Deficiency Records for Covenant Living - Windsor Park
Updated as of November 01, 2022
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-25 | 2020-03-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-02-25 | 2020-03-19 | N |
| Develop a communication plan. | Fire Safety | 2020-02-25 | 2020-03-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-25 | 2020-03-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-25 | 2020-03-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-25 | 2020-03-18 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-02-25 | 2020-03-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-25 | 2020-03-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-25 | 2020-03-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-25 | 2020-03-13 | N |
