Inspection Reports for Covenant Living at Windsor Park
124 Windsor Park Dr, Carol Stream, IL 60188, IL, 60188
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Inspection Report
Annual Inspection
Census: 69
Deficiencies: 2
Jul 28, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey and included a Complaint Investigation Survey which was unsubstantiated with no deficiencies cited.
Findings
The facility failed to ensure tuberculosis testing was conducted within the required timeframe for one of eight employees reviewed, and was found to be operating under an expired license affecting seven residents reviewed. The complaint investigation was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint Investigation Survey IL195795/2576085 was unsubstantiated with no deficiency cited.
Deficiencies (2)
| Description |
|---|
| Failed to ensure Tuberculosis testing was done within 90 days prior to hire or within 10 days after hire for one employee (E8). |
| Facility was operating under an expired license affecting seven residents receiving services. |
Report Facts
Residents present: 69
Employees reviewed for TB screening: 8
Residents reviewed for expired license impact: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Certified Nursing Assistant | Employee with tuberculosis testing deficiency |
| E10 | Human Resources Director | Provided information about TB testing acceptance policy |
| E2 | Nurse Manager | Presented resident roster at entrance |
| E1 | Executive Director | Confirmed expired license and submitted current license copy |
Inspection Report
Annual Inspection
Capacity: 72
Deficiencies: 2
Jul 28, 2025
Visit Reason
The document is a plan of correction submitted in response to the Annual Licensure Survey conducted on 7/28/25 at Covenant Living at Windsor Park Assisted Living, addressing compliance allegations.
Findings
The plan of correction addresses deficiencies related to employee health evaluations, specifically tuberculosis (TB) screening and license renewal requirements. Corrective actions include audits, updated onboarding checklists, re-education, and timely license renewal processes.
Deficiencies (2)
| Description |
|---|
| Failure to ensure employee compliance with TB testing policy. |
| Failure to timely renew facility license. |
Report Facts
Total licensed capacity: 72
License effective date: Jul 17, 2025
License expiration date: Jul 17, 2026
Corrective action completion date for TB screening: Aug 15, 2025
Corrective action completion date for license renewal: Jul 29, 2025
Renewal process initiation timeframe: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rene Flagg | Assisted Living Director | Signed plan of correction and named in training attendance record (Exhibit E) |
| Tracey Cook | HR | Named in TB screening training attendance record (Exhibit C) |
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