The most recent inspection on August 27, 2025, found no deficiencies during a desk audit verifying compliance. Earlier inspections showed a pattern of some deficiencies primarily related to medical record documentation, resident safety, and infection control practices, with several issues corrected in follow-up reviews. Complaint investigations were mostly unsubstantiated, though a few substantiated cases involved verbal abuse and lapses in resident care, including one substantiated abuse incident in 2019 that led to staff termination. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections indicating compliance and resolution of prior deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Connecticut average
Connecticut average: 5.6 deficiencies/year
Deficiencies per year
86420
2019
2020
2021
2022
2024
2025
Census
Latest occupancy rate93% occupied
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The inspection visit was conducted as a desk audit and onsite review to monitor the implementation of the Plan of Correction for previously cited violations dated 08/15/2024.
Findings
All previously identified violations numbered 1a, 2a, 3a, 3b, 4a, 4b, 5a, 6a, 7a, 8a, 9a, and 9b were found to be corrected as of 10/17/2024. The administrator was notified by telephone that all violations were corrected.
Report Facts
Violations corrected: 12
Employees Mentioned
Name
Title
Context
Peter Showstead
Administrator
Notified by telephone on 10/17/24 at 10:30 AM that all violations were corrected
Inspection Report Plan of CorrectionDeficiencies: 1Oct 1, 2024
Visit Reason
An unannounced visit was made to Villa At Stamford by the Facility Licensing and Investigations Section of the Connecticut Department of Public Health for the purpose of conducting an investigation related to a complaint.
Findings
The investigation found a violation related to incomplete and inaccurate medical record documentation following an allegation of abuse involving Resident #1. The facility failed to document social worker follow-up notes after the allegation, and the accused staff member denied the allegation with no witnesses or injuries noted.
Complaint Details
Complaint CT #40889. The allegation involved a nursing assistant slapping Resident #1 on the back on 9/4/2024. The facility was unable to substantiate the allegation after investigation and family notification.
Deficiencies (1)
Description
Failure to ensure the medical record was complete and accurate, including documentation of social worker visits following an allegation of abuse for Resident #1.
Report Facts
Residents reviewed for abuse: 3Date of incident: Sep 4, 2024Date of facility incident report: Sep 6, 2024Date of facility summary: Sep 11, 2024Date of social worker follow-up visit: Sep 10, 2023Audit frequency: 1Audit duration: 12
Employees Mentioned
Name
Title
Context
Maureen Golas-Markure
Supervising Nurse Consultant
Signed letter as Supervising Nurse Consultant from Facility Licensing and Investigations Section.
Peter Showstead
Administrator
Named as facility administrator in relation to the plan of correction.
Social Worker #1
Interviewed regarding failure to document follow-up visit notes after abuse allegation.
DNS
Director of Nursing Services interviewed regarding social worker documentation.
The inspection was conducted as a licensing renewal inspection for the facility.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as indicated by the attached violation letter.
Report Facts
Licensed Bed Capacity: 128Census: 113
Employees Mentioned
Name
Title
Context
Peter Shon Hwang
Administrator
Personnel contacted during inspection on 7/30/24 at 1:30 PM
Inspection Report Plan of CorrectionCensus: 125Capacity: 128Deficiencies: 1Apr 12, 2024
Visit Reason
A desk audit was conducted to review the implementation of the plan of correction for a prior violation letter dated 2024-01-31.
Findings
The desk audit found that Violation #1 and corresponding violations were corrected as of 2024-03-13. The DNS was notified by telephone on 2024-04-12 that all violations were corrected.
Deficiencies (1)
Description
Violation #1 and corresponding violations
Report Facts
Licensed Bed Capacity: 128Census: 125
Employees Mentioned
Name
Title
Context
Lynn Lyon
DNA
Personnel contacted during inspection on 2024-04-12
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #00032862.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. A narrative report and additional information were attached.
Complaint Details
Complaint Investigation #00032862 was the reason for the visit. Violations were not identified at the time of inspection.
The visit was a desk audit conducted on 04/22/2022 and 04/27/2022 for the purpose of reviewing the Plan of Correction (POC) for the violation letter dated 03/09/2022.
Findings
Violations 1, 2, 3, 4, 5, 6, 7, and 8 have been corrected and no violations were identified at the time of this desk audit. The facility is in compliance with all regulations surveyed.
Report Facts
Violations corrected: 8
Employees Mentioned
Name
Title
Context
Peter Showstead
Administrator
Personnel contacted on 04/27/2022 at 3:30pm during the inspection.
The inspection was conducted as a licensing inspection for renewal of the facility's license.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. The report includes verification of CMP fund, shift coach, and full-time infection prevention and control specialist.
Unannounced visits were made to The Villa At Stamford concluding on February 2, 2022, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a recertification survey to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
Multiple violations of Connecticut State Agencies regulations were identified during the visits, including failures related to urinary catheter care, abuse prevention, PASARR submissions, pressure ulcer care, oxygen tubing management, dialysis care, medication management, and medication cart cleanliness. Plans of correction were required for each violation with substantial compliance dates set for April 11, 2022.
Deficiencies (8)
Description
Facility failed to cover urinary drainage bags for residents #43 and #94 as required by physician orders and facility policy.
Facility failed to ensure resident #94 was free from physical abuse; abuse was substantiated between residents #59 and #91.
Facility failed to ensure PASARR was submitted timely for resident #74.
Facility failed to implement dietary recommendations for resident #20 with pressure ulcers and nutritional needs.
Facility failed to ensure oxygen tubing was labeled and changed as required for residents #57, #75, and #83.
Facility failed to provide dialysis care according to professional standards for resident #95, including monitoring AV fistula site and communication.
Facility failed to ensure pharmacy recommendations were followed timely for resident #74 regarding unnecessary medications.
Facility failed to maintain medication carts in a clean and sanitary manner with loose pills and blister pack back covers observed.
Report Facts
Plan of correction audit frequency: 2Plan of correction audit frequency: 1Plan of correction audit frequency: 3Plan of correction audit frequency: 3Plan of correction audit frequency: 10Plan of correction audit frequency: 12Plan of correction audit frequency: 5Plan of correction audit frequency: 5
Employees Mentioned
Name
Title
Context
Norma Schuberth
Supervising Nurse Consultant
Signed letter regarding notice of noncompliance and plan of correction instructions
The inspection visit was conducted as part of Complaint Investigation #30416 to review compliance with regulations and statutes.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint Investigation #30416 was the reason for the visit. The report indicates no violations were found during the inspection.
Report Facts
Licensed Bed Capacity: 128Census: 105
Employees Mentioned
Name
Title
Context
Peter Showstead
Administrator
Personnel contacted during inspection
Lynn Lyon
Director of Nursing Services (DNS)
Personnel contacted during inspection
Inspection Report Plan of CorrectionDeficiencies: 1Feb 17, 2021
Visit Reason
An unannounced visit was made to Villa At Stamford by the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The facility was found noncompliant with regulations related to the care and safety of a resident who sustained a wound and laceration. The investigation identified failures in reviewing and revising the plan of care to ensure interventions for accident prevention and safety were implemented.
Complaint Details
Complaint #28575 was the basis for the investigation.
Deficiencies (1)
Description
Failure to review and revise the plan of care to ensure interventions for accident prevention and safety were implemented for a resident with a previously identified head injury.
Report Facts
Staples required for laceration: 5Date of resident admission: Jul 7, 2020Date of MDS assessment: Jul 11, 2020Date of Resident Care Plan: Jul 27, 2020Physician order date: Aug 31, 2020Nursing progress note date: Sep 11, 2020Report summary date: Sep 18, 2020Reportable Event Report date: Sep 11, 2020Plan of Correction submission deadline: Mar 8, 2021Substantial Compliance completion date: Mar 31, 2021Audit frequency: 10
Employees Mentioned
Name
Title
Context
Connie Greene
Supervising Nurse Consultant
Signed the notice letter and involved in the complaint investigation.
Peter Showstead
Administrator
Named as recipient of the notice and plan of correction.
An unannounced visit was made to The Villa at Stamford on 2/17/21 by a representative of the Facility Licensing & Investigations Section for the purpose of conducting a CT # 28575 investigation.
Findings
The facility failed to review and revise the plan of care to ensure interventions for accident prevention and safety were implemented for a resident with a previously identified head injury of unknown origin. Specifically, the care plan was not updated to maintain padded side rails after the injury was resolved, potentially compromising resident safety.
Complaint Details
The investigation was triggered by a complaint related to Resident #1 who sustained a head injury from a side rail. The facility was unable to validate the exact cause of the injury due to inconsistent reports, but the injury required hospital treatment with staples. The care plan was not properly updated to maintain safety interventions after the injury was resolved.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Failure to review and revise the plan of care to ensure accident prevention and safety interventions were implemented for a resident with a head injury of unknown origin.
SS=D
Report Facts
Census: 116Total Capacity: 128Staples required: 5Tylenol administration time: 3Plan of Correction Completion Date: Mar 31, 2021Random audits per week: 10
Employees Mentioned
Name
Title
Context
NA #1
Nurse Aide
Assigned nurse aide for Resident #1 who provided care and reported no additional bed rail padding required
NA #2
Nurse Aide
Reported blood on Resident #1's pillow and notified nursing staff
LPN #1
Licensed Practical Nurse
Administered Tylenol for Resident #1's restlessness and reported no other incidents
LPN #2
Licensed Practical Nurse
Assigned nurse for 11-7 A.M. shift on 9/11/20, reported blood on Resident #1's head and pillow
Director of Nursing
Director of Nursing
Conducted interviews, assessed Resident #1, and identified care plan deficiencies
Director of Rehabilitation
Director of Rehabilitation
Evaluated Resident #1 post-incident and noted lack of documentation for side rail padding
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.
Findings
Deficiencies were identified related to failure to use proper hair and beard restraints in the kitchen area and failure to conduct staff COVID-19 testing according to established requirements and guidelines.
Severity Breakdown
SS=D: 2
Deficiencies (2)
Description
Severity
Failure to utilize hair restraints and beard guards in the kitchen area as per infection control policy.
SS=D
Failure to conduct staff COVID-19 testing based on established requirements, with some staff not tested weekly as required.
SS=D
Report Facts
Total Capacity: 128Census: 105Staff not tested weekly: 17Staff worked beyond last test date: 9Total staff: 137Random audits per week: 10Audit duration: 12
Inspection Report Plan of CorrectionDeficiencies: 3Sep 4, 2020
Visit Reason
An unannounced visit was conducted on September 4, 2020, by the Department of Public Health for the purpose of conducting a COVID-19 infection focused survey at Villa At Stamford.
Findings
The facility failed to properly utilize hair restraints in the kitchen, did not conduct required COVID-19 staff testing, and failed to ensure staff wore picture identification badges as required by policy and law.
Deficiencies (3)
Description
Failure to utilize hair restraints in accordance with infection control policy in the kitchen area.
Failure to conduct required weekly COVID-19 testing for all staff as per established requirements.
Failure to ensure staff wore picture identification badges while working on the resident care unit.
Report Facts
Staff total: 137Staff not completing weekly COVID-19 testing: 17Random audits per week for hair/beard restraints: 10Random weekly audits for COVID testing compliance: 10Random audits per week for name badges: 15
Employees Mentioned
Name
Title
Context
Norma Schuberth
Supervising Nurse Consultant
Author of the plan of correction notice
Inspection Report Plan of CorrectionDeficiencies: 1Aug 24, 2020
Visit Reason
An unannounced visit was made to Villa At Stamford by a representative of the Facility Licensing and Investigations Section of the Department of Public Health to conduct a COVID-19 Focused Infection Control survey.
Findings
The facility failed to ensure staff utilized eye protection on the observation unit as required by policy and protocol, with multiple staff observed not wearing eye protection during resident care.
Deficiencies (1)
Description
Facility failed to ensure staff utilized eye protection on the observation unit per standard of care.
Report Facts
Date of inspection: Aug 24, 2020Plan of correction submission deadline: Sep 7, 2020Audit frequency: 10Audit duration (weeks): 12Substantial compliance date: Sep 21, 2020
Employees Mentioned
Name
Title
Context
Norma Schuberth
Supervising Nurse Consultant
Signed letter as Supervising Nurse Consultant for Facility Licensing and Investigations Section
Inspection Report Plan of CorrectionDeficiencies: 1Aug 24, 2020
Visit Reason
An unannounced visit was made to Villa At Stamford for the purpose of conducting a COVID-19 Focused Infection Control survey.
Findings
The facility failed to implement the use of eye protection per standard of care on the observation unit. Staff were observed not wearing proper eye protection despite being aware of the requirement. Education and disciplinary actions were planned to address this issue.
Deficiencies (1)
Description
Failure to implement the use of eye protection per standard of care on the observation unit.
Report Facts
Random weekly audits: 10Random weekly audits: 15Plan of correction submission deadline: 2020
Employees Mentioned
Name
Title
Context
Norma Schuberth
Supervising Nurse Consultant
Signed letter regarding the inspection and plan of correction instructions
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to ensure staff utilized proper eye protection on the observation unit where residents' COVID-19 status was unknown. Multiple staff members were observed not wearing eye protection despite being aware of the requirement. The facility did not implement the use of eye protection per standard of care on the observation unit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Failure to ensure staff utilized eye protection on observation unit with residents of unknown COVID-19 status.
A COVID-19 Focused Infection Control Survey was conducted on 8/1/20 to determine compliance with infection prevention and control practices, and an investigation (ACTS reference number CT28010) was also conducted related to a grievance reported by a resident representative.
Findings
The facility failed to ensure a grievance reported by the resident representative regarding the shaving of a resident's eyebrows was properly documented, investigated, and resolved with a written response. The grievance process was deficient in documentation, follow-up, and corrective action.
Complaint Details
The grievance involved Resident #1 whose eyebrows were shaved off and penciled in without explanation. The resident was cognitively impaired and unable to explain the incident. The facility did not document the grievance investigation or provide a written response. The resident's representative reported missing items after discharge with no follow-up. The grievance was not properly handled according to facility policy.
Deficiencies (1)
Description
Failure to document, investigate, and respond to a grievance reported by a resident representative about a resident's eyebrows being shaved off and penciled in.
Inspection Report Plan of CorrectionDeficiencies: 1Aug 1, 2020
Visit Reason
An unannounced visit was made to Villa At Stamford on August 1, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 Focused Infection Control Survey.
Findings
The facility was found to have violations of Connecticut State regulations related to grievance documentation and investigation. Specifically, the facility failed to ensure that a concern reported by a resident representative was documented and investigated properly, including missing follow-up and documentation in nursing progress notes and social worker notes.
Deficiencies (1)
Description
Failure to ensure a concern reported by a resident representative was documented and investigated, including lack of documentation in nursing progress notes, social worker notes, and no documented investigation or follow-up.
Report Facts
Plan of correction submission deadline: 2020Substantial compliance date: 2020Audit duration: 12
Employees Mentioned
Name
Title
Context
Norma Schuberth
Supervising Nurse Consultant
Signed letter regarding violations and plan of correction instructions
Peter Showstead
Administrator
Named in relation to grievance investigation and plan of correction
The visit was a focused COVID-19 infection control survey and complaint investigation (CT #27770) conducted as an unannounced visit to The Villa At Stamford.
Findings
Violations of Connecticut State regulations were identified related to a resident fall during incontinent care, where staff failed to ensure resident safety and did not notify nursing when the resident indicated pain, resulting in a fall from bed. The facility was required to submit a plan of correction.
Complaint Details
Complaint investigation CT #27770 was substantiated with findings of noncompliance related to resident safety and care during incontinent care.
Deficiencies (2)
Description
Failure to ensure resident safety during incontinent care resulting in a fall from bed.
Nurse aide failed to notify nurse when resident indicated pain and continued care leading to fall.
Report Facts
Licensed Bed Capacity: 100Census: 88Inspection Dates: 2Fall Incident Date: 6Plan of Correction Submission Deadline: 7Random Observations: 15
Employees Mentioned
Name
Title
Context
Peter Showstead
Administrator
Personnel contacted during inspection.
Lynn Lyon
Director of Nursing Services
Interviewed regarding care procedures and staff education.
Alice Martinez
Supervising Nurse Consultant
Author of the notice letter regarding violations and plan of correction.
Inspection Report Plan of CorrectionDeficiencies: 1Jun 12, 2020
Visit Reason
Unannounced visits were made to The Villa At Stamford to conduct an investigation by the Facility Licensing and Investigations Section of the Department of Public Health.
Findings
The facility failed to ensure that a resident was kept safe during incontinent care, resulting in a fall from the bed. The investigation identified that nursing staff did not stop care or notify the nurse when the resident was moving away due to pain from pressure sores.
Deficiencies (1)
Description
Failure to ensure that the resident was kept safe during incontinent care which resulted in a fall from the bed.
Report Facts
Resident reviewed: 1Score: 15Date: Jun 2, 2020Date: Jun 3, 2020Date: Jun 6, 2020Date: Jun 12, 2020Observation frequency: 15Compliance date: Jul 24, 2020
Employees Mentioned
Name
Title
Context
Alice Martinez
Supervising Nurse Consultant
Signed the notice letter from Facility Licensing and Investigations Section
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at the facility.
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Survey.
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility was found to be in compliance with the requirements; no deficiencies were cited as a result of this COVID-19 focused survey.
The inspection visit was conducted for the purpose of license renewal and included a complaint investigation related to complaint numbers 25727 and 24039.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection. The certification file was reviewed as part of the process.
Complaint Details
Complaint investigation numbers 25727 and 24039 were reviewed; no violations were identified during this inspection.
The inspection visit was conducted as a renewal inspection and also referenced complaint investigations #25727 and #24039.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed Capacity: 128Census: 123
Employees Mentioned
Name
Title
Context
Peter Shustack
Personnel contacted during inspection
Lynn Lyon
Personnel contacted during inspection
Laura Knowles
ADNS
Personnel contacted during inspection
Inspection Report Plan of CorrectionDeficiencies: 2Aug 11, 2019
Visit Reason
Unannounced visits were made to Villa At Stamford on August 11, 12, and 13, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations, a licensure and certification inspection.
Findings
Two main violations were identified: 1) Verbal abuse of Resident #63 by staff member NA #2, which was substantiated and resulted in termination of NA #2's employment; 2) Failure to order medications in a timely manner for Resident #133, a newly admitted resident, resulting in missed medications on the day of admission.
Complaint Details
Complaint numbers 25727 and 24039 were investigated. The allegation of verbal abuse was substantiated by the facility.
Deficiencies (2)
Description
Failure to ensure Resident #63 was provided care in a dignified manner, including verbal abuse by NA #2.
Failure to order medications in a timely manner for Resident #133, resulting in missed medications on the day of admission.
Report Facts
Residents involved: 3Residents involved: 1Missed medications: 7Residents on NA #2's assignment: 10Substantial compliance date for Violation #1: Oct 15, 2019Substantial compliance date for Violation #2: Sep 24, 2019
Employees Mentioned
Name
Title
Context
Norma Schuberth
Supervising Nurse Consultant
Signed the letter and directed the plan of correction submission.
Peter Showstead
Administrator
Named as recipient of the letter and involved in incident discussions.
RN #1
Witnessed verbal abuse incident, sent email to Administrator and DON, failed to immediately remove NA #2 from assignment.
NA #2
Staff member who verbally abused Resident #63 and was terminated.
RN #4
Completed admission for Resident #133 and was educated on timely ordering of medications.
APRN #1
Interviewed regarding medication administration for Resident #133.
Pharmacy Director
Interviewed regarding pharmacy delivery schedules and medication orders.
DNS
Director of Nursing Services, responsible for monitoring plan of correction.
Report
Jun 23, 2025
File
complaint-inspection_2025-06-23.pdf
Report
Jan 28, 2025
File
complaint-inspection_2025-01-28.pdf
Report
Oct 1, 2024
File
complaint-inspection_2024-10-01.pdf
Report
Jul 30, 2024
File
health-inspection_2024-07-30.pdf
Report
Jan 31, 2024
File
complaint-inspection_2024-01-31.pdf
Report
Aug 9, 2023
File
infection-control-inspection_2023-08-09.pdf
Report
Feb 2, 2022
File
health-inspection_2022-02-02.pdf
Report
Aug 13, 2019
File
health-inspection_2019-08-13.pdf
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