COVENANT LIVING - WINDSOR PARK
Open-data reference.
COVENANT LIVING - WINDSOR PARK is a non profit - church related facility in CAROL STREAM, IL with 80 certified beds and a 5-star overall CMS rating. The facility has 18 deficiency records on file. Total penalties: $51K.
110 WINDSOR PARK DRIVE, CAROL STREAM, IL 60188
Phone: 6305105200
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 145606
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 80
- Residents
- 60
- In Hospital
- No
- County
- Du Page
- Last Inspection
- Feb 28, 2025
Staffing Data
- RN Hours
- 1.28 (nat'l avg: 0.68)
- LPN Hours
- 0.60
- CNA Hours
- 2.40
- Total Nursing Hours
- 4.28 (nat'l avg: 3.89)
- PT Hours
- 0.12
- Nursing Turnover
- 22.7%
- RN Turnover
- 20.0%
What the CMS Record Reveals About COVENANT LIVING - WINDSOR PARK
COVENANT LIVING - WINDSOR PARK operates 80 certified beds in CAROL STREAM, IL with approximately 60 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (5★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 18 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $51K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.28 total nursing hours per resident day (national average 3.89), with RN coverage at 1.28 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, COVENANT LIVING - WINDSOR PARK falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 22.7%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (18 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 11, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 10, 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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 10, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 3, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: May 3, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 6, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Jul 24, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 24, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 24, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Jul 24, 2023
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 24, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 24, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 8.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.0% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.4% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.1% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 8.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 91.1% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 96.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 17.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 9.1% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 85.7% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 80.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 4.6% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 10.4% | Yes |
Penalty History 1 penalties totaling $51K
| Date | Type | Amount |
|---|---|---|
| Jul 17, 2023 | Fine | $51K |
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Understanding Nursing Home Data
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Frequently Asked Questions
What is the overall CMS rating for COVENANT LIVING - WINDSOR PARK?
What are the staffing levels at COVENANT LIVING - WINDSOR PARK?
How many beds does COVENANT LIVING - WINDSOR PARK have?
Does COVENANT LIVING - WINDSOR PARK have any deficiencies on record?
Has COVENANT LIVING - WINDSOR PARK received any fines or penalties?
Who owns COVENANT LIVING - WINDSOR PARK?
When was COVENANT LIVING - WINDSOR PARK last inspected?
What quality measures are tracked for COVENANT LIVING - WINDSOR PARK?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.