Villa at Windsor Park Chicago: COVID-19 Summary

The Illinois Department of Public Health conducts yearly recertification procedures in which nursing homes are subjected to a review of their regulatory history and any violations occurring at the home. Furthermore, during the recertification process, when a nursing home has been found to have committed a regulatory violation, the facility is subsequently required to submit a plan of correction for how it will remedy the violation or prevent similar violations from occurring in the future.

The 2016 recertification survey conducted on February 4, 2016, found Villa at Windsor Park failed to provide residents, who depend on staff assistance, with oral care and cleaning nails, affecting five residents who are noted as needing assistance with activities with daily living, specifically with grooming and hygiene. The record provides that this failure resulted in these specific residents having long fingernails with a brownish substance caked underneath their nails; another resident was observed while in bed as having dry brownish debris on her lips along with food debris between her teeth. Moreover, the facility was found to have failed to ensure food and beverages served to residents were flavorful, attractive, and served at palatable temperatures to ensure resident’s satisfaction.

Lastly, and most importantly in the scope of the current COVID-19 pandemic, Villa at Windsor Park was found to have failed to: (1) follow standard kitchen sanitation and food handling practices; (2) store, prepare, and serve food under sanitary conditions; (3) date all canned foods; (4) document the holding temperatures at all three meals; (5) date and label open food; and (6) discard expired foods. The survey concludes these failures have the potential to cause food borne illness for all 179 residents receiving oral diets in the facility. The facility’s inability to follow sanitation requirements is especially concerning in the context of the COVID-19 pandemic as these sorts of failures are of the exact nature that will cause the disease to be rapidly transmitted throughout the facility.

The 2017 recertification survey, conducted on January 20, 2017, found Villa at Windsor Park failed to provide finger and toenail care for four residents, all of whom had been noted as needing increased assistance with activities of daily living. A similar finding was documented in the previous recertification survey for 2016, thus the repeated failure demonstrates the facility’s inability to implement and effectively follow its plan of correction. Furthermore, just as was the case in the 2016 recertification survey, the 2017 recertification survey cites Villa at Windsor Park as having failed to maintain proper food temperature when serving meals to residents.

This theme of repeated failures from 2016 to 2017 continues as the 2017 recertification survey provides the facility again failed to properly sanitize kitchen utensils and equipment, and further failed to provide clean mattresses for residents. The fact that many of these same failures have occurred for a second year in a row raises serious concerns about whether Villa at Windsor Park is able to effectively combat the outbreak of a deadly virus, as the facility clearly failed to implement its plan of correction and further remedy issues regarding sanitation which are so vital and relevant in the midst of the current pandemic.

The 2018 recertification survey, conducted on March 2, 2018, found Villa at Windsor Park failed to administer medications as ordered by physicians to prevent a medication error rate greater than 5%, the record found that out of the 27 opportunities for medication error the rate was at 11.11%, well above the preferred 5% rate. Moreover, the facility was found to have failed to accurately label medication to facilitate safe administration of medications to residents, resulting in one resident using the wrong eye drops and suffering further medical complications.

Finally, the 2018 recertification survey found Villa at Windsor again failed in its capacity to provide residents a safe and sanitary environment. Specifically, the facility failed to sterilize the top of certain medication bottle before insertion of a needle, and further staff members failed to wash their hands after removal of gloves. Once more, there is evidence of the facility failing to implement its plan of correction an effectively remedy its previous failures regarding sanitation and hygiene, both of which are especially relevant during the current COVID-19 pandemic.

The 2019 recertification survey, conducted on April 10, 2019, found Villa at Windsor Park failed to meet professional standards of quality for the administration of medications with a physician order for multiple residents, noting a nurse who did not perform the requisite hand hygiene before preparing a resident’s medications. The facility was also found to have failed in to ensure that three containers of expired medications were appropriately disposed and failed to ensure certain medications were available for residents who needed those particular kinds of medications.

Additionally, the recertification survey explains Villa at Windsor Park failed to ensure that staff members wore hair nets and beard coverings, and further failed to adequately check the facility dishwasher for sanitizing solution to decrease the potential risk of food borne illness. This failure was further noted to have the potential to affect all 196 residents living in the facility receiving oral care. The 2016 recertification survey documented a nearly identical failure on the part of Villa at Windsor Park, and is yet another example of the facility’s inability to effectively implement and follow its plan of correction. Lastly, the facility was found to have failed to follow the current standard of infection control practices during and following the provision of care for residents. Specifically, care involving infection control hand hygiene and use of respiratory equipment care were documented as complete failures. This finding is once again immensely concerning within the COVID-19 pandemic as these failures demonstrate the facility’s inability to prevent and combat infections and has repeatedly failed to adequately address the issues regarding hand hygiene and sanitation.

The 2020 recertification survey, conducted on February 7, 2020, found Villa at Windsor Park failed to follow their Abuse Policy, and failed to monitor and implement appropriate interventions to keep residents safe from abuse detailing an altercation that occurred between two residents and the staff’s failure to prevent the altercation. The survey also found the facility failed to provide the necessary additional services for blind residents as to attain or maintain the highest practical level of well-being for those residents. Moreover, just as the previous recertification surveys provided, the 2020 recertification survey found Villa at Windsor Park to have failed to follow their Storage and Expiration of Medications policy, not adequately disposing of expired medications or storing them in the appropriate manner. Yet another example of the facility’s inability to implement and follow its plan of correction as the same failures continue to occur.

However, this was not the only repeat failure found in a previous recertification survey, the 2020 recertification survey further found Villa at Windsor Park to have failed in properly labeling and dating food items as well as serving insufficient and unsatisfactory meals to residents. While this recertification survey was completed just a month prior to the climax of the COVID-19 outbreak, there is evidence of the facility’s inability to adequately combat the virus outbreak as it was found to have already failed to follow their Respiratory Therapy-Prevention of infection policy. Such a policy is the exactly the kind that will be most tested throughout the COVId-19 pandemic and the facility’s inability to follow the policy before the outbreak even began is extremely alarming.

Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, Villa at Windsor Park operated with insufficient staff and with a lack of adherence to recognized infection control protocols.  It is not surprising that they were ill equipped to handle this outbreak.”