A+
95/100COVENANT LIVING - WINDSOR PARK Inspection Report, Violations & Safety Grade (CAROL STREAM, Illinois)
110 WINDSOR PARK DRIVE, CAROL STREAM, Illinois 60188
Phone: 6305105200
CMS Overall:5/5
Overview & Bed Count
Certified Beds
80
Avg Residents/Day
63.1
Ownership
Non profit - Church related
Provider Type
Medicare and Medicaid
County
Du Page
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall5/5
Health4/5
Staffing5/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Illinois Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.25 | 0.71 | +0.54 |
| Total Nurse Hours per Resident per Day | 4.19 | 3.47 | +0.72 |
| CMS Staffing Rating | 5/5 | 2.2/5 | - |
| Nursing Staff Turnover | 22.4% | 43.7% | - |
Health Citation History
17 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-06-03 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-02-28 | Pharmacy Service Deficiencies | 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. | F – Moderate Harm Potential |
| 2025-02-28 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-02-28 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-02-28 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-02-28 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-04-19 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | E – Moderate Harm Potential |
| 2024-04-19 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-04-19 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-04-19 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-04-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2023-07-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | L – Immediate Jeopardy |
| 2023-07-17 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F – Moderate Harm Potential |
| 2023-07-17 | Nutrition and Dietary Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-07-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2023-07-17 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2023-07-17 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
Fire Safety Citation History
19 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-02-28 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-02-28 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-02-28 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-02-28 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-02-28 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2025-02-28 | Smoke Deficiencies | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | E – Moderate Harm Potential |
| 2025-02-28 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2024-04-19 | Construction Deficiencies | Install a two-hour-resistant firewall separation. | E – Moderate Harm Potential |
| 2024-04-19 | Egress Deficiencies | Have exits that are accessible at all times. | E – Moderate Harm Potential |
| 2024-04-19 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2024-04-19 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2024-04-19 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2024-04-19 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2024-04-19 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | E – Moderate Harm Potential |
| 2024-04-19 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2023-07-17 | Construction Deficiencies | Install a two-hour-resistant firewall separation. | E – Moderate Harm Potential |
| 2023-07-17 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | E – Moderate Harm Potential |
| 2023-07-17 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2023-07-17 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the CAROL STREAM area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.