Inspection Reports for Covenant Living at Windsor Park

124 Windsor Park Dr, Carol Stream, IL 60188, IL, 60188

Back to Facility Profile

Inspection Report Summary

The most recent inspection on July 28, 2025, identified deficiencies related to tuberculosis testing for one employee and the facility operating under an expired license affecting several residents. Earlier inspections were not provided for comparison, so broader inspection patterns cannot be determined. The main issues involved employee health screening and administrative compliance with licensing requirements. The complaint investigation conducted during this inspection was unsubstantiated with no deficiencies cited. The facility submitted a plan of correction addressing these deficiencies, including audits and re-education, indicating steps toward compliance.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

14% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

4 3 2 1 0
2025

Inspection Report

Annual Inspection
Census: 69 Deficiencies: 2 Date: 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.

Complaint Details
Complaint Investigation Survey IL195795/2576085 was unsubstantiated with no deficiency 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.

Deficiencies (2)
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
NameTitleContext
E8Certified Nursing AssistantEmployee with tuberculosis testing deficiency
E10Human Resources DirectorProvided information about TB testing acceptance policy
E2Nurse ManagerPresented resident roster at entrance
E1Executive DirectorConfirmed expired license and submitted current license copy

Inspection Report

Annual Inspection
Capacity: 72 Deficiencies: 2 Date: 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)
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
NameTitleContext
Rene FlaggAssisted Living DirectorSigned plan of correction and named in training attendance record (Exhibit E)
Tracey CookHRNamed in TB screening training attendance record (Exhibit C)

Viewing

Loading inspection reports...