Home / Illinois / Carol Stream
Covenant Living - Windsor Park
110 Windsor Park Drive, Carol Stream, IL 60188 · Du Page County · (630) 510-5200
80 certified beds, about 67 residents a day · Non profit - Church related · Medicare and Medicaid since 1989
CMS high performing icon Part of a continuing care retirement community Certified for Medicaid Certified for Medicare
Overall
5 of 5
Health inspections
4 of 5
Staffing
5 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145606 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on February 28, 2025, inspectors cited 5 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 17 health citations since July 2023, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.97 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 1.23 of those hours.
18.3% of nursing staff left within the year CMS measured (Illinois average 44.5%).
CMS links it to Covenant Living, an affiliated group of 15 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
607/23
504/24
502/25
106/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
10D
3E
2F
Potential for minimal harm
0A
0B
0C
June 3, 2025Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased 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.
February 28, 2025Standard inspection · 5 citations
- F 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.
Inspectors wroteBased 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.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow guidelines for Personal Protective Equipment (PPE) use and handwashing. This applies to 4 of 4 residents (R4, R256, R43, R209) reviewed for infection control in a sample of 19.
- D 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.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physican orders to ensure residents with gastrostomy feeding tubes (GT) recieved cares to prevent complications. This applies to 3 residents (R42, R43, and R4) reviewed for G-tube management in a sample of 19.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to investigate a resident's continued complaints of chest pain to identify the cause. This applies to 1 of 1 resident (R157) reviewed for pain in a sample of 19.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview, and record review, the facility failed to ensure proper care for resident receiving hemodialysis. This applies to 1 resident (R27) reviewed for dialysis in a sample of 19.
April 19, 2024Standard inspection · 5 citations
- E Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for resident medications and for it to be at the bedside. The facility failed to complete self-administration of medication assessment. This applies to 8 of 8 residents (R8, R9, R17, R22, R45, R50, R120, R122) reviewed for medications in a sample of 24.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide ADLs (Activity of Daily Living) care to residents. This applies to 3 of 3 residents (R5, R6 and R9) reviewed for ADL care in a sample of 24.
- D 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.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure anti-contracture devices were applied as ordered. This applies to 2 of 2 residents (R5 and R6) reviewed for anti-contracture devices in a sample of 24.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to properly position indwelling catheter bag/drainage bag during care. This applies to 1 of 1 resident (R5) reviewed for indwelling catheter in a sample of 24.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to: perform hand hygiene, contain soiled linen and follow current standards of infection control during pressure ulcer dressing change. This applies to 3 of 3 (R51, R167 and R168) residents reviewed for infection control in a sample of 24.
July 17, 2023Standard inspection · 6 citations
- L Respond appropriately to all alleged violations.
Inspectors wroteBased 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. V3 was not suspended from work until July 6, 2023, at 3:38 PM. [...]
- F Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased 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.
- E 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.
Inspectors wroteBased on observation, interview and record review, the facility failed to plan pureed menus to include the required number of grain/cereal servings per facility policy. This applies to all 5 residents (R9, R28, R39, R114, R213) reviewed for pureed diets.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy of reporting suspected abuse or a suspected crime against a resident to the local law enforcement agency. This applies to 1 of 3 residents (R263) reviewed for abuse in the sample of 14.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement pressure relieving interventions for a resident with pressure injuries. This applies to 1 of 2 residents (R15) reviewed for pressure ulcers in a sample of 14.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to follow their Pneumococcal Vaccine policy. This applies to 3 of 5 residents (R18, R26, and R41) reviewed for Pneumococcal Vaccine in the sample of 14.
Fire safety inspections
19 fire safety citations on file: 7 on February 28, 2025, 8 on April 19, 2024, 4 on July 17, 2023.
Every fire safety citation19 citations
- F Conduct testing and exercise requirements.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- E Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- E Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Install a two-hour-resistant firewall separation.
- E Have exits that are accessible at all times.
- E Install proper backup exit lighting.
- E Inspect, test, and maintain automatic sprinkler systems.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Meet requirements for the use of electrical equipment.
- E Ensure proper usage of power strips and extension cords.
- E Install a two-hour-resistant firewall separation.
- E Install a fire alarm system that can be heard throughout the facility.
- E Install an approved automatic sprinkler system.
- E Install corridor and hallway doors that block smoke.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.97 | 3.45 | 3.86 |
| Registered nurses | 1.23 | 0.72 | 0.69 |
| All nursing staff on weekends | 3.70 | 3.07 | 3.42 |
| Nurse aides | 2.13 | ||
| Licensed practical nurses | 0.61 | ||
| Nursing staff turnover (share who left in a year) | 18.3% | 44.5% | 45.8% |
| Registered nurse turnover | 20.0% | 41.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.86 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.08 on weekdays and 3.70 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.41 in April to June 2025 to 3.97 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.97 | 1.23 | 4.08 | 3.70 | 0.0% | 0 of 90 | 67 |
| Oct to Dec 2025 | 4.00 | 1.23 | 4.11 | 3.72 | 0.0% | 0 of 92 | 65 |
| Jul to Sep 2025 | 4.28 | 1.28 | 4.42 | 3.92 | 0.0% | 0 of 92 | 60 |
| Apr to Jun 2025 | 4.41 | 1.36 | 4.57 | 4.00 | 0.0% | 0 of 91 | 59 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.5 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.6 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 8.9 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.7 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 7.5 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.7 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.9 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 21.8 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.6 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 2.2 | 1.8 |
Owners and operators
Legal business name: WINDSOR PARK MANOR. CMS links this home to Covenant Living, a group of 15 nursing homes averaging 4.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Covenant Living Communities & Services | 5% or greater direct ownership interest | Organization | 100% | 03/13/1985 |
| Covenant Ministries of Benevolence | 5% or greater indirect ownership interest | Organization | 03/13/1985 | |
| The Evangelical Covenant Church of America | 5% or greater indirect ownership interest | Organization | 03/13/1985 | |
| Creaney, Janet | Corporate director | Individual | 08/01/2023 | |
| Hoffman, Janet | Corporate director | Individual | 07/01/2023 | |
| Means, Jennifer | Corporate director | Individual | 07/01/2025 | |
| Warnygora, Emily | Corporate director | Individual | 07/01/2021 | |
| Erickson, David | Corporate officer | Individual | 06/01/2024 | |
| Justie, Jeannie | Corporate officer | Individual | 09/21/2020 | |
| Kalheim, Cory | Corporate officer | Individual | 07/01/2024 | |
| Little, Abbie | Operational/managerial control | Individual | 08/11/2023 | |
| Milidrag, Sanja | Operational/managerial control | Individual | 07/23/2021 | |
| Pipitone, Anthony | Operational/managerial control | Individual | 11/14/2014 | |
| Smith, Shelly | Operational/managerial control | Individual | 01/18/2021 | |
| Erickson, David | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/01/2026 | |
| Covenant Living Communities & Services | Adp of the SNF | Organization | 03/13/1985 | |
| Little, Abbie | Adp of the SNF | Individual | 11/11/2025 | |
| Pipitone, Anthony | Adp of the SNF | Individual | 11/24/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 8 problems in this area, most recently on June 3, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 3 problems in this area, most recently on February 28, 2025: "Provide and implement an infection prevention and control program."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 2 problems in this area, most recently on July 17, 2023: "Respond appropriately to all alleged violations."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 1 problem in this area, most recently on February 28, 2025: "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."
Other nursing homes nearby
- Ahva Care of Winfield Winfield, 2.5 mi · 4 of 5 stars · 19 citations
- Wheaton Village Nrsg & Rhb Ctr Wheaton, 2.6 mi · 3 of 5 stars · 34 citations
- Wynscape Health & Rehab Wheaton, 2.8 mi · 5 of 5 stars · 12 citations
- Aperion Care West Chicago West Chicago, 3 mi · 2 of 5 stars · 54 citations
- Dupage Care Center Wheaton, 3 mi · 5 of 5 stars · 24 citations
- Alden Valley Ridge Rehab & HCC Bloomingdale, 4.2 mi · 5 of 5 stars · 23 citations
- West Suburban Nursing & Rehab Center Bloomingdale, 4.3 mi · 2 of 5 stars · 41 citations
- West Chicago Living and Rehab Center West Chicago, 4.4 mi · 1 of 5 stars · 44 citations
Illinois contacts for a concern about a nursing home
These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Illinois Department of Public Health, Nursing Homes, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Illinois Long-Term Care Ombudsman Program, Illinois Department on Aging, 1-800-252-8966. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: IDPH Quarterly Reports of Nursing Home Violators, where Illinois publishes its own records on licensed homes.
Common questions
- What is Covenant Living - Windsor Park's Medicare star rating?
- CMS rates Covenant Living - Windsor Park 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Covenant Living - Windsor Park get at its last inspection?
- 5 health deficiencies at the standard inspection on February 28, 2025. The Illinois average is 12.6.
- Has Covenant Living - Windsor Park been fined?
- CMS lists no fines in the last three years.
- Does Covenant Living - Windsor Park accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Covenant Living - Windsor Park?
- CMS lists 18 owners and managers, and links the home to Covenant Living. Legal business name: WINDSOR PARK MANOR.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.