Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Covenant Living - Windsor Park during CMS and state inspections, most recent first.
A resident with a history of falls and multiple medical conditions was not provided with required staff assistance or a gait belt during a toilet transfer. The CNA left the resident walking alone with a walker and did not use a gait belt, leading to a fall that caused multiple rib fractures and other injuries. Facility policy and training required the use of a gait belt and staff assistance, which were not followed.
The facility failed to dispose of expired medications, including hemorrhoidal cream and Diphenhydramine, which were found during inspections. Staff interviews revealed that the night nurse and supervisor were responsible for discarding expired medications, but this was not done, leading to a deficiency.
The facility failed to follow proper PPE and hand hygiene protocols, as observed in several instances. Staff entered a COVID-19 isolation room without face shields, provided care to residents under Enhanced Barrier Precautions without gowns, and neglected hand hygiene during incontinence care. These actions were contrary to the facility's policies, risking infection spread among residents with conditions like COVID-19 and surgical wounds.
The facility failed to follow physician orders and proper procedures for managing gastrostomy feeding tubes (GT) for three residents, leading to potential complications. A resident with a history of dysphagia had their bed improperly elevated, increasing aspiration risk. Two other residents received GT feedings without proper placement verification, as the facility's practice of checking placement by gravity was unsupported by documented procedures. These deficiencies highlight lapses in adhering to care protocols for residents with complex medical needs.
A resident experienced ongoing chest pain after a fall, which was initially dismissed as muscular by facility staff. Despite severe pain complaints, the resident's condition was not thoroughly investigated until days later, when a sternal fracture was discovered. The facility's reliance on an initial ER evaluation without further follow-up led to inadequate pain management and delayed diagnosis.
A facility failed to provide appropriate dialysis care for a resident with ESRD, as evidenced by the lack of a current dialysis contract and incomplete communication forms. Despite the resident's regular dialysis schedule, the facility's administrator and DON initially claimed no residents were receiving dialysis. The absence of a formal agreement and incomplete communication forms compromised the resident's continuum of care.
The facility failed to obtain physician orders and complete self-administration assessments for eight residents who had medications at their bedside. Medications were found without proper authorization or documentation, and staff acknowledged that necessary assessments and documentation were not completed.
The facility failed to provide adequate ADL care to three residents, as they were observed with facial hair on multiple occasions despite needing assistance with personal hygiene. Staff interviews confirmed that CNAs are responsible for grooming tasks, which are supposed to be performed twice a week and as needed, but this was not adhered to according to the facility's policy.
The facility failed to ensure that anti-contracture devices were applied as ordered for two residents. One resident with right wrist pain and another with hemiplegia were observed multiple times without their required splints, despite care plans indicating their necessity. The Restorative Nurse confirmed that CNAs were responsible for applying the splints during the day, highlighting a lapse in adherence to care plans and facility policy.
A facility failed to properly position an indwelling catheter bag during care, causing urine backflow. The CNA placed the catheter drainage bag on the bed and lifted it above the bladder line while cleaning the tubing. The DON confirmed that the catheter bag should be below the bladder line to allow urine to flow with gravity, as per the facility's policy.
The facility failed to follow infection control protocols during wound care for three residents. Staff did not perform hand hygiene, change gloves, or properly contain soiled linen, leading to potential cross-contamination and infection risks.
Failure to Provide Required Assistance and Use Gait Belt During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide required assistance and utilize a gait belt during a toilet transfer for a resident identified as needing moderate assistance. The resident, who had a history of falls, muscle weakness, and multiple orthopedic conditions, was documented as high risk for falls and required one-person assistance for transfers according to the care plan and staff assignment sheet. On the day of the incident, a CNA assisted the resident out of bed and provided a walker but did not remain with the resident during ambulation, instead stepping into the bathroom to retrieve gloves. The CNA also did not use a gait belt during the transfer or ambulation, contrary to facility policy and the resident's care plan. As a result, the resident lost balance while walking unassisted to the bathroom, fell backward, and sustained multiple serious injuries, including rib fractures, a lung laceration, and a large bruise. The incident was confirmed by interviews with the resident, CNA, and nursing staff, as well as review of the medical record and hospital report. Facility policy and recent fall prevention training both required the use of a gait belt during all transfers and ambulation, which was not followed in this case.
Failure to Dispose of Expired Medications
Penalty
Summary
The facility failed to dispose of expired house stock medications from the medication room, which has the potential to affect all 58 residents. During inspections on two consecutive days, surveyors observed several expired medications, including hemorrhoidal cream, Elder Tonic, Diphenhydramine, and Oyster Shell Calcium with Vitamin D tablets. These medications had expiration dates ranging from July 2024 to November 2024, indicating they were not removed in a timely manner. Interviews with facility staff revealed that the responsibility for checking and discarding expired medications fell to the night nurse and the night supervisor. The Director of Nursing confirmed that expired medications should be disposed of promptly to prevent administration to residents, as expired medications may have reduced potency. The facility's policy requires contacting the dispensing pharmacy for instructions on returning or destroying outdated medications, but this procedure was not followed, leading to the deficiency.
Inadequate PPE Use and Hand Hygiene in Infection Control
Penalty
Summary
The facility failed to adhere to proper Personal Protective Equipment (PPE) protocols and hand hygiene practices, as observed in multiple instances involving staff and residents. In one case, two CNAs entered the room of a resident on contact and droplet isolation for COVID-19 without wearing the required face shields, despite the signage indicating the need for a gown, gloves, N95 respirator mask, and face shield. The CNAs acknowledged the oversight and the potential risk of spreading infection. The facility's policy required adherence to these precautions for residents with suspected or confirmed SARS-CoV-2 infection. Another incident involved a CNA providing care to a resident under Enhanced Barrier Precautions (EBP) without wearing a gown, as required by the facility's policy for high-contact activities. The CNA initially believed the precautions were only for handwashing but later recognized the need for a gown, gloves, and mask. The resident had multiple diagnoses, including attention to gastrostomy and severe protein-calorie malnutrition, necessitating strict adherence to EBP to prevent the spread of multi-drug resistant organisms. Additionally, a CNA failed to perform proper hand hygiene while providing incontinence care to a resident. The CNA used the same soiled gloves to handle clean items and did not wash hands between glove changes, contrary to the facility's hand hygiene policy. Another instance involved two CNAs providing care to a resident on EBP for surgical wounds without wearing gowns, as required. The Assistant Director of Nursing confirmed the expectation for staff to wear appropriate PPE, including gloves, gowns, and masks, to protect residents and prevent infection spread.
Failure to Follow GT Management Protocols
Penalty
Summary
The facility failed to adhere to physician orders and proper procedures for managing gastrostomy feeding tubes (GT) for three residents, leading to potential complications. Resident R42 was observed with a wet, gargly cough, indicating possible aspiration due to the head of the bed being elevated only to 20 degrees instead of the required 45 degrees as per physician orders. This resident had a history of dysphagia and acute respiratory issues, making the correct bed elevation crucial to prevent aspiration during continuous tube feeding. Despite the presence of aspiration precautions in the care plan, staff failed to maintain the necessary head elevation, increasing the risk of aspiration. For Resident R4, the facility did not follow proper procedures to verify GT placement before administering water and medications. The LPN did not check for placement by aspirating gastric content or checking residual volume, which is a critical step to ensure the tube is correctly positioned. The facility's practice of checking placement by gravity was not supported by documented procedures or literature, and the Director of Nursing could not provide evidence of this practice being acceptable. This resident had severe cognitive impairment and multiple diagnoses, including gastroesophageal reflux disease, which necessitated careful management of the GT. Similarly, Resident R43's GT feeding was administered without verifying tube placement by aspirating gastric content or checking residual volume. The LPN poured water into the GT without ensuring proper placement, which could lead to improper administration of feedings. This resident had severe protein-calorie malnutrition and cognitive communication deficits, requiring precise management of nutritional intake. The facility's policy lacked specific procedural steps for checking GT placement, contributing to the deficiencies observed in the care of these residents.
Failure to Investigate Resident's Chest Pain Leads to Delayed Diagnosis
Penalty
Summary
The facility failed to adequately investigate and address a resident's ongoing complaints of chest pain, which were initially dismissed as muscular pain following a fall. The resident, admitted for orthopedic aftercare post-hip fracture surgery, began experiencing chest pain after a fall in the facility. Despite repeated complaints of severe pain, rated as 10-11 out of 10, and the administration of pain medication, the resident's condition was not thoroughly investigated. The resident was sent to the hospital after the fall, but upon return, continued to experience significant pain, which was not immediately addressed by the facility staff. The resident's pain was eventually found to be due to a sternal fracture, discovered only after being sent back to the hospital days later. The facility's staff, including the RN and NP, did not conduct a comprehensive assessment or follow-up on the initial emergency room visit findings, leading to a delay in identifying the true cause of the resident's pain. The Director of Nursing acknowledged that the staff relied on the initial emergency room evaluation and did not pursue further investigation, resulting in inadequate pain management and a more complex rehabilitation process for the resident.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease (ESRD) who required hemodialysis. Despite the resident's care plan indicating that she attends dialysis sessions three times a week, the facility's administrator and director of nursing initially claimed that no residents were receiving dialysis. The resident, however, confirmed her regular dialysis schedule and showed the surveyor her access port. The facility lacked a current dialysis contract, which is necessary to ensure a mutual understanding of services and resident safety. The administrator acknowledged the absence of a contract and a hemodialysis policy. Additionally, the facility did not maintain proper communication with the dialysis center. The Dialysis Communication Forms, which are supposed to be completed by both the facility and the dialysis center, were found incomplete for several dates since the resident's admission. The facility's policy requires agreements with the dialysis center to manage the resident's care, including communication and care plan development. However, the lack of completed communication forms and a formal agreement indicates a failure to adhere to these standards, compromising the resident's continuum of care.
Failure to Obtain Physician Orders and Complete Self-Administration Assessments
Penalty
Summary
The facility failed to obtain physician orders for resident medications and to complete self-administration of medication assessments for eight residents. Medications were found at the bedside of these residents without proper authorization or documentation. For instance, one resident had Nasacort nasal spray on her bedside table without an order for it to be there, and no self-administration assessment or care plan was completed. Another resident had Klayesta topical powder in her room without an order for it to be at the bedside, and similarly, no self-administration assessment or care plan was done. Several other residents were found with medications at their bedside, including an inhaler, eye drops, and a pill box containing various supplements, none of which had corresponding physician orders or self-administration assessments. One resident had a Levalbuterol Tartrate inhaler on her bedside table without an order, and she stated that no one had taught her how to use it. Another resident had a pill box with multiple medications prepared by her daughter, but there was no physician order or self-administration assessment for these medications. The facility's policy requires a physician's order, a self-administration assessment, and a care plan for residents to self-administer medications. However, these steps were not followed for the residents in question. The Director of Nursing and other staff members acknowledged that no residents had orders to self-administer medications and that the necessary assessments and documentation were not completed. This lack of compliance with the facility's policy and regulatory requirements led to the deficiencies observed by the surveyors.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care to three residents, as observed and documented by surveyors. Resident R5, who has moderately impaired cognition and requires partial assistance with personal hygiene, was observed on multiple occasions with facial hair on her chin, indicating a lack of grooming. Similarly, Resident R6, who has severely impaired cognition and is dependent on staff for all personal hygiene, was also observed with facial hair on her chin. Resident R9, who has intact cognition but requires substantial assistance with personal hygiene, expressed dissatisfaction with her facial hair, which was noted on multiple occasions as well. Interviews with staff, including a CNA and the Director of Nursing, confirmed that CNAs are responsible for grooming tasks such as shaving and nail care, which are supposed to be performed twice a week and as needed. The facility's ADL Support policy, revised in March 2018, mandates that appropriate care and services be provided for residents who are unable to carry out ADLs independently, including support with hygiene. The observations and interviews indicate that the facility did not adhere to its own policy, resulting in the deficiency in providing necessary grooming and hygiene care to the residents.
Failure to Apply Anti-Contracture Devices as Ordered
Penalty
Summary
The facility failed to ensure that anti-contracture devices were applied as ordered for two residents. Resident 5 (R5) was observed on multiple occasions without the required right wrist splint, despite having diagnoses of injury to the right wrist, hand, and finger, as well as right wrist pain and wrist drop. R5's care plan indicated the need for a right wrist splint due to wrist pain, but observations on three different days showed that the splint was not applied. R5's cognition was noted to be moderately impaired, which may have contributed to the resident's inability to ensure the splint was applied independently. Similarly, Resident 6 (R6) was observed without the required right hand splint on multiple occasions. R6 had diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The care plan for R6 indicated the need for a right hand splint due to contracture, but observations showed that the splint was not applied. R6's cognition was severely impaired, further necessitating the need for staff to ensure the splint was applied. The Restorative Nurse confirmed that the splints were to be applied during the day and removed at night, and that CNAs were responsible for this task, indicating a lapse in adherence to the care plan and facility policy.
Improper Positioning of Catheter Bag
Penalty
Summary
The facility failed to properly position an indwelling catheter bag during care for a resident. During an observation, a Certified Nurse Aide placed the resident's catheter drainage bag on the bed and lifted it above the bladder line while cleaning the catheter tubing, causing backflow of urine. The Director of Nursing confirmed that the catheter bag should be positioned below the bladder line to allow urine to flow with gravity. The facility's policy on urinary catheter care, revised in August 2022, also states that the drainage bag should be positioned lower than the bladder at all times to prevent urine backflow.
Infection Control Deficiencies During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during wound care for three residents. In the first instance, a wound care doctor (WCD) did not perform hand hygiene or change gloves after measuring a resident's wounds and touched the door handle before re-entering the room. The wound care nurse (WCN) also failed to perform hand hygiene or change gloves after handling soiled gauze and applied a dressing that had fallen on the wheelchair to the resident's wound. In the second instance, the WCD did not establish a clean field while measuring another resident's wound and failed to perform hand hygiene after removing gloves and touching the door handle. The WCN then applied a dressing without cleaning the wound or performing hand hygiene. In the third instance, a certified nursing assistant (CNA) was observed throwing soiled linen on the floor instead of placing it in a covered hamper, as required by facility policy. The Director of Nursing (DON) confirmed that soiled linen should not be thrown on the floor and must be placed directly into a covered hamper. The DON also acknowledged that the wound care nurse did not follow infection control principles during the dressing changes for the two residents. Facility policies on 'Laundry and Linen' and 'Wound Care' were not adhered to, leading to potential cross-contamination and infection risks for the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ahva Care Of Winfield | 2.5 mi | ★★★★★ | 0 | 0 |
| Wheaton Village Nrsg & Rhb Ctr | 2.6 mi | ★★★★★ | 2 | 0 |
| Wynscape Health & Rehab | 2.8 mi | ★★★★★ | 3 | 0 |
| Aperion Care West Chicago | 3 mi | ★★★★★ | 22 | 0 |
| Dupage Care Center | 3 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.