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 19 of 19 citations

  1. 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).

  2. 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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

  9. 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).

  10. 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).

  11. 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).

  12. 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).

  13. 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).

  14. 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).

  15. 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).

  16. 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).

  17. 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).

  18. 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).

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

    Install corridor and hallway doors that block smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0363, 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.