Below 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 Laurel Meadows Wellness & Rehabilitation during CMS and state inspections, most recent first.
A resident with ALS and communication difficulties was not treated with dignity and respect by a CNA, who failed to follow the care plan's communication strategies, rushed the resident, and responded impatiently and dismissively during a meal service. The resident became upset and distressed as a result of the interaction, which did not align with facility policy on resident rights.
Two residents reported rough handling by a CNA during care, causing pain and distress. One resident with severely impaired cognition felt rushed and tearful, while another with moderately impaired cognition experienced pain during incontinence care. The DON acknowledged the CNA might have been hurried but was unaware of the issues.
The facility failed to maintain safe and comfortable temperatures on the third floor when air conditioning blower units malfunctioned. Residents, including those with hypertension and dementia, experienced discomfort due to high temperatures, with some rooms reaching 86.5 degrees Fahrenheit. The facility did not follow its policy for extreme temperatures, failing to relocate residents or monitor temperatures adequately.
The facility failed to serve correct portion sizes and menu items to residents on regular, mechanical soft, and pureed diets. Dietary staff did not use the spreadsheet menu to select appropriate serving utensils, resulting in incorrect portions and food items being served. A resident on a pureed diet received different items than those listed on the menu, highlighting a lack of adherence to dietary guidelines.
The facility failed to maintain cleanliness and proper labeling in food storage areas, leading to potential contamination. Observations revealed debris in the ice machine, unlabeled food items, and improper food handling practices during meal service. Staff interviews confirmed lapses in adherence to facility policies on sanitation and food safety.
The facility failed to provide updated pneumococcal vaccine education and options according to CDC guidelines for four residents admitted after new guidance was released. Despite having policies in place, the facility did not ensure these residents were offered the PCV20 vaccine. Interviews revealed a lack of awareness about vaccination status, and both the DON and MD expected staff to educate and offer vaccines based on guidelines.
The facility failed to inspect bed frames, mattresses, and bed rails for safety, leading to potential entrapment risks for four residents. Observations showed loose bed rails with significant gaps, and no entrapment risk assessments were documented. Despite residents reporting issues, the facility did not address these safety concerns, and the DON was unaware of the relevant regulations.
A resident with severe cognitive impairment was found with a small bruise on the pubic area, which was not reported to the administration or state agency as required. The LPN assessed the bruise but did not consider it concerning enough to report, despite facility policy mandating immediate reporting of any injury of unknown origin. The DON and administrator were unaware of the incident until informed by the state agency.
A resident with unspecified psychosis and on a daily aspirin regimen was found with a bruise of unknown origin. The bruise was discovered by an aide and reported to an LPN, who assessed it but did not notify the DON or administrator, contrary to facility policy. The DON and administrator were unaware of the bruise until informed by the state agency, highlighting a failure to investigate potential abuse.
A resident with severe cognitive impairment and multiple diagnoses experienced medication administration errors due to improper flushing of a feeding tube. The LPN failed to follow facility policy and physician orders, resulting in a 23.3% medication error rate. The resident's medications were not flushed appropriately between doses, leading to a clogged tube and missed medication.
The facility failed to maintain a meat slicer in the main kitchen, which was found to be broken and sitting in a layer of grease. The Dietary Director and Consultant Dietitian confirmed the slicer had been non-functional for years, with safety concerns due to improper blade attachment. The Administrator was unaware of the issue and cited budget constraints as a barrier to purchasing a new slicer.
Failure to Provide Dignified and Respectful Care to Resident with Communication Needs
Penalty
Summary
A deficiency occurred when a resident with ALS, who was cognitively intact but had significant communication difficulties, was not treated with dignity and respect by a Certified Nurse Aide (CNA). The resident relied on a dry erase board and required extra time to communicate, as documented in the care plan. During a meal service, CNA A interacted with the resident in an impatient and dismissive manner, failing to allow adequate time for the resident to express preferences and not following established communication strategies such as asking yes/no questions or using a patient, positive approach. Video footage showed that CNA A did not introduce themselves, used a flat and later frustrated tone, and repeatedly rushed the resident, not giving them time to respond or write on the communication board. CNA A became visibly frustrated, spoke loudly, and ultimately dismissed the resident's attempts to communicate, telling the resident to "eat your food and drink your Coke" before leaving the room. The resident was left upset, continued to call for help, and was visibly distressed after the interaction. Interviews confirmed that CNA A was unfamiliar with the resident's needs and communication methods, and did not follow the care plan instructions for interacting with the resident. The resident reported feeling scared, frustrated, and disrespected by CNA A's behavior, and a family member expressed concern about CNA A working with vulnerable residents. The facility's policy required staff to treat residents with consideration, respect, and dignity, which was not upheld in this incident.
Failure to Provide Dignified and Respectful Care
Penalty
Summary
The facility failed to provide care in a dignified and respectful manner for two residents, both of whom were dependent on staff for activities of daily living and had impaired cognition. Resident #5, who had severely impaired cognition and was always incontinent, reported that CNA C was rough while moving them in bed, causing pain and distress. The resident expressed feeling upset and tearful, indicating that the care provided was not in line with the facility's policy of treating residents with consideration, respect, and dignity. Similarly, Resident #4, who had moderately impaired cognition and required maximal assistance, reported that CNA C was rough during incontinence care, causing pain by grabbing the resident's arm. The resident was upset by the interaction and did not understand why CNA C was upset with them. The Director of Nursing acknowledged that CNA C might have been in a hurry, leading to unintentional roughness, but was unaware of the residents' concerns prior to the interviews.
Failure to Maintain Safe Temperature Levels on Third Floor
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature for residents on the third floor when the blower units for the air conditioner stopped functioning. The facility did not monitor the air temperatures while waiting for the units to be replaced and did not relocate residents to areas with acceptable temperatures. This affected rooms 321 through 331, with temperatures recorded as high as 86.5 degrees Fahrenheit in some rooms. The facility's policy for extreme temperatures was not followed, as the staff did not move residents to other air-conditioned parts of the building or monitor the environment thermometers on a 24-hour basis. The Maintenance Director was aware of the issue but did not monitor the temperatures or know the acceptable temperature range. Portable air conditioning units were placed in the hallways, and fans were used in the affected rooms, but these measures were insufficient to maintain a comfortable environment. Several residents were affected by the high temperatures, including those with conditions such as hypertension, dementia, and stroke. Interviews with residents and their families revealed discomfort due to the heat, with some residents appearing flushed and disheveled. The Administrator was initially unaware of the facility's policy regarding temperature control and only began implementing it after the surveyors left.
Failure to Serve Correct Portions and Menu Items
Penalty
Summary
The facility failed to serve the correct portion sizes and appropriate food items to residents on regular, mechanical soft, and pureed diets. Observations revealed that dietary staff did not use the dietary spreadsheet menu to select the correct serving utensils, resulting in all residents on regular and mechanical soft diets receiving a 4-ounce portion of turkey tetrazzini instead of the prescribed 6-ounce portion. Additionally, residents on a mechanical soft diet were served from the same pan as those on a regular diet, and they received regular carrots instead of diced ones. For the resident on a pureed diet, the facility did not adhere to the dietary spreadsheet menu. Instead of receiving the planned pureed turkey tetrazzini, pureed carrots, pureed bread, and pureed dessert, the resident was served pureed chicken, pureed green beans, and mashed potatoes with gravy. The resident did not receive any pureed bread or dessert, and the meal did not match the menu items that were supposed to be served. Interviews with dietary staff and the dietary director confirmed that the spreadsheet menu should guide the selection of serving utensils and ensure that residents on pureed diets receive the same food items as those on regular diets. However, the staff failed to follow these guidelines, leading to inconsistencies in meal preparation and service. The consultant dietitian also emphasized the importance of using the spreadsheet menu to ensure proper serving sizes and adherence to the menu for all therapeutic diets.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the ice machine in a clean and sanitary condition, as evidenced by the accumulation of pink and black debris on the interior of the unit. Despite the facility's policy requiring regular cleaning, observations revealed that the ice machine had not been adequately maintained. Interviews with the Dietary Director and Consultant Dietitian confirmed that the machine should be clean to prevent bacterial growth. The facility also failed to properly label, date, and store food and beverage items, leading to potential contamination. Observations showed unlabeled and undated pitchers of liquid, improperly stored chocolate syrup and lemon juice, and expired or improperly dated meat products. The Dietary Director acknowledged that staff were responsible for cleaning and labeling, but these tasks were not consistently performed, resulting in expired and potentially unsafe food items being stored. Additionally, the facility did not adhere to safe food handling practices during meal service. Observations noted that staff did not change gloves after handling utensils and ready-to-eat food, and a staff member's nametag came into contact with food. The Dietary Director and Consultant Dietitian confirmed that proper hand hygiene and glove use were not followed, increasing the risk of cross-contamination during food preparation and service.
Failure to Provide Updated Pneumococcal Vaccine Education and Options
Penalty
Summary
The facility failed to provide updated pneumococcal vaccine education and the option to receive the updated vaccination according to the current CDC guidelines for four residents. These residents were admitted after new guidance was released, yet the facility did not ensure they were offered the PCV20 vaccine. The facility's policy, dated 7/2016, required that all residents be assessed for eligibility and offered the pneumococcal vaccine series within thirty days of admission unless medically contraindicated or already vaccinated. However, the facility did not adhere to this policy for the residents in question. Resident #271, who was over a certain age and admitted with acute on chronic systolic heart failure and dementia, had a signed consent for immunization but no documentation of receiving the pneumococcal vaccine. Similarly, Resident #54, admitted with an intestinal obstruction, had received previous pneumococcal vaccines but was not offered the PCV20. Resident #275, admitted with a surgical site infection and emphysema, had no documentation of receiving or being offered the pneumococcal vaccine. Resident #318, admitted with fractures, had received previous pneumococcal vaccines but was not offered the PCV20. Interviews with the residents and their representatives revealed a lack of awareness about the vaccination status and offerings. The Director of Nursing and the Medical Director both expressed expectations that staff should educate and offer vaccines based on CDC guidelines and follow physician orders. However, the facility's failure to update its practices and documentation led to the deficiency in providing appropriate pneumococcal vaccination options to the residents.
Failure to Inspect Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails for safety, leading to potential entrapment risks for four residents. The facility's policy required thorough assessments and consent for the use of side rails, but these were not completed for the residents in question. Observations revealed that the bed rails were loose and had significant gaps between the rails and mattresses, which were not addressed by the facility's maintenance checks. Resident #1, who had cognitive impairments and was dependent on staff for mobility, used mobility bars that were loose and had a 3-inch gap between the rail and mattress. Despite the resident's use of these bars for bed mobility, there was no documentation of an entrapment risk assessment. Similarly, Resident #32, who was cognitively intact but required assistance for transfers, reported loose rails with a 5-6 inch gap, which had been brought to staff attention but not resolved. Resident #24, with severe cognitive and vision impairments, had bed rails that were not addressed in the care plan, and no entrapment risk assessment was documented. Resident #271, who required staff assistance for ADLs and transfers, also had a mobility bar without an entrapment risk assessment. The director of maintenance confirmed that while weekly safety checks were conducted, they did not include assessments for entrapment zones, and the DON was unaware of the regulations regarding these assessments.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, which is a requirement for reporting to the state survey agency. The incident involved a resident with a diagnosis of unspecified psychosis and severe cognitive impairment, who was found to have a small bruise on the pubic area during peri care. The bruise was noted by a CNA and assessed by an LPN, who did not report it to the Director of Nursing (DON) or the administrator, as required by the facility's policy. The LPN assessed the bruise, which was pale bluish gray and about the size of a dime, and determined it was not concerning enough to report, as it appeared older and the resident had no recollection of any incident causing it. The LPN informed the resident's guardian and primary care provider but failed to notify the facility's administration. The facility's policy mandates that any injury of unknown origin, regardless of size or presumed age, should be reported immediately to the administration and the state agency. The DON and the administrator were unaware of the bruise until informed by the state agency. Both expressed that the LPN should have reported the bruise immediately, as any bruise of unknown origin could potentially indicate abuse and requires immediate investigation and reporting. The facility's policy requires such incidents to be reported within two hours if there are concerns related to possible abuse or neglect.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate a bruise of unknown origin found on a resident, which was identified during a review of 18 sampled residents. The resident, who had a legal guardian, was diagnosed with unspecified psychosis and was on a daily aspirin regimen. The bruise was discovered by a certified nurse aide during peri care and reported to an LPN, who noted the bruise was pale bluish gray, about the size of a dime, and located on the pubis. The LPN assessed the bruise, informed the resident's guardian and primary care provider, but did not notify the Director of Nursing (DON) or the administrator. The facility's policy on abuse prevention requires that any suspicious bruising or incidents of potential abuse be promptly reported to the DON and administrator, and that an investigation be initiated immediately. However, the LPN did not report the bruise to the administration, as they did not consider it concerning due to its size and appearance. The DON and administrator were unaware of the bruise until informed by the state agency. Both stated that any bruise, regardless of size or presumed age, should be reported and investigated as a potential sign of abuse. The deficiency was identified when the state agency brought the incident to the attention of the facility's administration. The facility's policy mandates that all injuries of unknown origin be reported and investigated to determine if there are concerns for intentional abuse. The failure to report and investigate the bruise as per the facility's policy led to the deficiency being cited by the surveyors.
Medication Administration Errors via Feeding Tube
Penalty
Summary
The facility failed to ensure proper administration of medications via a feeding tube for a resident, resulting in a medication error rate of 23.3%. The resident, who had a feeding tube, was administered medications without appropriate flushing between each medication, contrary to the facility's policy. The policy required flushing with at least 15 mL of water before and after each medication to prevent interactions and clumping, but this was not followed during the observed medication pass. The resident involved had severe cognitive impairment and multiple diagnoses, including anemia, Parkinson's disease, malnutrition, depression, and psychotic disorder. The resident was on high-risk medications, including antipsychotics, antidepressants, and opioids, and was dependent on a gastrostomy tube for medication and nutrition. The physician's orders specified that medications should be crushed and administered through the g-tube with a 20 mL water flush before and after each medication, which was not adhered to by the staff. During the medication administration, the LPN prepared the medications by dissolving them in water but failed to flush the tube between medications, leading to a clogged tube. The LPN also forgot to administer one of the prescribed medications and did not flush the tube after the last medication before reconnecting the feeding tube. Interviews with the LPN, the resident's alternate care physician, and the Director of Nursing confirmed that the facility's policies and physician orders were not followed, contributing to the medication errors.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain and repair essential food preparation equipment in the main kitchen, specifically a meat slicer. Observations revealed that the meat slicer was covered with a vinyl/plastic cover and sat in a layer of yellowish grease or liquid, indicating a possible oil leak. Interviews with the Dietary Director and Consultant Dietitian confirmed that the meat slicer had been broken for a couple of years and had not been used much since the COVID-19 pandemic. The Dietary Director, who has been in her role since September 2023, stated that the slicer was unsafe to use because the blade did not attach properly, and she had been unable to find replacement parts. The Administrator was unaware of the slicer's unsafe condition and expressed a desire to purchase a new slicer, but budget constraints were a limiting factor.
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What surveyors actually found near you
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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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Nursing homes near Saint Charles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lewis & Clark Gardens | 0.8 mi | ★★★★★ | 7 | 0 |
| Windsor Estates Of St Charles | 1.2 mi | ★★★★★ | 10 | 1 |
| Aspen Point Health And Rehabilitation | 2 mi | ★★★★★ | 9 | 0 |
| Nhc Healthcare, St Charles | 2.5 mi | ★★★★★ | 0 | 0 |
| Ssm Health Depaul Hospital - Anna House | 3.9 mi | ★★★★★ | 1 | 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.