A list of the most recent deficiencies for Covenant Living - 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-25 | 2023-09-06 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-07-27 | 2023-08-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-27 | 2023-08-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-27 | 2023-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-27 | 2023-08-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-17 | 2023-07-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-07-17 | 2023-07-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-17 | 2023-07-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-17 | 2023-07-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-17 | 2023-07-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-17 | 2023-07-24 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-30 | 2022-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-30 | 2022-10-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-30 | 2022-09-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-30 | 2022-09-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-08-30 | 2022-09-23 | 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 | 2022-08-30 | 2022-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-30 | 2022-09-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-08-18 | 2022-09-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-09-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-18 | 2022-09-09 | 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 | 2022-08-18 | 2022-09-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-17 | 2021-11-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-17 | 2021-11-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-11-17 | 2021-11-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-17 | 2021-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-17 | 2021-11-30 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-11-17 | 2021-11-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-17 | 2021-11-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-29 | 2021-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-29 | 2021-10-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-29 | 2021-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-29 | 2021-10-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-09-29 | 2021-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-06 | 2021-05-25 | Y |
