01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-02-28 | 5 | 2025-02-28 | 7 |
| Cycle 2 | 2024-04-19 | 6 | 2024-04-19 | 8 |
| Cycle 3 | 2023-07-17 | 7 | 2023-07-17 | 4 |
CMS CCN 1456062026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Covenant Living - Windsor Park
110 Windsor Park Drive · Carol Stream, IL 60188 · Du Page County
Certified beds80CMS provider file
Recent citation rows37current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-06-03 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-06-11 · complaint2025-02-28 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-02-28 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-02-28 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-02-28 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-02-28 · HEALTHF0761Severity F · widespread; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-02-28 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-02-28 · FIREK0225Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2025-03-242025-02-28 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-03-262025-02-28 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-28 · FIREK0361Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-02-28 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-03-242025-02-28 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-03-252024-04-19 · HEALTHF0554Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-19 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-19 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-19 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-19 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-19 · FIREK0133Severity E · pattern; potential for more than minimal harm
Construction Deficiencies
Install a two-hour-resistant firewall separation.
Correction field: Deficient, Provider has date of correction · 2024-05-242024-04-19 · FIREK0271Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2024-05-242024-04-19 · FIREK0281Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Deficient, Provider has date of correction · 2024-05-242024-04-19 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-05-242024-04-19 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2024-05-242024-04-19 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-05-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- COVENANT LIVING COMMUNITIES & SERVICESOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/13/1985
- COVENANT MINISTRIES OF BENEVOLENCEOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/13/1985
- THE EVANGELICAL COVENANT CHURCH OF AMERICAOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/13/1985
- CREANEY, JANETIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/01/2023
- HOFFMAN, JANETIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2023
- MEANS, JENNIFERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2025
- WARNYGORA, EMILYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2021
- ERICKSON, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/01/2024
- JUSTIE, JEANNIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/21/2020
- KALHEIM, CORYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2024
- LITTLE, ABBIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/11/2023
- MILIDRAG, SANJAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/23/2021
- PIPITONE, ANTHONYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/14/2014
- SMITH, SHELLYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/18/2021
- ERICKSON, DAVIDIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 04/01/2026
- COVENANT LIVING COMMUNITIES & SERVICESOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/13/1985
- LITTLE, ABBIEIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/11/2025
- PIPITONE, ANTHONYIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/24/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.97per resident day
RN hours1.23per resident day
Weekend nurse hours3.70per resident day
Staff turnover18.3%CMS reported field
06 / LOCAL RECORDS
Open the Illinois ledger →Other published facilities nearby
No second facility in the same city met the directory rule.