Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COVENANT LIVING - WINDSOR PARK
CAROL STREAM, IL · 80 certified beds · Last Life Safety survey February 28, 2025
CMS Certification Number 145606 · first certified March 1989
Ownership
Operated by COVENANT LIVING · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
19 citations — more than 61% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (January 2026 to April 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was February 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 19 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 17, 2023 | 4 |
| April 19, 2024 | 8 |
| February 28, 2025 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-02-28 |
| K-0133 | Install a two-hour-resistant firewall separation. | 2 | 2024-04-19 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-02-28 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2024-04-19 |
| K-0281 | Install proper backup exit lighting. | 1 | 2024-04-19 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2023-07-17 |
| K-0271 | Have exits that are accessible at all times. | 1 | 2024-04-19 |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | 1 | 2025-02-28 |
What the citations cover
- Smoke Deficiencies 10
- Egress Deficiencies 3
- Construction Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Egress Deficiencies | 3 |
| Construction Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 28, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 25, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 26, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (March 25, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 25, 2025) |
April 19, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 24, 2024) |
July 17, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (August 2, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 2, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 2, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.