Covenant Living - Windsor Park

Penalties

• Jul 17, 2023 — IDPH fine (Nursing Home Care Act) ($2,200)

Inspection findings

1. Jun 3, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 11, 2025 · CMS health inspection

2. Feb 28, 2025 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Mar 24, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Mar 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 11, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0361 Smoke Deficiencies

     Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 24, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 25, 2025 · CMS fire safety

3. Apr 19, 2024 Health · 13 findings
   • Not serious Scope/severity E

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0133 Construction Deficiencies

     Install a two-hour-resistant firewall separation.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected May 24, 2024 · CMS fire safety

4. Aug 25, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Sep 6, 2023 · CMS health inspection

5. Jul 17, 2023 Health · 11 findings
   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 24, 2023 · CMS health inspection

   • Serious Scope/severity L

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jul 24, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 24, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Jul 24, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0835 Administration Deficiencies

     Administer the facility in a manner that enables it to use its resources effectively and efficiently.

     Corrected Jul 24, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Jul 24, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0133 Construction Deficiencies

     Install a two-hour-resistant firewall separation.

     Corrected Aug 4, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Aug 2, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Aug 2, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Aug 2, 2023 · CMS fire safety

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.3240a). This instance in accordance with 300.282f) and j) of the Code is assessed a fine due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.3240a).

     Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• CREANEY, JANET — corporate director, NOT APPLICABLE, since 08/01/2023
• ERICKSON, DAVID — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 04/01/2026
• ERICKSON, DAVID — corporate officer, NOT APPLICABLE, since 06/01/2024
• HOFFMAN, JANET — corporate director, NOT APPLICABLE, since 07/01/2023
• JUSTIE, JEANNIE — corporate officer, NOT APPLICABLE, since 09/21/2020
• KALHEIM, CORY — corporate officer, NOT APPLICABLE, since 07/01/2024
• LITTLE, ABBIE — adp of the snf, NOT APPLICABLE, since 11/11/2025
• LITTLE, ABBIE — operational/managerial control, NOT APPLICABLE, since 08/11/2023
• MEANS, JENNIFER — corporate director, NOT APPLICABLE, since 07/01/2025
• MILIDRAG, SANJA — operational/managerial control, NOT APPLICABLE, since 07/23/2021
• PIPITONE, ANTHONY — adp of the snf, NOT APPLICABLE, since 11/24/2025
• PIPITONE, ANTHONY — operational/managerial control, NOT APPLICABLE, since 11/14/2014
• SMITH, SHELLY — operational/managerial control, NOT APPLICABLE, since 01/18/2021
• WARNYGORA, EMILY — corporate director, NOT APPLICABLE, since 07/01/2021
• COVENANT LIVING COMMUNITIES & SERVICES — adp of the snf, NOT APPLICABLE, since 03/13/1985
• COVENANT LIVING COMMUNITIES & SERVICES — 5% or greater direct ownership interest, 100%, since 03/13/1985
• COVENANT MINISTRIES OF BENEVOLENCE — 5% or greater indirect ownership interest, since 03/13/1985
• THE EVANGELICAL COVENANT CHURCH OF AMERICA — 5% or greater indirect ownership interest, since 03/13/1985