Nursing HomeInspections

Covenant Living - Windsor Park

Nursing home in Carol Stream, IL

Medicare & Medicaid certified5★ overall (CMS)

Call (630) 510-5200Send a messageMap ↗

Public-record details

Address
110 Windsor Park Drive, Carol Stream, IL 60188
Phone
(630) 510-5200
Listed under
Nonprofit, 4–5 star overall rating, No fines in 3 years, Part of a retirement community
Medicare CCN
145606
Overall star rating
5 of 5 ★★★★★
Health inspection rating
4 of 5
Staffing rating
5 of 5
Quality measures rating
5 of 5
Certified beds
80
Average residents per day
67
Ownership
Nonprofit, church related
Legal business name
Windsor Park Manor
Chain
Covenant Living (15 facilities)
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
Mar 3, 1989
Changed ownership in last 12 months
No
Continuing care retirement community
Yes
Located inside a hospital
No
Resident or family council
Resident council
Sprinklers in all required areas
Yes

CMS certification number 145606. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Feb 28, 2025. CMS lists 18 health citations for this facility across its last three standard inspection cycles and complaint inspections (Jul 17, 2023 to Jun 3, 2025): 2 from complaint inspections, 2 at the “actual harm” level or higher, including 1 at “immediate jeopardy”.

InspectionCitationSeverity
Jun 3, 2025Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care · complaint inspection		G
Actual harm, isolated
Feb 28, 2025Ensure 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.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Feb 28, 2025Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Feb 28, 2025Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Feb 28, 2025Provide and implement an infection prevention and control program.
Infection Control		E
Potential for more than minimal harm, pattern
Feb 28, 2025Ensure 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…
Pharmacy Service		F
Potential for more than minimal harm, widespread
Apr 19, 2024Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Apr 19, 2024Provide 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.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Apr 19, 2024Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Apr 19, 2024Provide and implement an infection prevention and control program.
Infection Control		D
Potential for more than minimal harm, isolated
Apr 19, 2024Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights		E
Potential for more than minimal harm, pattern
Aug 25, 2023Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation · complaint inspection		D
Potential for more than minimal harm, isolated

Showing the 12 most recent of 18. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records no fines or payment denials for this facility in the last three years.

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day
3.97 hours
Registered nurse (RN) time per resident per day
1.23 hours
Nurse aide time per resident per day
2.13 hours
Total nurse staffing on weekends
3.70 hours
Nursing staff turnover (yearly)
18%
RN turnover (yearly)
20%
Administrators who left in the past year
0

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.