents separated or to address the specific conflict were not implemented in the care plans until after the physical altercation occurred. The lack of targeted interventions and failure to update care plans contributed to the occurrence of resident-to-resident physical abuse.
Incomplete Documentation Following Abuse Allegation
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate following an allegation of abuse. The resident, who was admitted with hemiplegia/hemiparesis after a cerebral infarction, was reported by family to have been slapped by a nursing assistant. An assessment was conducted with no injuries noted, and the facility's investigation could not substantiate the allegation. However, the clinical record did not include documentation of a follow-up visit by social services after the incident. The social worker admitted to seeing the resident for a follow-up support visit but failed to document the encounter, stating she forgot to write a note. The Director of Nursing Services confirmed that the social worker should have documented the visit. The facility's Charting and Documentation Policy requires all observations and services performed to be documented in the resident's clinical record, which was not adhered to in this case.
Failure to Follow Dental and Medical Orders
Penalty
Summary
The facility failed to follow dental orders for a resident requiring a tooth extraction. The resident, who had a history of dysphagia and other conditions, was scheduled for a tooth extraction to facilitate the fitting of dentures. However, the facility did not discontinue the resident's aspirin as ordered by the dentist, nor did they have an order in place for Ativan to manage the resident's anxiety prior to the procedure. This oversight led to multiple cancellations of the dental procedure, delaying the resident's dental care and denture fitting. Another deficiency involved a resident with a surgical incision who required treatment with 1 percent sulfadiazine cream. The physician's order specified that the cream should be applied twice daily to the resident's left chest. However, the treatment administration record did not reflect that the cream was administered as ordered, indicating a failure to follow the physician's directive. This lapse in care was identified during a review of the treatment records and confirmed through staff interviews. Interviews with facility staff, including LPNs and the DNS, revealed that there was a breakdown in the process of transcribing and administering physician orders. The DNS acknowledged that the orders were not followed as expected, and the facility's policies required that all medications be administered according to written orders from licensed prescribers. These deficiencies highlight a failure in the facility's processes to ensure that residents receive the prescribed care and treatment.
Failure to Notify Responsible Party of Smoking Incident
Penalty
Summary
The facility failed to notify the responsible party of a resident who was found smoking in their room, which is a violation of the facility's policy on reporting incidents. The resident, who has diagnoses including chronic obstructive pulmonary disease, dementia, and a psychotic disorder with delusions, was found smoking in their room with their spouse present. The nursing note documented that the resident was educated on the smoking policy, a room search was conducted, and a new order for a Nicotine patch was obtained. However, the reportable event report did not indicate that the resident's responsible party was notified of the incident. Interviews revealed that the responsible party was not informed of the incident until five days later, via an email from a social worker. The Director of Nursing Services (DNS) acknowledged that the responsible party should have been notified at the time of the incident and that the reportable event report was not completed until two days after the incident due to her being busy. The facility's policy requires that all incidents be promptly investigated and reported, with the family being notified and the date/time of notification documented on the reportable event form.
Failure to Complete Timely PASRR Screening for Resident
Penalty
Summary
The facility failed to complete a necessary Preadmission Screening and Resident Review (PASRR) for a resident with multiple mental health diagnoses, including paranoid personality disorder, delusional disorder, post-traumatic stress disorder, and major depressive disorder. The resident, who had intact cognition and was dependent on a wheelchair for mobility and all activities of daily living, was initially given a short-term approval without specialized services, which required a follow-up Level II screening. However, this screening was not completed until seven months after the short-term approval had expired. The deficiency was identified during a review of the resident's clinical records and interviews with facility staff. The social worker responsible for the PASRR process acknowledged that she should have submitted the resident for a Level II screening following the expiration of the short-term approval. The facility's policy required the social worker to complete a new level screen and level of care assessment if a resident was admitted with a short-term or time-sensitive PASRR. Despite this policy, the necessary screening was delayed, resulting in a failure to comply with the required procedures for residents with mental health needs.
Failure to Update Care Plans for Residents After Incidents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents following significant incidents. Resident #23, diagnosed with chronic obstructive pulmonary disease, dementia, and a psychotic disorder, was found smoking in their room, which violated the facility's smoking policy. Despite the incident, the care plan was not updated to reflect the new interventions, such as the use of a nicotine patch, to address the unauthorized smoking behavior. Interviews with staff, including the Director of Nursing and a Social Worker, revealed that the care plan had not been revised due to time constraints, despite the facility's policy requiring an interdisciplinary team to develop individualized care plans. Resident #45, admitted for short-term rehabilitation following a cervical vertebrae fracture, required the use of an Aspen neck collar and had an implanted loop recorder. The care plan failed to include necessary interventions for the use of the neck collar and the monitoring of the surgical incision related to the loop recorder. Nursing notes did not reflect monitoring for signs of infection at the incision site. Interviews with an LPN and the Director of Nursing Services indicated that the care plan should have addressed these needs, but it was not updated to include the physician's instructions for care and monitoring. The facility's policy mandates that the interdisciplinary team is responsible for creating comprehensive care plans for each resident. However, in both cases, the care plans were not updated to reflect the residents' current needs and interventions following significant incidents, highlighting a deficiency in the facility's care planning process.
Failure to Apply Splints as Ordered for Resident
Penalty
Summary
The facility failed to ensure that a resident, who had specific physician orders for splint use, had the splints in place daily as required. The resident, diagnosed with hemiplegia, hemiparesis, legal blindness, rheumatoid arthritis, and vascular dementia, was observed multiple times without the necessary splints on their upper extremities. Despite the care plan and physician's orders specifying the use of various splints, including a left elbow splint, right resting hand splint, and left-hand carrot splint, these were not consistently applied during morning care. Interviews with the resident revealed that the splints had not been placed for some time, and the resident had not refused their use. Observations confirmed the absence of splints on several occasions, and staff interviews indicated a lack of consistent application of the splints. Nursing staff and nursing assistants were both responsible for ensuring the splints were applied, yet there was a failure to do so, as evidenced by the resident's contracted limbs and the absence of splints during observations. The facility's policy on the use of orthotics for contracture management was not adhered to, as splints were not applied according to the individualized wearing schedule. The policy required splints to be removed every two hours for skin inspection and reapplication, but this was not consistently followed. The therapy director and other staff interviews highlighted a lack of adherence to the care plan and physician's orders, contributing to the deficiency in care for the resident.
Inadequate Supervision Leads to Resident Smoking Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from smoking in their room, which posed a significant safety hazard. The resident, who had a history of chronic obstructive pulmonary disease, dementia, and a psychotic disorder, was found smoking in their room despite the facility's no-smoking policy. The resident's care plan indicated they required supervision for personal care, but the incident revealed a lapse in monitoring. The resident's spouse had brought smoking materials, which the resident accessed, leading to the incident. Interviews with staff highlighted several procedural lapses. The Nursing Supervisor noted the incident but did not complete the Accident and Incident report promptly. The Director of Nursing acknowledged that the resident should have been treated as a new admission due to their extended absence from the facility, which would have required updated admission paperwork, including acknowledgment of the no-smoking policy. However, the necessary documentation was missing, and the care plan was not updated following the incident. The facility's policies on reportable events and smoking were not adequately enforced. The Admissions Director could not locate the signed no-smoking agreement for the resident, and the Social Worker failed to document discussions with the resident and their spouse about the dangers of smoking. The facility's failure to implement and document preventive measures and update care plans contributed to the deficiency, as did the lack of a timely investigation into the incident.
Failure to Implement Contact Precautions for Resident with MDRO
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident actively infected with a multi-drug resistant organism (MDRO). The resident, identified as having lymphedema, sepsis, Methicillin Resistant Staphylococcus Aureus (MRSA) infection, and schizoaffective disorder, was not placed on contact precautions despite having a wound with heavy drainage. The resident's care plan included enhanced barrier precautions (EBP) due to a lower extremity wound, but the facility did not update the precautions to contact precautions as recommended by the Centers for Disease Control and Prevention (CDC) for residents with active infections and uncontained drainage. The resident's clinical records showed a wound culture with heavy growth of pseudomonas aeruginosa and moderate growth of MRSA, and the resident was treated with intravenous antibiotics. Despite this, the facility's infection control tracking sheet and physician's orders for April 2024 only indicated EBP, not contact precautions. Interviews with staff, including the Infection Preventionist and Director of Nursing Services, revealed a lack of communication and oversight in updating the resident's precautionary status, even though the resident exhibited behaviors such as refusing dressing changes and having copious wound drainage. The facility's policies on multidrug-resistant organisms and contact precautions were not followed, as the resident's condition warranted contact precautions due to the inability to contain wound drainage and the resident's non-compliance with care. Staff interviews confirmed that the resident was never placed on contact precautions, and there was a misunderstanding among staff regarding the difference between EBP and contact precautions. This oversight in implementing the correct precautions contributed to the deficiency identified by the surveyors.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three nurse aides, as required by their policy. The personnel files of the nurse aides, hired on various dates, did not contain documentation of a performance evaluation for the year 2023. During an interview, the Director of Nursing Services (DNS) acknowledged the oversight and confirmed that it was her responsibility to ensure that annual performance reviews were conducted on each employee's anniversary date. The facility's policy mandates that all employees undergo a written annual review by their department supervisor on their anniversary date, which was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Stamford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Civita Care Center At Long Ridge | 3.2 mi | ★★★★★ | 1 | 0 |
| Waveny Care Center | 3.6 mi | ★★★★★ | 12 | 0 |
| Edgehill Health Center | 5.5 mi | ★★★★★ | 2 | 0 |
| Stamford Care Center | 6 mi | ★★★★★ | 18 | 0 |
| Nathaniel Witherell, The | 6.4 mi | ★★★★★ | 3 | 0 |
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