Inspection visit
Inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to follow physican orders to ensure residents
with gastrostomy feeding tubes (GT) recieved cares to prevent complications.
This applies to 3 residents (R42, R43, and R4) reviewed for G-tube management in a sample of 19.
The findings include:
1. On February 25, 2025 at 11:52 AM, R42 was noted with cough and talking with a gargly voice as though
excessive moisture was present in his throat. On 2/26/25 at 9:26 AM, after wound care was completed by
V13 (Wound Care Nurse) and V14 (CNA/Certified Nurse Assistant), V14 raised the head of R42's bed to 20
degrees. At 9:50 AM, V13 restarted R42's feeding pump at 85 mLs/hr (milliliters per hour). R42 was
observed with wet, gargly cough again. V13 and V14 then left R42's room. Eight minutes later at 9:58 AM,
V5 (LPN/Licensed Practical Nurse) entered R42's room, checked that his tube feeding had been restarted,
and walked back out of the R42's room. Surveyor then asked V5 (LPN) to come back into R42's room to the
side of his bed to assess the elevation angle of the head of R42's bed. V5 said it was not raised high
enough for continuous tube feeding administration, adding R42's head of bed should be elevated to 45
degrees.
R42's POS (Physician Order Sheet) shows an order dated February 21, 2025 saying to keep head of bed
elevated at least 45 degrees to prevent aspiration. An additional order dated February 20, 2025 showed
Aspiration Precautions. R42's Face Sheet shows he has a history of dysphagia, acute respiratory failure
with hypoxia and hypercapnia on February 11, 2025, and Influenza A with pneumonia on February 11,
2025. R42's Care Plan dated February 22, 2025 says he receives nutrition/hydration through tube feeding
related to diagnosis of dysphagia. R42's Goal states he will receive adequate nutrition without side effects
associated with tube feedings (aspiration, etc).
On February 27, 2025 at 10:04 AM, V10 (LPN) said R42's head of bed should be 45 degrees to prevent
aspiration, per R42's physician orders. V10 said if R42's head of bed is not above 45 degrees while tube
feeding is infusing, there is greater risk of the feeding coming up the esophagus and the resident
choking/aspirating the feeding into the lungs.
On February 27, 2025 at 1:15 PM, V2 (DON/Director of Nursing) said an aspiration precaution order means
the staff should be paying attention to the angle of the head of bed. V2 said 20 degrees is not high enough
for the head of the bed for a resident with aspiration precautions who is receiving continuous tube feeding.
V2 said she would expect that the physician order stating to keep the head of bed 45 degrees would be
followed. V2 said residents with tube feedings are at greater risk for
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
145606
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
aspiration because of their impaired swallowing and the risk of backflow of the tube feeding leading to
regurgitation/aspiration.
The facility's policy titled, Enteral Tube Feeding via Continuous Pump last revised November 2018 states,
Purpose: The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.
Preparation .2. Review the resident's care plan and provide for any special needs of the resident .Steps in
the Procedure .4. Position the head of the bed at 30-45 degrees (semi-Fowler's position) for feeding, unless
medically contraindicated .
2. On February 26, 2025 at 1:56 PM, V5 (LPN) went to R4's room to administer her medication and a GT
feeding. V5 attached the syringe without the plunger to R4's GT port, and poured 30 ML of water into the
syringe. V5 did not check for placement by aspirating any gastric content or checking residual volume prior
to infusing the fluid.
R4's face sheet showed she was admitted to the facility with diagnoses including attention to gastrostomy,
bipolar disorder, dementia, gastroesophageal reflux disease, and dysarthria and anarthria. R4's MDS dated
[DATE] shows she had severe cognitive impairment.
On February 27, 2025 at 11:21 AM, V15 (RN/Registered Nurse) said nurses checked for placement by
gravity. V15 said they would connect the syringe to the port, hold the syringe close to the resident's
abdomen, and wait to see if any gastric content comes back into the syringe. V15 said she would wait one
to two minutes to see if anything comes up to check for placement.
On February 27, 2025 at 11:25 AM, V16 (RN) said they do not push air bubbles through the syringe or
aspirate gastric contents to check for GT placement as it could cause a rupture of the GT. V16 said they
check for placement by flushing the GT with water and watching it drain by gravity.
On February 27, 2025 at 11:43 AM, V10 (LPN) said she does not aspirate to check for placement and
would flush with water before administering formula or medications.
On February 27, 2025 at 12:04 PM, V2 (DON/Director of Nursing) said they check for placement by gravity,
and if there was any resistance with the initial flush, they would stop the procedure and call the doctor. V2
said aspirating or putting air causes more discomfort to the stomach, so they use the natural process of
gravity. V2 said if the GT catheter dislodged or was not properly placed, nothing would infuse down the
tube. V2 said they used to aspirate for gastric content, but their practice changed. V2 said she did not
remember when the practice changed and would look for literature showing this practice was acceptable,
which she was unable to provide.
The Equipment and Supplies portion of the facility's Enteral Tube Feeding Via Continuous Pump Level III
policy (revised November 2018) included 9. pH strips and 10. Stethescope. The Steps in the Procedure
section of the policy showed 8. Verify placement of tube. 9. If anything suggests improper tube positioning,
do not administer feeding or medication . 10. When correct tube placement has been verified, flush tubing
with at least 30 mL warm water (or prescribed amount) . The policy does not include specific procedural
steps for checking for GT placement, and it does not specify what is to be done with either the pH strips or
the stethescope.
3. On February 26, 2025 at 1:01 PM, V5 (LPN/Licensed Practical Nurse) went to R43's room to administer
his GT formula feeding. R43 attached the syringe without the plunger to R43's GT port marked feed and
began by pouring 120 ML (Milliliters) of water into the GT. V5 did not check for placement by
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
aspirating any gastric content or checking residual volume.
Level of Harm - Minimal harm
or potential for actual harm
R43's face sheet showed he was admitted to the facility with diagnoses including attention to gastrostomy,
Parkinson's disease without dyskinesia, severe protein-calorie malnutrition, and cognitive communication
deficit.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to investigate a resident's continued complaints
of chest pain to identify the cause.
Residents Affected - Few
This applies to 1 of 1 resident (R157) reviewed for pain in a sample of 19.
Findings include:
R157 admitted to the facility on [DATE] for orthopedic after care following the surgical repair of a left hip
fracture. On 02/25/25 at 11:45 AM, R157 was lying across the bed with his feet dangling off the bed. V23
(Physical Therapy Assistant) was attempting to place R157's feet back in the bed. V23 stated R157 was
complaining of chest pain. V23 stated he would inform the nurse of R157's complaint of chest pain. R157
face was grimaced and he did not respond to surveyor's questions.
On 02/25/25 at 11:48 AM, V18 RN (Registered Nurse) came to R157's bedside. V18 stated R157 fell a
couple of days ago and has been complaining of chest pain since then. V18 stated she would speak to the
NP (Nurse Practitioner) about the chest pain.
On 02/26/25 at 11:13 AM, V19 RN stated she had just sent R157 to the hospital for his complaint of chest
pain at 9:44 AM. He had been complaining of sternal and left chest / shoulder pain. V19 stated R157 was
given pain medication overnight for his complaints of pain. V19 stated the report she received was that
R157 had been yelling out since he came back to the facility on Sunday 2/23/25. V19 stated R157 was sent
back to the hospital on Sunday after his fall in the facility and he had been complaining about his chest pain
for days. V19 stated R157 had been medicated for his pain and the doctor thought it was muscular. V19
stated R157 had been rating his pain 10-11 out of 10 and he was still complaining of the pain after he
received pain medication. V19 stated she had a call out to the doctor this morning to update him about the
resident's pain. V19 stated while I was waiting for the doctor's return call, R157's wife called me stating
R157 told her he was being sent to the hospital. V19 stated she did not tell R157 he was being sent back to
the hospital and there was no plan to send R157 back to the hospital. V19 stated because R157 told his
wife he was being sent to the hospital, the doctor said to send him out.
On 02/27/25 at 11:56 AM, V20 (NP) stated R157 is not her regular patient, but V18 (RN) had asked her to
address his complaint of chest pain. V20 stated she look at R157's records and saw he was sent out for
chest pain. V20 stated she did not see any documentation of findings for R157's emergency room visit on
2/23/25. V20 stated when she spoke to R157, he stated he had rib pain with deep breathing and coughing.
V20 stated per V18, the chest CT (Computed Tomography) was done and was negative. V20 stated
because of those reasons, she did not order an X-ray. V20 stated she believed R157's pain was muscular.
On 02/27/25 at 02:27 PM, V2 DON (Director of Nursing) stated on Sunday 2/23/25, R157 was sent to the
hospital after a fall, and based on the imaging that was done, noting was found. V2 stated they did a CT
scan of his abdomen and pelvis and a hip X-Ray, that were negative. V2 stated V19 (RN) informed her
R157 was continuously complaining about his chest pain, and if a patient is complaining of chest pain, we
get their description of the pain and vital signs, talk to the doctor and send them to the hospital. V2 stated if
the chest pain is a new onset of chest pain, we send them out immediately. V2 stated when R157 initially
complained of chest pain, we sent him to the emergency room, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
they sent him back. V2 stated she did not know if a sufficient work up was done. V2 stated she believed the
nurses thought because he was sent out and evaluated by the emergency room, his concerns had been
addressed. V2 stated they would trust the emergency room worked R157 up correctly. V2 stated R157 was
sent back to the emergency room three days later on 2/26/25, when it was discovered that R157 actually
had a sternal fracture. V2 stated R157's rehabilitation will be more complex now with the sternal fracture in
addition to his hip fracture.
On 02/27/25 at 01:01 PM, V21 (Physical Therapist) stated for a resident with a sternal fracture, we try to
avoid that area and do deep breathing to improve the lung capacity. V21 stated if it is not a recent fracture,
we have the resident brace the sternal area to improve mobility and prepare the patient for their ADLs
(Activities of Daily Living). V21 stated we check the medical records for any information regarding fractures.
V21 stated the resident's pain could be increased if we move them without knowledge of the fracture and
they may begin to refuse therapy. V21 stated if we transfer them incorrectly and they have a fracture we are
unaware of, their fracture could become aggravated and worsen.
On 02/27/25 at 03:37 PM, V22 MD (Medical Doctor) stated he last saw R157 on Monday 2/24/25. V22
stated he believed R157 was complaining of pain everywhere, mostly his lower body. V22 stated the pain
complaints were peculiar because R157 was already receiving a high hydrocodone/acetaminophen. V22
stated he would expect staff to call 911 for residents that have complaints of chest pain.
Nursing progress notes by V18 (RN) on 2/24/25 at 1:33 PM showed R157 complained of pain in both arms
and chest area. R157 denied shortness of breath, nausea, vomiting and diarrhea. Pain mediation given.
Seen by NP. Vital signs- NP ordered calcium carbonate.
Hospital emergency room records dated 2/26/25 showed a fracture of the mid sternum.
The facility provided policy Pain -Clinical Protocol (dated October 2022) states the physician will help
identify causes of pain; for example, by examining the resident directly, reviewing the resident's history, and
via discussion with the resident and staff .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure proper care for resident receiving hemodialysis.
Residents Affected - Few
This applies to 1 resident (R27) reviewed for dialysis in a sample of 19.
The findings include:
On 2/25/25 at 9:52 AM, V1 (Administrator) and V2 (DON/Director of Nursing) said they do not have any
residents currently receiving Dialysis.
On 2/25/25 at 11:49 AM, it was noted that R27 was at a dialysis center outside the facility, receiving
dialysis. On 2/26/25 at 10:02 AM, R27 said she goes to outside facility for dialysis every Tuesday, Thursday,
and Saturday. R27 showed surveyor her right upper chest access port that is used for dialysis.
R27's Face Sheet shows she was admitted to the facility on [DATE] with primary diagnoses of end stage
renal disease (ESRD) and history of dependence on renal dialysis. R26's Care Plan dated 1/9/25 states
she goes to hemodialysis on Tuesday, Thursday, and Saturday.
On 2/26/25 at 1:45 PM, V1 (Administrator) said she did not have a current dialysis contract that she could
provide to the Surveyor. V1 said she was working on getting an agreement because she knew she needed
one.
On 2/27/25 at 9:40 AM, V10 (LPN/Licensed Practical Nurse) said R27 just left to go to dialysis. On 2/27/25
at 10:26 AM, V1 said she still could not provide surveyor with a dialysis agreement/contract. V1 said dialysis
agreements are a requirement because they ensure the resident's safety by having in writing a mutual
understanding of the services the facility is providing and the services the dialysis facility is providing and
any liability that may be imposed. V1 said she did not have a hemodialysis policy.
On 2/27/25 at 12:27 PM, V10 (LPN) said the only required communication between the facility and Dialysis
is the completion of the Dialysis Communication Form in the Dialysis binder kept at the nurse's station. V10
said the facility staff complete the top portion of the form labeled Pre-Dialysis and the dialysis facility will
then fill out the bottom portion labeled Dialysis and send it back to the facility with the resident after
completion of that day's dialysis.
R27's dialysis binder contained six Dialysis Communication Forms that were not completed since
admission: [DATE], 2/4/25, 2/8/25, 2/11/25, 2/15/25, and 2/18/25. There was also no Dialysis
Communication Form from 2/25/25.
On 2/27/25 at 1:15 PM, V2 (DON) said a dialysis contract/agreement is required to establish
communication and continuum of care for the dialysis resident. V2 said the communication that is expected
between the facility staff and dialysis staff is the completion of the Dialysis Communication Form. On
2/27/25 at 2:03 PM, V11 (Dialysis Center Nurse) said communication takes place on the Dialysis
Communication form in which the top portion is filled out by the facility and the bottom is filled out by
Dialysis Center staff. V11 said if there is any change in the resident's medications or the resident gets sent
to the hospital, the Dialysis staff will call the facility to update them, otherwise
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
they only communicate by the Dialysis Communication Form.
Level of Harm - Minimal harm
or potential for actual harm
The facility's policy titled, End-Stage Renal Disease, Care of a Resident with (revised September 2010)
states, Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to
currently recognized standards of care. Policy Interpretation and Implementation . 4. Agreements between
this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed,
including: a. how the care plan will be developed and implemented; b. how information will be exchanged
between the facilities; and c. responsibility for waste handling, sterilization and disinfection of equipment. 5.
The resident's comprehensive care plan will reflect the resident's needs related to ESRD/Dialysis care .
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
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.
Based on observation, interview and record review, the facility failed to dispose of expired house stock
medications from the medication room.
This has the potential to affect all 58 residents in the facility.
The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 2/25/2025 to 2/28/2025
showed a census of 58 residents.
The findings include:
On 2/26/2025 at 10:45 AM and 2/27/2025 at 10:45 AM, inspection of the facility's medication room showed
the following expired house stock medication:
Four boxes of hemorrhoidal cream that expired on 11/2024. A tube of expired hemorrhoidal cream was
found inside the medication cart in the north hall.
Four bottles of Elder Tonic that expired on 7/2024.
Seven boxes of Diphenhydramine 25 mg (100 capsules/box) that expired on 11/2024
Two bottles of Oyster Shell Calcium 500 mg plus Vitamin D tablet (1000 tablets) that expired on 10/2024.
On 2/26/2025 at 11:00 AM, V5 (LPN-Licensed Practical Nurse) said the night nurse checks the medication
room and is responsible for discarding expired medications.
On 2/26/2025 at 12:30 PM, V2 (DON-Director of Nursing) said it was the night supervisor's responsibility to
make sure the medication room is organized and expired medications are disposed of. On 2/27/2025 at
1:45 PM V2 said expired medications should be disposed of promptly so there is no chance of them being
administered to a resident. She said if medication is expired, medication has less potency. She said the
proper process of disposing of expired medication is to send medication, including house stock, back to the
pharmacy to be destroyed.
The facility's Medication Labeling and Storage Policy (revised February 2023) states if the facility has
discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted
for instructions regarding returning or destroying these items .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
4. On February 27, 2025 at 9:22 AM, V8 (CNA-Certified Nurse Assistant) provided incontinence care to
R209. While providing care, V8 wore gloves and surgical mask. After providing incontinent care and putting
on R209's clothes, V8 informed R209 she was stepping out of the room to call another staff to help her with
transfer.
Residents Affected - Some
On February 27, 2025 at 9:59 AM, V8 came back to R209's room with V9 (CNA). V8 and V9 were only
wearing gloves and surgical masks. V8 and V9 straightened out R209's clothing and proceeded to transfer
R209 using a mechanical lift.
R209's EHR (Electronic Health Record) documents she is on Enhanced Barrier Protection (EBP) for
surgical wounds. R209's wound is on her right hip. R209's door had a sign stating she is on EBP.
On February 27, 2025 at 10:57 AM, V3 (ADON-Assistant Director of Nursing/IP-Infection Preventionist) said
staff should wear gloves, gowns and mask when entering enhance barrier precaution room to provide care.
She said if there is a chance for splashing, staff should wear a face shield as well. She said all staff are
expected to wear appropriate PPE (Personal Protective Equipment). She said the purpose for wearing
appropriate PPE is to protect resident.
Based on observation, interview, and record review, the facility failed to follow guidelines for Personal
Protective Equipment (PPE) use and handwashing.
This applies to 4 of 4 residents (R4, R256, R43, R209) reviewed for infection control in a sample of 19.
The findings include:
1. On February 25, 2025 at 9:29 AM, V7 (CNA) went to assist R256 and did not apply the face shield before
entering R256's room. R256 was on contact isolation, droplet isolation, and EBP (Enhanced Barrier
Precautions) due to being positive for COVID-19. R256's isolation signages showed the staff should wear a
gown, gloves, N95 respirator mask, and a face shield prior to entering the room. At 9:30 AM, V6 (CNA) also
entered R256's room without applying a face shield.
R256's face sheet showed he was admitted to the facility with diagnoses including COVID-19.
On February 27, 2025 at 11:39 AM, V7 said she should wear a gown, N95, face shield, and gloves before
entering a COVID-19 positive room. V7 said not wearing the appropriate PPE (Personal Protective
Equipment) could expose her to COVID-19 and she could also spread the infection to other residents.
On February 27, 2025 at 11:34 AM, V17 (CNA) said for COVID-19 isolation, the staff should wear an N95
mask, gown, gloves, and goggles or face shield. V17 also said she would wear a gown, gloves, and a mask
for residents on EBP. V17 said when she provided incontinence care, she would clean her hands upon
entry of the resident's room and after she had completed providing incontinence care, prior to leaving the
room.
On February 27, 2025 at 11:25 AM, V6 (RN) said for residents under COVID-19 isolation, the staff should
wear an N95 mask, gown, face shield, and gloves. V6 said for residents on EBP, the staff should wear a
gown and gloves. V6 also said for incontinence care, the staff should change their gloves
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145606
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Living - Windsor Park
110 Windsor Park Drive
Carol Stream, IL 60188
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
and wash their hands before touching the clean items.
Level of Harm - Minimal harm
or potential for actual harm
The facility's Coronavirus Disease (COVID-19)- Using Personal Protective Equipment policy revised
September 2022 showed Personnel who enter the room of a resident with suspected or confirmed
SARS-CoV-2 infection adhere to standard precautions and use a NIOSH-approved N95 or equivalent or
higher-level respirator, gown, gloves, and eye protection.
Residents Affected - Some
2. On February 26, 2025 at 1:50 PM, R43's room was on EBP (Enhanced Barrier Precautions), with
signage for EBP and an isolation cart outside his room containing gowns and gloves. R43 was in the
bathroom and V4 (CNA) was wiping R43's perianal area and was not wearing a gown.
On February 26, 2025 at 1:52 PM, V4 said R43 was only on precautions for handwashing. V4 then looked
at R43's EBP signage and said she should have worn a gown, gloves, and a mask when taking him to the
bathroom.
R43's face sheet showed he was admitted to the facility with diagnoses including attention to gastrostomy,
Parkinson's disease without dyskinesia, severe protein-calorie malnutrition, and cognitive communication
deficit.
The facility's Enhanced Barrier Precautions revised August 2022 showed Enhanced barrier precautions
(EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug
resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact
resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident
care activities requiring the use of gown and gloves for EBPs include: providing hygiene; changing briefs or
assisting with toileting .
3. On February 26, 2025 at 9:35 AM, V6 (CNA/Certified Nurse Assistant) provided incontinence care for
R4. V6 wiped R4's perineal area, tucked the dirty incontinence brief and incontinence pad underneath R4
and then placed the clean brief and pad underneath her using the same soiled gloves. V6 then said R4 had
a bowel movement, so wiped her again, went to the bathroom and turned on the water but did not perform
hand hygiene with soap and water or alcohol-based hand sanitizer, and applied new gloves. V6 then
grabbed a clean brief and placed it under R4 and affixed her brief. V6 went into the bathroom again, turned
on the water, but did not wash her hands with soap and water or alcohol-based hand sanitizer before
applying new gloves. V6 returned to the resident and fixed her blanket. V6 then returned to the bathroom
again, turned on the water, and did not wash her hands with soap and water or use alcohol-based hand
sanitizer, and applied new gloves. V6 said she should have washed her hands with each of the glove
changes.
The facility's Handwashing/Hand Hygiene policy revised August 2019 showed Use an alcohol-based hand
rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for
the following situations: Before and after direct contact with residents; after contact with blood or bodily
fluids; After removing gloves .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145606
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
12 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F693 - Assisted nutrition and hydration
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.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F761 - Labeling of Drugs and Biologicals
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0361GeneralS&S Epotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
FAQ · About this visit
Common questions about this visit
What happened during the February 28, 2025 survey of COVENANT LIVING - WINDSOR PARK?
This was a inspection survey of COVENANT LIVING - WINDSOR PARK on February 28, 2025. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COVENANT LIVING - WINDSOR PARK on February 28, 2025?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriat..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.