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Deficiency Records for Covenant Living - Windsor Park
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.
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? |
---|---|---|---|---|
Install a two-hour-resistant firewall separation. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Have exits that are accessible at all times. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Install proper backup exit lighting. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-14 | 2024-05-24 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-04-19 | 2024-05-03 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-19 | 2024-05-03 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-04-19 | 2024-05-03 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-19 | 2024-05-03 | N |
Provide and implement an infection prevention and control program. | Health | 2024-04-19 | 2024-05-03 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-25 | 2023-09-06 | Y |
Install a two-hour-resistant firewall separation. | Fire Safety | 2023-07-27 | 2023-08-04 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-27 | 2023-08-02 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2023-07-27 | 2023-08-02 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-27 | 2023-08-02 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-17 | 2023-07-24 | 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 | 2023-07-17 | 2023-07-24 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-17 | 2023-07-24 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-17 | 2023-07-24 | Y |
Respond appropriately to all alleged violations. | Health | 2023-07-17 | 2023-07-24 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-17 | 2023-07-24 | Y |
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 |
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