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.

Back to Covenant Living - Windsor Park

Last standard health inspection on record

February 28, 2025

Showing 1 to 12 of 12 citations

  1. 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).

  2. 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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

  9. 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).

  10. No harm, with potential for more than minimal harm

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0693, Quality of Life and Care Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 10, 2025).

  11. No harm, with potential for more than minimal harm

    Provide safe, appropriate pain management for a resident who requires such services.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 10, 2025).

  12. No harm, with potential for more than minimal harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0698, Quality of Life and Care Deficiencies. Inspection of February 28, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 10, 2025).

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.