Covenant Living - Windsor Park
110 Windsor Park Drive, Carol Stream, IL 60188
Covenant Living - Windsor Park is a nursing home in Carol Stream, Illinois. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (630) 510-5200
- Last standard health inspection
- February 28, 2025 (1 year ago)
- Certified beds
- 80
- Residents per day, on average
- 63.1
- Ownership type
- Non profit - Church related
- Legal business name
- Windsor Park Manor
- Chain
- Covenant Living
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Illinois average (17 vs 38).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
1 citation
Health inspection on June 3, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 11, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
5 citations
Health inspection on February 28, 2025
CMS lists this as a standard inspection.
Citation F0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on March 10, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 10, 2025.
CMS has cited this home for F0880 2 times since 2024.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 10, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on March 10, 2025.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on March 10, 2025.
7 citations
Fire safety inspection on February 28, 2025
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on March 25, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 26, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 25, 2025.
Citation K0225. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on March 24, 2025.
Citation K0361. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
CMS lists it as corrected on March 25, 2025.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on March 24, 2025.
CMS has cited this home for K0372 2 times since 2024.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Fine
CMS changed the fine from July 17, 2023 from $77,730 to $50,525.
5 citations
Health inspection on April 19, 2024
CMS lists this as a standard inspection.
Citation F0554. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on May 3, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 3, 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 3, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on May 3, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 3, 2024.
8 citations
Fire safety inspection on April 19, 2024
CMS lists this as a standard inspection.
Citation K0133. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a two-hour-resistant firewall separation.
CMS lists it as corrected on May 24, 2024.
CMS has cited this home for K0133 2 times since 2023.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on May 24, 2024.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on May 24, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 24, 2024.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on May 24, 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on May 24, 2024.
Citation K0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on May 24, 2024.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 24, 2024.
6 citations
Health inspection on July 17, 2023
CMS lists this as a standard inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
46 of 664 Illinois homes (7%) got a citation at the immediate jeopardy level in 2023.
Citation F0610. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on July 24, 2023.
Citation F0835. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on July 24, 2023.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 24, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 24, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 24, 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on July 24, 2023.
4 citations
Fire safety inspection on July 17, 2023
CMS lists this as a standard inspection.
Citation K0133. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a two-hour-resistant firewall separation.
CMS lists it as corrected on August 4, 2023.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on August 2, 2023.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on August 2, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on August 2, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- COVENANT LIVING COMMUNITIES & SERVICES5% or greater direct ownership interest · 100% · since 03/13/1985
- COVENANT MINISTRIES OF BENEVOLENCE5% or greater indirect ownership interest · no percentage provided · since 03/13/1985
- THE EVANGELICAL COVENANT CHURCH OF AMERICA5% or greater indirect ownership interest · no percentage provided · since 03/13/1985
- LITTLE, ABBIEOperational/managerial control · not applicable · since 08/11/2023
- MILIDRAG, SANJAOperational/managerial control · not applicable · since 07/23/2021
- PIPITONE, ANTHONYOperational/managerial control · not applicable · since 11/14/2014
- SMITH, SHELLYOperational/managerial control · not applicable · since 01/18/2021
Questions
When was Covenant Living - Windsor Park last inspected?
CMS lists February 28, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Covenant Living - Windsor Park have?
CMS lists 17 health citations since July 17, 2023. CMS also calls these deficiencies.
Has Covenant Living - Windsor Park been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Covenant Living - Windsor Park?
Its CMS overall star rating is 5 of 5.
Is Covenant Living - Windsor Park a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.