Covenant Living - Windsor Park
110 Windsor Park Drive, Carol Stream, IL 60188 · Du Page County · 80 certified beds · avg 67 residents/day · certified since Mar 3, 1989
Part of chain: COVENANT LIVING (15 facilities, chain avg rating 4.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Jul 17, 2023 · F-0610
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Jul 24, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 3, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 11, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 3, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 28, 2025 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 28, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 28, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Feb 28, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 28, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 19, 2024 | E · Potential for harm, repeated | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 25, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 17, 2023 | ▲ L · Immediate jeopardy, facility-wide | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Jul 17, 2023 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jul 17, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jul 17, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jul 17, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 17, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 1 | L ▲ |
| 2024 | 5 | 0 | E |
| 2025 | 6 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.94 | 2.99 | 3.95 | top 17% in Illinois; top 42% in the U.S. |
| Registered Nurse hours | 1.23 | 0.63 | 0.69 | top 8% in Illinois; top 9% in the U.S. |
| Weekend total nurse staffing | 3.67 | 2.67 | 3.50 | top 15% in Illinois; top 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.08 | 0.56 | 0.48 | top 8% in Illinois; top 5% in the U.S. |
| Total nursing staff turnover (%) | 18.3 | 44.5 | 45.8 | top 2% in Illinois; top 2% in the U.S. |
| RN turnover (%) | 20.0 | 41.8 | 42.9 | top 15% in Illinois; top 13% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.97, RN 1.23, weekend 3.70. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Covenant Living Communities & Services | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/13/1985 |
| Covenant Ministries of Benevolence | Organization | 5% or Greater Indirect Ownership Interest | — | 03/13/1985 |
| The Evangelical Covenant Church of America | Organization | 5% or Greater Indirect Ownership Interest | — | 03/13/1985 |
| Covenant Living Communities & Services | Organization | ADP of the SNF | NOT APPLICABLE | 03/13/1985 |
| Creaney, Janet | Individual | Corporate Director | NOT APPLICABLE | 08/01/2023 |
| Erickson, David | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2024 |
| Erickson, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/01/2026 |
| Hoffman, Janet | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Justie, Jeannie | Individual | Corporate Officer | NOT APPLICABLE | 09/21/2020 |
| Kalheim, Cory | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2024 |
| Little, Abbie | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/11/2023 |
| Little, Abbie | Individual | ADP of the SNF | NOT APPLICABLE | 11/11/2025 |
| Means, Jennifer | Individual | Corporate Director | NOT APPLICABLE | 07/01/2025 |
| Milidrag, Sanja | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/23/2021 |
| Pipitone, Anthony | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/14/2014 |
| Pipitone, Anthony | Individual | ADP of the SNF | NOT APPLICABLE | 11/24/2025 |
| Smith, Shelly | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/18/2021 |
| Warnygora, Emily | Individual | Corporate Director | NOT APPLICABLE | 07/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Ahva Care of Winfield | 2.5 mi | Winfield, IL | ★★★★☆ | 4/5 | |
| Wheaton Village Nrsg & RHB Ctr | 2.6 mi | Wheaton, IL | ★★★☆☆ | 3/5 | |
| Wynscape Health & Rehab | 2.8 mi | Wheaton, IL | ★★★★★ | 5/5 | |
| Aperion Care West Chicago | 3.0 mi | West Chicago, IL | ★★☆☆☆ | 2/5 | abuse |
| Dupage Care Center | 3.0 mi | Wheaton, IL | ★★★★★ | 4/5 | |
| Alden Valley Ridge Rehab & HCC | 4.2 mi | Bloomingdale, IL | ★★★★★ | 4/5 | |
| West Suburban Nursing & Rehab Center | 4.3 mi | Bloomingdale, IL | ★★☆☆☆ | 2/5 | abuse |
| West Chicago Living and Rehab Center | 4.4 mi | West Chicago, IL | ★☆☆☆☆ | 2/5 | abuse |
| Bella Terra Bloomingdale | 4.4 mi | Bloomingdale, IL | ★★☆☆☆ | 2/5 | abuse |
| Ignite Medical Hanover Park | 5.9 mi | Hanover Park, IL | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145606.