Covenant Living - Windsor Park
Carol Stream, Illinois · CCN 145606
18 surveys since 2011, 3 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 59
- Surveys
- 18
- Harm or worse
- 3
- Immediate jeopardy
- 1
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 80
- Ownership
- Non profit - Church related
- Chain
- COVENANT LIVING
- County
- Du Page
- Medicare-certified since
- 1989
CMS ratings
- Overall
- 5
- Health inspection
- 4
- Staffing
- 5
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 31 not-for-profit facilities of 66–99 beds in Illinois.
Last survey on record
Jun 3, 2025
524 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.97 | 4.49 |
| Registered-nurse hours per resident day | 1.23 | — |
| Annual nurse turnover | 18.3% | 36.9% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L15.6% |
| Actual harm | G15.6% | H— | I— |
| No harm, potential for more than minimal | D1161.1% | E316.7% | F211.1% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F8802×
Provide and implement an infection prevention and control program.
- F5541×
Allow residents to self-administer drugs if determined clinically appropriate.
- F6001×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6091×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6101×
Respond appropriately to all alleged violations.
In the surveyor’s words
From the most serious findings on record at Covenant Living - Windsor Park, in the surveyor’s own words.
- Immediate jeopardy, widespreadF610Jul 17, 2023
Based on interview and record review the facility failed to protect residents from further abuse by allowing an alleged perpetrator of sexual abuse to continue to work and care for residents in the facility for at least four and a half hours after the allegation was reported to the administrator. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on July 6, 2023, when R263 reported to V4 (Speech Therapist) on July 6, 2023, during R263's speech therapy session that V3 (CNA/Certified Nursing Assistant) sexually abused her. V1 (Administrator) was notified of the alleged abuse on July 6, 2023, between 10:30 AM and 11:00 AM. Following V1's notification, V3 continued to remain in the facility and care for residents. […]
- Actual harm, isolatedF689Jun 3, 2025
Based on observation, interview, and record review, the facility failed to provide assistance and utilize gait belt during a toilet transfer for a resident identified as requiring assistance. This resulted in a fall in which R1 sustained multiple rib fractures and other injuries. This applies to 1 of 3 residents (R1) reviewed for fall incident in the sample of 5. The Finding includes: According to the Electronic Medical Record (EMR), R1 is a [AGE] year-old with diagnoses including chronic obstructive pulmonary disease (COPD), muscle weakness, muscle wasting, history of falls, major depressive disorder, diabetes mellitus, bilateral knee replacement, left hip arthroplasty, compression fracture, and restless leg syndrome. […]
- No harm, potential for more than minimal, widespreadF761Feb 28, 2025
Based on observation, interview and record review, the facility failed to dispose of expired house stock medications from the medication room. This has the potential to affect all 58 residents in the facility. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 2/25/2025 to 2/28/2025 showed a census of 58 residents. The findings include: On 2/26/2025 at 10:45 AM and 2/27/2025 at 10:45 AM, inspection of the facility's medication room showed the following expired house stock medication: Four boxes of hemorrhoidal cream that expired on 11/2024. […]
- No harm, potential for more than minimal, widespreadF835Jul 17, 2023
Based on interview and record review, the administrator was aware of the potential sexual abuse and allowed the alleged perpetrator to remain on duty with access to all residents. The administrator also failed to follow their abuse policy and notify the local law enforcement agency of an allegation of sexual abuse in a timely manner. This has the ability to affect all 52 residents in the facility. The findings include: The Resident Census and Conditions of Residents report dated July 11, 2023, shows the facility census was 52 residents. On July 11, 2023, at 12:06 PM, V1 said I am the abuse coordinator. […]
- No harm, potential for more than minimal, widespreadF882Sep 29, 2021
Based on interview and record review the facility failed to have a Certified Infection Preventionist to oversee the Infection Control Program of the facility. This applies to all residents residing in the facility. Findings include: The Census and Condition report dated 9/27/21 show there are 57 residents residing in the facility. On 9/28/21 at 10 AM, V2 (Director of Nursing-DON) said the facility has no Infection Control Preventionist (IP) at this time. V2 (DON) said the IP nurse quit last month. V2 said the IP oversee the facility infection prevention of the facility. V2 said she is the designee and has been trying to do facility infection surveillance but she has not completed the specialized training for infection prevention and control. […]
Read 21 findings in full →The most serious and the most recent: 21 of 59 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 3, 2025Complaint1 finding · 1 harm
- Feb 28, 2025Standard5 findings
- Apr 19, 2024Standard5 findings
- Aug 25, 2023Complaint1 finding
- Jul 17, 2023Standard and complaint6 findings · 1 harm
- Aug 18, 2022Standard4 findings
- Sep 29, 2021Standard5 findings
- May 6, 2021Complaint1 finding
Show the 10 earlier surveys
- Feb 28, 2020Standard3 findings
- Jan 10, 2019Standard1 finding
- Mar 8, 2018Standard2 findings
- Feb 17, 2017Standard3 findings
- Jan 14, 2016Standard5 findings
- Mar 19, 2015Standard6 findings
- Feb 27, 2014Standard4 findings
- Oct 11, 2013—1 finding · 1 harm
- Mar 30, 2012—1 finding
- Feb 9, 2011—5 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction