Deficiency Records for Covenant Living - Windsor Park
Updated as of May 01, 2020
This is not the most recent data for Covenant Living - Windsor Park. For the most recent information, click here.
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? |
|---|---|---|---|---|
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2020-02-28 | 2020-04-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-28 | 2020-04-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-28 | 2020-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-08 | 2019-03-20 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-01-08 | 2019-02-20 | 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 | 2019-01-08 | 2019-02-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-01-08 | 2019-02-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-08 | 2019-02-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-01-08 | 2019-02-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-08 | 2019-02-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-08 | 2019-02-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-10 | 2019-02-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-03-13 | 2018-04-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-13 | 2018-04-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-13 | 2018-04-06 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2018-03-08 | 2018-04-06 | 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 | 2018-03-08 | 2018-04-06 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2018-03-13 | 2018-03-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-13 | 2018-03-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-13 | 2018-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-13 | 2018-03-15 | N |
| Be properly staffed | Fire Safety | 2018-03-13 | 2018-03-15 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2018-03-13 | 2018-03-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-25 | Not Fixed | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Develop a communication plan. | Fire Safety | 2020-02-25 | Not Fixed | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-25 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-25 | Not Fixed | N |
