Cycle 1
Health 2025-02-28 · Fire 2025-02-28
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Carol Stream, IL
Covenant Living - Windsor Park
5-star overall rating with 3-star inspections with $50,525 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
110 Windsor Park Drive, Carol Stream, IL
(630) 510-5200
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
1989-03-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.28
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.02
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.24
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,859
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.52
Baseline 20.05% · Performance 20.73% · Measure score 1.52 · Achievement 1.52 · Improvement 0
Healthcare-associated infections
3.14
Baseline 5.85% · Performance 6.90% · Measure score 3.14 · Achievement 3.14 · Improvement 0
Total nurse turnover
8.38
Performance 29.41% · Measure score 8.38 · Achievement 8.38 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.91
Baseline 3.70 hours · Performance 4.19 hours · Measure score 3.91 · Achievement 3.91 · Improvement 1.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.28% |
10.72%
2.6 pts worse
|
Worse than the National Rate · Eligible stays 528 · Observed rate 13.26% · Lower 95% interval 10.88% |
| Discharge to community | 63.81% |
50.57%
13.2 pts better
|
Better than the National Rate · Eligible stays 534 · Observed rate 58.8% · Lower 95% interval 58.62% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.05% |
95.27%
2.8 pts better
|
Numerator 251 · Denominator 256 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 2 · Denominator 256 |
| Discharge self-care score | 52.15% |
53.69%
1.5 pts worse
|
Numerator 109 · Denominator 209 |
| Discharge mobility score | 56.94% |
50.94%
6 pts better
|
Numerator 119 · Denominator 209 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 256 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 301 · Observed rate 5.65% · Lower 95% interval 4.85% |
| Staff COVID-19 vaccination coverage | 48.15% |
8.2%
40 pts better
|
Numerator 65 · Denominator 135 |
| Staff flu vaccination coverage | 18.46% |
42%
23.5 pts worse
|
Numerator 24 · Denominator 130 |
| Discharge function score | 56.94% |
56.45%
0.5 pts better
|
Numerator 119 · Denominator 209 |
| Transfer of health information to provider | 86.96% |
95.95%
9 pts worse
|
Numerator 40 · Denominator 46 |
| Transfer of health information to patient | 90.22% |
96.28%
6.1 pts worse
|
Numerator 166 · Denominator 184 |
| Resident COVID-19 vaccinations up to date | 65.32% |
25.2%
40.1 pts better
|
Numerator 81 · Denominator 124 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
89.6%
1.5 pts better
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 92.0% · Q3 85.0% · Q4 87.5% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.7% |
91.6%
5.9 pts worse
|
95.5%
9.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.9% |
3.3%
5.6 pts worse
|
3.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 12.0% · Q3 10.0% · Q4 8.3% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
50.3%
46.2 pts better
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.5%
6.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
18.5%
9.4 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
22.8%
12.4 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.5% |
17.2%
0.3 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
15.0%
7 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.6% |
21.3%
16.7 pts better
|
19.8%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.9% · 4Q avg 4.6% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.2%
1.3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.0% · Q4 5.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
68.8%
27.3 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 92.7% · Q3 94.4% · Q4 99.2% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
14.0%
3.1 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 9.5% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.3%
1.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 1.0% · Q4 0.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
63.0%
17 pts better
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
26.2%
2.9 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 20.6% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-19 · Fire 2024-04-19
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-17 · Fire 2023-07-17
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-02-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-02-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-03-24
E · Potential for more than minimal harm
2025-02-28
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-24
E · Potential for more than minimal harm
2024-04-19
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-19
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-24
E · Potential for more than minimal harm
2023-07-17
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-07-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-07-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-02
Inspection history
Recent health citations
G · Actual harm
2025-06-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-02-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-28
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-10
E · Potential for more than minimal harm
2024-04-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-19
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
D · Potential for more than minimal harm
2023-08-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-06
L · Immediate jeopardy
2023-07-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-07-17
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-07-17
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-07-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-07-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-24
Penalties and ownership
What sits behind the stars
$50,525
2023-07-17
Fine
Fine · fine $50,525
Fine
Ownership
Covenant Living Communities & Services
5% Or Greater Direct Ownership Interest · Organization
Bentley, Sarah
Corporate Director · Individual
Christensen, Pamela
Corporate Director · Individual
Covenant Living Communities & Services
Operational/Managerial Control · Organization
Cunliffe, Terri
Corporate Officer · Individual
Davis, Kara
Corporate Director · Individual
Eastburg, Mark
Corporate Director · Individual
Erickson, David
Corporate Officer · Individual
Erickson, Rebekah
Corporate Officer · Individual
Holt, Jody
Corporate Officer · Individual
Holt, Jody
W-2 Managing Employee · Individual
Kincannon, Kurt
Corporate Director · Individual
Manlove, Matt
Corporate Director · Individual
Martin, Robert
Corporate Director · Individual
Nelson, Richard
Corporate Director · Individual
Oxendale, Roger
Corporate Director · Individual
Rinard, Dale
Corporate Director · Individual
Vanover, Andrew
Corporate Director · Individual
Wenrich, John
Corporate Director · Individual
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#3
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