All citations for Covenant Living - Windsor Park

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

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Last standard health inspection on record

February 28, 2025

Showing 1 to 25 of 36 citations

Immediate jeopardy to resident health or safety
Respond appropriately to all alleged violations.
Widespread (many residents). CMS level L.
Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of July 17, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2023).
Harm to a resident
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Isolated (one or a few residents). CMS level G.
Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of June 3, 2025. Found during a complaint inspection.
The home gave a date the problem would be corrected (June 11, 2025).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Widespread (many residents). CMS level F.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 10, 2025).
No harm, with potential for more than minimal harm
Conduct testing and exercise requirements.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 26, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 11, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2025).
No harm, with potential for more than minimal harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Widespread (many residents). CMS level F.
Health citation F-0835, Administration Deficiencies. Inspection of July 17, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2023).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Pattern (more than a few residents). CMS level E.
Health citation F-0880, Infection Control Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 10, 2025).
No harm, with potential for more than minimal harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0225, Egress Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 24, 2025).
No harm, with potential for more than minimal harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0361, Smoke Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2025).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 24, 2025).
No harm, with potential for more than minimal harm
Allow residents to self-administer drugs if determined clinically appropriate.
Pattern (more than a few residents). CMS level E.
Health citation F-0554, Resident Rights Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Install a two-hour-resistant firewall separation.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0133, Construction Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
Have exits that are accessible at all times.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0271, Egress Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
Install proper backup exit lighting.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0281, Egress Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
Properly select, install, inspect, or maintain portable fire extinguishes.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0355, Smoke Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
Meet requirements for the use of electrical equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0919, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
Ensure proper usage of power strips and extension cords.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 19, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (May 24, 2024).
No harm, with potential for more than minimal harm
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.
Pattern (more than a few residents). CMS level E.
Health citation F-0803, Nutrition and Dietary Deficiencies. Inspection of July 17, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2023).
No harm, with potential for more than minimal harm
Install a two-hour-resistant firewall separation.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0133, Construction Deficiencies. Inspection of July 17, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (August 4, 2023).
No harm, with potential for more than minimal harm
Install a fire alarm system that can be heard throughout the facility.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0341, Smoke Deficiencies. Inspection of July 17, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (August 2, 2023).
No harm, with potential for more than minimal harm
Install an approved automatic sprinkler system.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0351, Smoke Deficiencies. Inspection of July 17, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (August 2, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.