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 Windsor Estates Of St Charles during CMS and state inspections, most recent first.
A resident with major cardiac and respiratory diagnoses was not properly monitored after admission, including missed VS checks and failure to follow a midodrine order requiring BP checks before administration. Staff did not document or escalate repeated complaints of chest pressure, did not notify the POA, and the resident’s code status was not accurately reflected in the chart; CPR was started when the resident was found unresponsive despite the POA stating the resident was DNR.
Failure to Reorder Scheduled Alprazolam Led to Missed Doses and Withdrawal Symptoms: A resident with anxiety disorder, depression, and insomnia missed multiple scheduled doses of alprazolam after staff did not ensure the controlled medication was available for administration. The MAR showed repeated missed doses, and records noted the medication was out, on order, or unavailable, with no documentation that the physician or pharmacy was notified in time. The resident later reported withdrawal symptoms and a panic attack, and physician office staff observed the resident as red, sweating, shaking, tearful, and expressing hopelessness before the resident was sent to the hospital.
Unsafe, Unclean, and Non-Homelike Environment: The facility failed to maintain a clean, odor-free, and homelike environment. Residents reported broken closet doors and malfunctioning beds that were repeatedly brought to staff attention, while surveyors observed strong urine odors, soiled linen receptacles in halls, trash and soiled linens left on the floor, soiled briefs in a wheelchair, and a shower room with feces, standing water, used gloves, and dirty equipment. A resident said the odors were offensive and the shower room smelled like a sewer.
A facility failed to follow physician orders for three residents. One newly admitted resident with multiple diagnoses, including glaucoma and a seizure disorder, did not receive several ordered meds until later than prescribed, and staff delayed entering and processing the orders. Two other residents had ordered lab work that was not fully obtained or documented: one lacked a CBC, and another lacked a lipid test. The DON said there was no official tracking to ensure ordered blood tests were obtained, and an LPN documented blood work as completed without confirming what the lab actually drew.
Failure to Provide Required ADL Assistance and Hygiene Care Multiple residents who required staff help with oral care and toileting hygiene were observed with debris on their teeth, dry lips, saturated briefs, and red or moisture-damaged skin. Residents and roommates reported that staff did not provide oral care regularly, did not answer call lights, and left residents wet for long periods. CNA and LPN interviews confirmed that oral care should have been provided daily or after meals, but it was not consistently done, and the record showed missing documentation for oral care during the review period.
Unsafe transfers and transport practices led to accident hazards for multiple residents. Staff pushed a resident in a wheelchair without foot pedals while the resident’s foot dragged on the floor and the resident cried in pain. An LPN manually lifted another resident under the arms and pivot transferred the resident without a gait belt or locked wheelchair brakes. Staff also used a sit-to-stand lift to transport a resident across the room to and from the bathroom, even though the device’s manual stated it was not a transport device.
The facility failed to timely provide final accountings and proper disposition of resident trust funds after death for multiple residents. In several cases, only part of a deceased resident’s trust balance was reported to the state TPL unit, while remaining funds were withdrawn for current or back room and board without written authorization or were left unreported for extended periods. Interest that continued to accrue in deceased residents’ accounts was also held for months without required Personal Funds Account Balance Reports. During interviews, the Administrator and BOM attributed these issues to turnover in the business office, ongoing attempts to "clean up" accounts, uncertainty about handling interest, lack of awareness that transferred funds were personal trust funds, and an incorrect assumption about the allowed timeframe for completing required financial reports and refunds.
A resident who was at risk for falls was not assessed or treated after a reported fall, resulting in a fractured wrist that went unaddressed for two days. Staff failed to follow physician orders for x-ray, immobilization, and RICE treatment, and did not document or provide the prescribed brace or sling. Communication lapses and lack of documentation contributed to the resident experiencing ongoing pain and lack of appropriate care.
A resident with significant mobility limitations and a high fall risk experienced multiple falls from bed due to staff failing to keep the bed in the lowest position and not setting the low air loss mattress to the correct weight. The mattress was repeatedly set too high, and new fall prevention interventions were not consistently implemented or documented after each fall, despite the resident's ongoing incidents and injuries.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, leading to the occurrence and worsening of pressure ulcers.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Multiple residents reported receiving meals that were not hot, and observations confirmed that hot foods and beverages were served below required temperatures due to improper temperature monitoring, lack of insulated covers, and malfunctioning equipment. Staff interviews revealed inconsistent temperature checks and inadequate procedures for maintaining food safety and palatability during meal service.
The facility did not maintain the main parking lot, leaving a large, deep area of damaged asphalt in the visitor parking section. This unrepaired damage affected vehicles traveling through the area, and the Administrator was aware of the issue but had not yet addressed it.
A resident who was dependent on staff for bed mobility and care fell from bed and sustained injuries after a CNA turned away to retrieve supplies, leaving the resident unattended on an unsecured air mattress overlay. The CNA had previously noticed the mattress shifting but did not report it, and the facility lacked a policy for monitoring such overlays. The care plan and therapy evaluation did not clearly specify the number of staff needed for bed mobility, contributing to the incident.
The facility did not ensure the Dietary Manager had completed the necessary training or certification to fulfill the role, and lacked a policy for training or competency requirements. The DM was enrolled in a course but had not finished it, and the required food protection manager certification was not posted, resulting in non-compliance.
Surveyors identified multiple deficiencies in food storage and labeling, including unlabeled and expired food items, lack of discard dates, visible spoilage, and improper refrigerator maintenance such as rust, ice buildup, and missing thermometers. Dietary staff were unclear about cleaning responsibilities, and only food from the dietary department was supposed to be stored in the dining room refrigerator.
Staff failed to consistently provide scheduled ADL care, including showers, nail care, shaving, and grooming, to several dependent residents. Documentation was often incomplete or missing, and residents were observed with poor hygiene, long nails, and unkempt hair. Interviews with residents and family members confirmed that care was not provided as scheduled, and staff gave inconsistent explanations about responsibilities for ADL tasks.
A persistent leak from the water pipe under the dishwasher led to pooled water on the kitchen floor, with staff mopping up the water several times daily. Inspection reports and staff interviews confirmed that the plumbing issue had been ongoing, and the facility was cited for non-compliance with plumbing standards.
The facility failed to provide ordered medications for two residents, leading to deficiencies in care. A resident with a joint prosthesis infection and low back pain did not receive Tramadol for pain management due to delays in prescription and delivery. Another resident with cellulitis and osteomyelitis missed doses of IV antibiotics because the medication was not available upon admission. Staff interviews revealed communication lapses in ensuring medication availability, impacting resident care.
The facility's call system failed to provide audible alerts, requiring staff to rely on visual cues to respond to residents' needs. This deficiency affected all residents, with some experiencing significant delays in assistance. Staff interviews confirmed the absence of pagers or phones to receive alerts, and the administrator was unaware of a state requirement for such devices.
A facility failed to ensure the safety of two residents, leading to serious injuries. One resident, dependent on staff for bed mobility, fell from the bed due to the absence of a required fall mat and lack of reassessment for safety. The resident sustained severe injuries, including intracranial hemorrhage and rib fracture. Another resident, with a rotator cuff tear, was unsafely transferred by staff using a gait belt, causing pain in the injured shoulder. The facility's policies for fall management and safe lifting were not effectively implemented, contributing to these incidents.
A resident with a history of heart failure and muscle weakness was left unattended on a mechanical lift mat in a high bed position, resulting in a fall and a fractured left leg. The resident, who was dependent on staff for transfers, was left alone when a CNA left the room to get a nurse. The incident was witnessed by the resident's roommate, who called for help. The resident was assisted off the floor and diagnosed with a fractured tibia.
The facility failed to implement an admission policy, resulting in a resident's admission without a signed agreement. Additionally, several residents and their representatives did not receive the required 30-day written notice of rate increases, leading to confusion and dissatisfaction. The previous administrator claimed to have mailed the notices, but many residents reported not receiving them.
The facility failed to employ a Food Service Director (FSD) with valid credentials. The FSD, who started in October 2023, did not have a current certification in food safety management. The Administrator had planned to enroll the FSD in a certification course, but this did not occur. The FSD confirmed that he had started but not completed the course, and the Regional Director of Operations acknowledged the lack of certification. A review of the FSD's employee file revealed an expired certification.
A facility failed to ensure a resident with nasal and inhaler medications had a self-administration assessment, physician's order, and care plan. The resident, who was cognitively intact, had medications at their bedside without the required documentation, increasing the potential for medication errors.
A resident with Alzheimer's and repeated falls was found with a swollen, discolored knee, but the injury was not reported to the state agency until six days later, violating the facility's policy requiring immediate notification.
A resident with Alzheimer's and repeated falls was found with a swollen and discolored knee, but the injury was not reported or investigated until several days later, violating the facility's policy on immediate reporting and investigation of injuries of unknown origin.
The facility failed to update the care plan for a resident with wandering behaviors after two incidents where the resident left the skilled nursing unit without staff knowledge or supervision. Despite the resident's Alzheimer's disease and repeated falls, no new interventions were added to the care plan following the incidents.
The facility failed to prevent a resident with Alzheimer's and wandering behaviors from leaving the skilled nursing unit without supervision on two occasions. Staff were unclear about specific interventions, and the doors did not have effective alarms. The DON confirmed the lack of an elopement assessment and root cause analysis.
A facility failed to ensure CNAs changed gloves and performed hand hygiene during catheter care for a resident with neuromuscular dysfunction of the bladder. The CNAs did not adhere to the facility's infection control policies, leading to potential cross-contamination.
Failure to Monitor Change in Condition and Honor Code Status
Penalty
Summary
Facility staff failed to provide necessary monitoring and follow-through for a resident with significant cardiac and respiratory history, including complete AV block, a pacemaker, congestive heart failure, hypertension, COPD, and a history of respiratory failure with hypoxia. On admission, staff did not complete the required nursing assessments and vital signs monitoring for the first 72 hours, and they did not follow the physician’s order to check blood pressure before giving scheduled midodrine. The resident’s admission paperwork also included advance directive information indicating a preference to withhold life-prolonging procedures, including CPR, under certain conditions, but the resident’s code status was not accurately reflected in the medical record. When the resident reported anxiety and a feeling of something sitting on the chest, staff did not document the change in condition as required by facility policy, did not complete an SBAR, and did not notify the POA, DON, or ADON. The resident was evaluated by telehealth and hydroxyzine was ordered and later administered, but there was no documentation of the communication details, no documented follow-up after the medication, and no evidence that staff monitored the resident’s condition as directed. The resident later again reported a sensation of chest pressure, and a second provider visit documented that the resident had advanced cardiopulmonary disease and required careful evaluation and medication adjustment, including tizanidine and monitoring of respiratory status, anxiety symptoms, and blood pressure parameters. The record did not show that staff monitored the resident’s vital signs or followed the provider’s instructions. Staff also failed to notify the resident’s POA about the resident’s chest-related complaints and medication changes, despite the POA stating he/she would have wanted hospital evaluation if informed. On the day the resident was found unresponsive and not breathing, staff initiated CPR because the resident was listed as full code in the chart, even though the POA reported the resident had been designated DNR at admission. The resident’s medical record did not accurately reflect the preferred code status, and staff performed life-saving measures contrary to the resident’s wishes as documented in the report.
Failure to Reorder Scheduled Alprazolam Led to Missed Doses and Withdrawal Symptoms
Penalty
Summary
The facility failed to provide alprazolam 1 mg as ordered for a resident with anxiety disorder, major depressive disorder, and insomnia after the medication was not reordered in time. The resident’s care plan directed staff to give anti-anxiety medications as ordered, and the physician order sheet showed alprazolam 1 mg three times daily for anxiety. The resident’s controlled drug record showed the last dose from the resident’s supply was administered on 04/05/26 at 8:00 A.M., and the treatment administration record showed missed doses at 12:00 P.M. and 9:00 P.M. that day, as well as missed doses at 8:00 A.M., 12:00 P.M., and 9:00 P.M. on 04/06/26 and 8:00 A.M. on 04/07/26. Staff documented that the medication was reordered on 04/05/26 at 11:40 A.M., but later notes stated the medication was out, on order, unavailable, or awaiting a signed script. The record showed no documentation that staff notified the physician or pharmacy when the medication was unavailable. The pharmacist stated the facility did not notify the pharmacy until 04/07/26, and that 120 pills were available on 04/05/26. Staff also reported that controlled medications should be reordered when approximately 10 doses remained or when the card was half empty, and that the pharmacy could be contacted for access through the automated medication dispensing system. The resident reported running out of alprazolam and having withdrawal symptoms that led to a panic attack during a scheduled appointment on 04/07/26. The physician’s office staff reported the resident was red, sweating, shaking, tearful, and upset about not receiving the scheduled alprazolam, and the physician believed the resident was withdrawing from the medication and sent the resident to the hospital after the resident expressed not wanting to live anymore. The hospital record listed panic attack as the chief complaint and noted the resident had not had alprazolam for three days.
Unsafe, Unclean, and Non-Homelike Environment
Penalty
Summary
The facility failed to provide residents with a safe, clean, and homelike environment, including housekeeping and maintenance services needed to keep the interior orderly, odor free, and comfortable. The Regional Nurse Consultant stated the facility did not have a specific policy related to a homelike environment. In one occupied resident room, the shared closet door was off the track and dragged on the floor, and the resident reported the door repeatedly broke after staff fixed it. In the same room, one bed would not lower to a low position and the other bed was difficult to raise and lower; both residents said the beds were not working correctly, one said the bed had been broken for some time despite repeated reports to staff, and the other said the current bed was also broken and could not be manually adjusted even though staff knew the resident could not manipulate a manual bed. In another occupied resident room, the shared closet door was again observed off the track and difficult to open, and the resident said a family member repeatedly fixed it after bringing in clean laundry, but it did not stay fixed for long and the facility was aware of the problem. Multiple areas of the facility had strong urine odors, including the 100 and 200 halls, and soiled linen receptacles were left in hallways and outside resident rooms. An open bag of trash with soiled incontinence supplies was on the floor, an open bag of soiled linens was on the floor in a resident room, and soiled briefs were found in a wheelchair at the foot of a resident's bed. The 200 hall shower room contained a foul odor, used gloves, used paper towels, a shower chair with brown residue, a wet medicated patch, feces on the floor, standing water, wet towels, soiled linen receptacles full of odorous linens and clothing, and a sit-to-stand lift soiled with hair, dirt, and grime. A resident stated the facility smelled of odors, had urine and body odors, and that the shower room smelled like a sewer and was not cleaned or sanitized between residents.
Failure to Follow Physician Orders for Medications and Lab Tests
Penalty
Summary
The facility failed to follow physician orders for three residents during a review of 28 sampled residents. The deficiency involved missed medications for one newly admitted resident and missed blood tests for two other residents. The facility also did not have a specific policy for following physician orders or obtaining blood tests, and staff described relying on a nursing communication book for admission instructions. For one resident admitted from a hospital with diagnoses including anxiety disorder, hypertension, hyperlipidemia, stroke, GERD, depression, glaucoma, and a seizure disorder, hospital discharge paperwork included orders for multiple medications such as Cosopt eye drops, Depakote, Latanoprost eye drops, trazodone, potassium chloride, amlodipine, vitamin D-3, and acetaminophen. The resident told staff shortly after admission that he or she did not think any medications had been received overnight and was unsure whether any had been given that day. The medication administration record showed that several ordered medications were not administered until later, including some not given until the evening of the next day or the following morning. The resident’s orders were not entered and processed until after admission, and staff reported that the admission assessment was completed but the physician orders had not been addressed before the end of the shift. For one resident with orders for CBC, CMP, and A1C testing every three months, the record showed a CMP and A1C result but no documentation that the CBC was obtained. The TAR contained a code directing staff to see progress notes, but the only note was a copy of the order for the blood tests. The DON stated there was no official tracking to ensure ordered blood tests were obtained and confirmed that a CBC was not drawn as ordered. For another resident with orders for CBC, CMP, TSH, lipids, and vitamin D every six months, the TAR showed the blood test box marked as administered, but the record contained results only for CMP, CBC, TSH, and vitamin D, with no lipid result and no documentation that staff reviewed the results. The LPN stated the lab company was on-site to draw blood but that he or she documented the TAR without confirming what tests were actually drawn, and the DON stated that a lipid blood test was not drawn as ordered.
Failure to Provide Required ADL Assistance and Oral/Toileting Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically oral hygiene and toileting hygiene, for multiple residents who required staff help. The report states that eight sampled residents did not receive the care needed to maintain good personal hygiene. The facility’s ADL policy said residents were to receive care according to their individualized care plans, and the facility did not provide a policy related to oral care. Resident #2 was dependent on staff for oral hygiene, had a feeding tube, was NPO, and required one staff member to assist with oral care. Observations on multiple days showed debris on the resident’s teeth and lips, dry lips, and thick, discolored secretions flowing from the mouth onto the shirt. The resident shook his/her head when asked whether staff brushed the teeth. A CNA stated he/she washed the resident’s face but did not perform oral care, and an LPN stated the resident required staff oral care once per day. Resident #9 required assistance with personal hygiene and oral care and had intact cognition but needed partial to moderate assistance with oral hygiene. The resident had a significant tremor in both hands, said he/she could not perform oral care without help, and stated staff did not provide oral care regularly. Observations showed debris on the teeth on several occasions, including after breakfast when staff assisted with eating but did not offer oral care. The electronic record showed no documentation of oral care from 05/11/26 through 05/15/26. Resident #52 also required assistance with oral care, said he/she could brush the teeth if staff set up the supplies, and reported asking staff for help without receiving it. Oral care supplies were observed out of reach, debris was seen on the teeth on multiple days, and the record showed no documentation of oral care during the same period. Resident #42 required staff assistance for personal hygiene and oral care and was cognitively impaired. The resident was observed with debris on the teeth, and staff assisted with dressing, transfers, and breakfast but did not provide or offer oral care. The electronic record showed no documentation of oral care during the review period. Staff interviews indicated oral care should be provided in the morning, after meals, and at least daily, but CNA staff responsible for Residents #9, #42, and #52 stated they did not assist those residents with oral care that day. Resident #29 required assistance with toileting hygiene and was frequently incontinent of bladder and always incontinent of bowel. The resident was observed with a urine-saturated brief and pad, and the buttocks were red. The resident stated staff did not change him/her all night, that he/she was left wet, and that the call light was not answered or was turned off without staff returning. Resident #68, the roommate, said staff left Resident #29 wet all night and that the roommate had to help get staff’s attention. Resident #45 required assistance with toileting hygiene and had a history of skin redness and incontinence. The resident was observed at 5:30 A.M. with a heavily saturated brief, red genital and buttock skin, and stated staff had not checked or changed him/her since 10:00 P.M. Resident #64 was totally dependent for personal hygiene and toilet use, incontinent of bladder, and required substantial to maximum assistance. The resident was observed with a strong urine odor in the room, a heavily saturated brief, and buttocks that were white and heavily wrinkled from moisture. A CNA stated the night shift was to check and change Resident #45 every two hours, while the other residents on the hall were described as independent and using the call light if needed.
Unsafe transfers and transport practices
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible when staff did not follow safe transfer and transport practices for three residents. The report states that the facility’s policy on safe lifting and movement required staff training in manual and mechanical lifting devices and periodic observation for adherence to policies and procedures. The report also notes that the policy did not address when to use a gait belt or locking wheelchair wheels during a transfer. One resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, used a wheelchair for mobility, and required substantial to maximum assistance for wheeling 50 feet. During observation, the Staffing Coordinator pushed the resident down the hall in a wheelchair without foot pedals, and the resident’s right foot was bent backwards and dragged against the floor underneath the wheelchair. The resident was crying, said he or she was in pain, and the foot continued to drag as the resident was pushed back and forth. The Staffing Coordinator later stated that the resident should not have been pushed without foot pedals and that doing so could cause an accident or injury. Another resident had moderate cognitive impairment, limited range of motion in one upper extremity, required substantial to maximum assistance for sit-to-stand transfers, and had a history of falls. During observation, the resident attempted to stand from a wheelchair in the common area, and an LPN lifted the resident under the arms and pivot transferred the resident to a couch without using a gait belt and without locking the wheelchair brakes. The LPN stated the resident should have been asked to sit back down so a gait belt could be obtained and used, and the DON stated staff should not manually lift residents under the arm or shoulder and should use a gait belt with all manual transfers. A third resident had diagnoses including muscle weakness, lack of coordination, Parkinson’s disease with dyskinesia, gait and mobility abnormalities, unsteadiness on feet, and left foot drop. The resident required partial to moderate assistance with transfers and used a wheelchair for locomotion. Staff used a sit-to-stand lift to move the resident from the bed to the bathroom and back across the room, with the resident suspended in the sling during transport. The lift manufacturer’s instructions stated the device was not a transport device and was intended only for short, direct transfers between surfaces. Staff stated they used the lift because it was the resident’s preference, and the DON stated staff should not transport residents to the bathroom using any mechanical lifting device.
Failure to Timely Account for and Properly Disburse Resident Trust Funds After Death
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and disburse resident trust funds and to provide final accountings of resident fund balances within 30 days of a resident’s death, as required. Record review showed that for multiple deceased residents, the facility either did not report the full balance of funds to the Department of Social Services Third Party Liability (TPL) Unit, did not submit Personal Funds Account Balance Reports timely, or withdrew funds for room and board without written authorization or after the resident had expired. For one resident, the ledger showed a trust balance of $8,119.01 at the time of death, but only $3,904.41 was initially reported to TPL, while $3,311.00 was later withdrawn for current and back room and board and an additional $51.60 was withdrawn, leaving $2,311.60 unreported for over 200 days; interest of $2.22 was also held and not reported until more than two months after it was deposited. Another resident’s ledger showed a deposit of $1,073.37 from a previous facility that was documented as personal spending money, but the facility withdrew $690.00 for room and board without authorization and did not use those funds for cremation services or report them to TPL within the required timeframe. Additional record reviews showed similar issues for other deceased residents. One resident had $2,792.85 in the trust account and a subsequent direct deposit of $2,064.00; only $2,618.55 was reported to TPL more than 40 days after death, while $2,058.60 was withdrawn for room and board and not reported. Another resident’s $51.30 trust balance was withdrawn for back room and board and not reported to TPL for over 300 days, and interest of $0.04 remained without a Personal Funds Account Balance Report submitted for more than 300 days after the interest was deposited. A further resident’s $1,295.84 trust balance was not reported to TPL until 81 days after death, and interest of $1.15 was held without a balance report for over 200 days. For another deceased resident, interest of $3.46 continued to be held, and a Personal Funds Account Balance Report was not submitted for more than 200 days after the interest deposit. In an interview, the Administrator and Business Office Manager cited turnover in the Business Office Manager position, the new BOM’s efforts to “catch up” paperwork, uncertainty about how to handle remaining interest, lack of awareness that transferred funds were trust funds, and an incorrect belief that there were 60 days to complete the Personal Funds Balance Report and/or submit refunds.
Failure to Assess and Treat Resident After Fall Resulting in Fracture
Penalty
Summary
Staff failed to assess a resident after a reported fall, did not provide timely treatment, and did not implement or follow physician orders for care following the identification of a fall with injury. The resident, who had diagnoses including heart disease, macular degeneration, muscle weakness, and was at risk for falls, self-reported a fall that occurred two days prior to being evaluated by clinical staff. The fall was not reported by staff at the time it occurred, and no assessment or documentation was completed immediately following the incident. The resident subsequently developed pain, swelling, and bruising to the left arm, which was not addressed until the resident reported these symptoms to a nurse practitioner. Despite clear physician orders to obtain an x-ray, immobilize the arm, and provide RICE (Rest, Ice, Compression, Elevation) treatment, staff did not document or provide these interventions in a timely manner. The x-ray, when eventually performed, revealed an acute distal radial metaphysis fracture. The resident was sent to the emergency room for further evaluation and returned with a splint, but staff continued to fail in documenting assessments, treatments, or the application of the prescribed brace or sling. Interviews with staff and the resident confirmed that the resident was often left without the prescribed immobilization device and continued to experience pain. Multiple staff interviews revealed a lack of communication and failure to follow protocol regarding fall reporting, assessment, and implementation of physician orders. The charge nurse was not informed of the fall, and staff did not provide or document the required treatments. The resident's pain and injury went unaddressed for an extended period, and staff were unaware of the current treatment plan or the location of the prescribed immobilization devices. The facility's own policies required assessment and intervention after any fall, but these were not followed in this case.
Failure to Prevent Falls and Ensure Safe Bed Settings
Penalty
Summary
The facility failed to provide adequate protective oversight and prevent falls for a resident with multiple risk factors, including end stage renal disease, heart failure, muscle weakness, and a right above-the-knee amputation. The resident was assessed as a high fall risk, required extensive assistance with activities of daily living, and was dependent on staff for transfers and mobility. Despite these needs, staff did not consistently ensure that the resident's bed was kept in the lowest position while the resident was in bed, as required by the care plan and facility policy. Additionally, the resident's low air loss mattress was repeatedly set at a weight setting significantly higher than the resident's actual weight, contrary to manufacturer instructions and facility expectations. Observations confirmed that the mattress was set at 340 pounds while the resident weighed 268 pounds, which staff acknowledged could contribute to the resident rolling out of bed. The resident experienced multiple falls from bed, often while reaching for personal items or attempting to reposition, and reported discomfort from frequently sliding down in bed, with feet resting on the footboard. After several falls, there was no documentation that new fall risk interventions were implemented in a timely manner following each incident, as required by the facility's fall policy. Staff interviews revealed inconsistent practices regarding the use of mechanical lift slings, bed positioning, and mattress settings. The resident continued to experience falls, some resulting in skin tears, and staff failed to consistently apply or document new interventions after each event.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages were prepared and served at safe and appetizing temperatures, as required by their own policy. Multiple residents who received meals in their rooms and in the assisted dining room reported that their food was not hot when served. Observations confirmed that during meal service, hot foods such as roast pork, mashed potatoes, and corn were plated, covered with plastic film, and placed on an open metal cart without insulation. The cart also contained beverages, including milk, tea, and juice, which were not kept on ice. The last meal tray was delivered over 30 minutes after plating, and temperature checks of a test tray revealed that hot foods were below the required serving temperatures, and milk was above the safe cold temperature. Interviews with dietary staff and the Dietary Manager revealed that food temperatures were not consistently checked at the steam table, and two wells on the steam table were not functioning to keep food warm. The facility lacked insulated plate covers, and the timing of room tray delivery depended on staff availability. The Dietary Manager and Administrator both acknowledged that food and beverages should be served at proper temperatures, but the observed practices and equipment issues led to food being served at temperatures that did not meet policy or safety standards.
Failure to Maintain Safe and Clean Parking Lot Environment
Penalty
Summary
The facility failed to maintain the main parking lot, resulting in a large area of damaged asphalt at the end of the visitor parking area. Observations revealed that the damaged area was approximately ten feet in diameter and 8-10 inches deep at the center, affecting any vehicle using the area for travel. The Administrator acknowledged awareness of the needed repair and indicated that several projects were in progress, but the area remained unrepaired at the time of the survey.
Resident Fall Due to Unsecured Mattress Overlay and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who required staff assistance for bed mobility and care, fell out of bed while receiving personal care and sustained multiple injuries, including a laceration to the forehead, skin tears, and bruising. The resident was dependent on staff for bed mobility, dressing, and hygiene, and had significant physical limitations due to diagnoses such as respiratory failure, dementia, and stroke. The resident was also on hospice care and used an air mattress overlay on top of a regular mattress, which was reported by staff to shift on the bed. On the day of the incident, a CNA was providing care and rolled the resident onto their side. The CNA then turned away from the resident to retrieve additional supplies from a bedside table, during which time the resident slid off the bed and fell to the floor. The CNA admitted to not having all necessary supplies at the bedside before starting care and did not request additional assistance, despite the mattress overlay shifting and the resident's dependency for mobility. The CNA had previously repositioned the air mattress overlay multiple times during the shift but had not reported the issue to anyone. The facility did not have a policy for monitoring residents using air mattresses or mattress overlays. Interviews with staff and leadership confirmed expectations that supplies should be prepared in advance and that staff should seek help when needed. The physical therapy evaluation did not specify the number of staff required for bed mobility, and the care plan indicated only one staff member was needed for repositioning and turning. The lack of a secure mattress overlay and insufficient supervision during care contributed to the resident's fall and subsequent injuries.
Dietary Manager Lacked Required Competency and Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the appropriate competencies and skill set required to manage the food and nutrition services for all residents. The DM had been in the role since September of the previous year and was enrolled in an online dietary manager course but had not completed it. The DM was unable to specify when the course began or when it would be completed and had not taken any other relevant classes. The DM reviewed some course modules with the Registered Dietician during weekly visits but lacked a completed certification. Additionally, the facility did not have a policy regarding training or competency requirements for the DM position. A review of the Food Establishment Inspection Report from the local county health department indicated that the facility was out of compliance with the requirement for a Certified Food Protection Manager. The required certificate of training was not posted in the food establishment, and the Administrator was unaware of the DM's progress in the course or the expected completion timeline.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
The facility failed to comply with food storage, labeling, and sanitation policies as evidenced by multiple observations in the main dining room and kitchen prep/storage area refrigerators. Surveyors found several food items, such as Jello with fruit, ham sandwiches, potato salad, slaw, thickened lemon water, milk, and cut fruit, that were either not labeled with the date opened, lacked discard dates, or were past their expiration or use-by dates. Some food items showed visible signs of spoilage, such as dried and discolored fruit. Additionally, five pieces of cake in the freezer were not dated, and there was a buildup of food debris in the freezer. Both refrigerators lacked hanging thermometers, and the main dining room refrigerator had rust spots and ice buildup inside. Interviews with dietary staff and the administrator confirmed that only food from the dietary department should be stored in the dining room refrigerator, and that all food should be labeled and discarded according to policy. However, staff were unaware of when the refrigerator was last cleaned or who was responsible for its maintenance. The facility census at the time was 62, and the deficiencies were identified through observation, interview, and record review.
Failure to Provide Scheduled ADL Care and Personal Hygiene Services
Penalty
Summary
Facility staff failed to provide necessary care and services to maintain good personal hygiene and prevent body odor for four residents who were unable to perform their own activities of daily living (ADLs). Multiple instances were documented where residents did not receive scheduled showers, bed baths, nail care, shaving, or haircuts as outlined in their individualized care plans. Documentation was often missing regarding whether care was offered, refused, or provided, and there was a lack of follow-up when residents reportedly refused care. In several cases, there was no resident signature to confirm refusals, and staff did not consistently attempt to reschedule or offer care at a later time. Residents affected by these deficiencies included individuals who were cognitively intact, dependent on staff for bathing and personal hygiene, and in some cases, frequently or always incontinent of urine and/or bowel. Observations revealed that residents had greasy, matted hair, facial hair, long and dirty fingernails, dry and flaky skin, and rooms with noticeable body odor. Interviews with residents confirmed that they had not received showers, shaves, or haircuts for extended periods, despite expressing a desire for such care. Some residents reported that staff told them services like haircuts could not be provided due to regulations, and others stated that staff promised to provide care but did not follow through. Staff interviews revealed inconsistencies in understanding and executing responsibilities for ADL care. CNAs and nurses gave conflicting accounts regarding who was responsible for nail care, shaving, and grooming, particularly for diabetic residents. The facility lacked specific policies for showers, shaving, nail care, or haircuts, and staff assignments for showers and grooming were not always completed as scheduled. Family members and responsible parties also reported concerns about the lack of ADL care, with some having to provide grooming themselves or escalate complaints to facility leadership.
Failure to Maintain Dishwasher Plumbing in Good Repair
Penalty
Summary
The facility failed to maintain the water supply to the dishwasher in good working condition, resulting in a persistent leak from the water pipe under the dishwasher. Observations over multiple days showed water dripping from pipes beneath the dishwashing machine, leading to pooled water under the dishwasher and shelving, which then flowed onto the kitchen floor. The issue was noted during inspections and was observed to have been ongoing for over a year, with kitchen staff mopping up the water several times daily. Inspection reports from the local county public health department documented leaking plumbing and plumbing in disrepair, with the facility being cited for non-compliance. Interviews with staff revealed that while a previous leak under the sink had been repaired, the leak under the dishwasher was considered new by some, though others indicated it had persisted for an extended period. The administrator was not aware of the leak until recently, despite repeated findings by the health department during follow-up visits, where the leak remained uncorrected.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure that ordered medications were available for administration to two residents, leading to deficiencies in care. Resident #1 was admitted with a diagnosis of infection of a joint prosthesis and low back pain, with an order for Tramadol to manage pain. However, the medication was not available upon admission, and the resident experienced pain without relief. Despite attempts to contact the physician and pharmacy, the medication was not delivered promptly, resulting in the resident being administered Tylenol instead. The resident's family member expressed concerns about the lack of pain management, and the resident was eventually transferred to another facility. Resident #2 was admitted with cellulitis, diabetes with a foot wound, and osteomyelitis, requiring IV antibiotics. The facility did not have the necessary medication upon the resident's arrival, as the hospital did not send the medication orders in advance. The resident missed several doses of the prescribed IV antibiotic, Cefazolin, due to the delay in medication delivery. The facility's cubex contained the medication, but it was not utilized, leading to a lapse in the resident's treatment. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of communication and coordination in ensuring medications were available and administered as ordered. The pharmacy consultant confirmed delays in receiving prescriptions and medication deliveries. The deficiencies highlight the facility's failure to adhere to professional standards of practice in medication management, impacting the residents' care and well-being.
Deficient Call System Lacks Audible Alerts
Penalty
Summary
The facility failed to maintain an effective call system that adequately alerted staff when residents required assistance. Observations and interviews revealed that the call system did not produce an audible sound to notify staff of activated call lights. Instead, staff had to rely on visual cues, such as a monitor at the nurses' station or a light above the resident's door, to know when a call light was on. This deficiency affected the entire facility, which had a census of 66 residents across three halls. Interviews with staff, including CNAs and an LPN, confirmed that they did not carry pagers or phones to receive alerts, and the system's lack of an audible function meant that staff could miss calls for assistance, especially if they were not near the monitors or the resident's room. Several residents reported significant delays in response times when they activated their call lights. One resident mentioned waiting over 30 minutes for assistance and having to resort to yelling for help. Another resident noted that staff often walked past their room without acknowledging the activated call light. The facility's administrator acknowledged the absence of an audible alert in the call system and was unaware of a state agency exception that required staff to carry pagers. The corporate office was reportedly working with the state agency on updates to the call light system, but the reason for the lack of an audible function remained unclear.
Failure to Ensure Resident Safety and Proper Transfer Techniques
Penalty
Summary
The facility failed to ensure the safety of a resident who was dependent on staff for bed mobility. During care, the resident was rolled to their side, reached out to the opposite side, and fell from the bed to the floor. The care plan required a fall mat to be in place, but it was not present at the time of the fall. The resident, who often reached out during care, had not been reassessed for safety with bed mobility. As a result of the fall, the resident required hospitalization and sustained serious injuries, including intracranial hemorrhage, epidural hematoma, subdural hematoma, concussion, and a right rib fracture. Another resident, who required staff assistance for transfers, was unsafely transferred by two staff members using a gait belt. The resident, who had a rotator cuff tear, reported pain in the injured shoulder during the transfer. The facility's policy for safe lifting and movement of residents was not adhered to, as staff did not use the appropriate techniques or equipment for the transfer. The resident's care plan indicated a need for two-person assistance, but the staff failed to follow the correct procedures, leading to the resident experiencing pain and discomfort. The facility's policies for fall management and safe lifting were not effectively implemented or followed. Staff did not communicate the resident's resistive behavior during care, which could have prompted a reassessment for safety. Additionally, the facility did not ensure that the necessary equipment, such as fall mats and mechanical lifts, was used as required by the care plans. These failures contributed to the incidents involving both residents, resulting in injuries and hospitalizations.
Resident Left Unattended on Bed Results in Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was dependent on staff for transfers and at risk for falls. The resident was left unattended on a mechanical lift mat with the bed in a high position, leading to the resident sliding off the bed and sustaining a fracture of the left leg. This incident occurred when a staff member left the room to get a nurse after noticing the resident had scratched their back and was bleeding. The resident involved had a history of heart failure, stage 5 chronic kidney disease, a below-the-knee amputation of the right leg, and muscle weakness. The resident was assessed as being at risk for falls due to deconditioning and was dependent on staff for bed mobility, transfers, and wheelchair mobility. The resident was alert, oriented, and able to make needs known, as documented in their care plan and Minimum Data Set (MDS). The incident was reported to the administrator, and it was noted that the resident had been left on the side of the bed while the staff member left the room. The resident's roommate witnessed the fall and called for help. The resident was subsequently assisted off the floor by staff and sent to the emergency room, where a fractured left tibia was diagnosed.
Deficiency in Admission Policy and Rate Increase Notification
Penalty
Summary
The facility failed to develop and implement an admission policy and protocol, resulting in a deficiency related to the admission agreement for a resident. The resident, who was cognitively impaired and admitted for rehabilitation, did not have an admission agreement signed by their representative. The representative, who held power of attorney, reported not receiving any admission packet or signing any paperwork upon the resident's admission. Additionally, the representative was informed verbally by the previous administrator about an immediate payment requirement and a future rate increase, but did not receive any written documentation. The facility also failed to provide at least a 30-day written notice of rate increases to several residents and their representatives. Multiple residents and their representatives reported not receiving any notification of rate increases, despite the facility's policy requiring such notice. In some cases, residents were cognitively intact and responsible for their own financial matters, yet they were unaware of the rate changes until they received a bill reflecting the increase. The facility's business office manager was on vacation when the rate increase letters were supposedly sent, and the previous administrator claimed to have mailed the letters, but several residents and their representatives did not receive them. The facility's documentation showed inconsistencies in the communication of rate increases, with some letters lacking addresses and others not being sent at all. The corporate office had approved the rate increase, and the previous administrator signed a memo acknowledging the implementation of the increase. However, the lack of proper notification to residents and their representatives led to confusion and dissatisfaction among those affected. The facility's failure to adhere to its own policies and ensure proper communication contributed to the deficiency identified by the surveyors.
FSD Lacks Valid Certification
Penalty
Summary
The facility failed to employ a Food Service Director (FSD) with valid credentials, as required by their job description. The Director of Nursing (DON) confirmed that the FSD, who started in October 2023, did not have a current certification in food safety management. The Administrator had planned to enroll the FSD in a certification course, but this did not occur. The FSD himself confirmed that he had started but not completed the certification course. The Regional Director of Operations (RDO) also acknowledged that the FSD lacked the necessary certification. A review of the FSD's employee file revealed that his previous certification had expired. This deficiency had the potential to affect all 55 residents in the facility, although there were no residents receiving enteral feeding at the time of the survey.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident with nasal and inhaler medications at their bedside had a self-administration of medication assessment, a physician's order, and a care plan completed. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had Astepro nasal solution, Albuterol sulfate HFA inhalation aerosol solution, and Trilogy inhaler at their bedside. However, there was no evidence of a self-administration assessment, physician's order, or care plan for these medications in the resident's electronic medical record (EMR). During an interview, the resident confirmed using the medications as needed. The facility's policy requires an interdisciplinary team (IDT) assessment and a physician's order for self-administration of medications, but these steps were not documented. The Director of Nursing (DON) acknowledged the oversight and removed the medications until an assessment could be completed. This failure to follow protocol increases the potential for medication errors for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident (R21) to the State of Missouri Department of Health and Senior Services in a timely manner. R21, who had diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls, was found to have a swollen and discolored left knee on 03/12/24. Despite the observation and subsequent X-ray order by RN3, the incident was not reported to the Administrator or Director of Nursing (DON) until 03/18/24, when the DON learned of the fracture and reported it to the state agency the same day. The facility's policy mandates that such injuries be reported within two hours of discovery, which was not adhered to in this case. The deficiency was identified during a review of R21's records and interviews with the staff involved. RN3 noted the injury but failed to report it to the appropriate authorities, and the DON only became aware of the situation six days later. This delay in reporting violated the facility's abuse prevention and prohibition policy, which requires immediate notification to the state agency and law enforcement. The failure to report the injury promptly was confirmed by the DON during the interview, acknowledging that the injury should have been reported on the day it was discovered.
Failure to Immediately Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an investigation was immediately initiated when an allegation of injury of unknown origin was found for a resident. The resident, who had diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls, was found to have a swollen and discolored left knee on 03/12/24. Despite the observation and documentation by a Registered Nurse (RN), the injury was not reported to the Administrator or Director of Nursing (DON) until 03/18/24, when the resident was found to have a fracture. The facility's policy requires that injuries of unknown origin be reported immediately and an investigation initiated, which did not occur in this case. The DON confirmed that she first learned of the injury on 03/18/24 and initiated an investigation on the same day. The delay in reporting and investigating the injury of unknown origin was a clear violation of the facility's abuse prevention and prohibition policy. The policy mandates that nursing staff report such injuries immediately to the Administrator and that an investigation be conducted promptly. The failure to follow these procedures resulted in a significant delay in addressing the resident's injury and ensuring their safety.
Failure to Update Care Plan for Wandering Resident
Penalty
Summary
The facility failed to update the care plan for a resident with wandering behaviors after two incidents where the resident left the skilled nursing unit without staff knowledge or supervision. The resident, diagnosed with Alzheimer's disease, cerebral infarction, and repeated falls, was found in the independent living Bistro and later in the chapel, both times without any changes made to the care plan. The care plan, dated several months prior, only included general interventions such as offering pleasant diversions and redirection, with no updates following the incidents. The Director of Nursing confirmed that there was no incident report for the first incident and acknowledged that the facility did not have a policy related to updating care plans. Despite the resident's wandering behaviors and the incidents, the care plan remained unchanged, and no new interventions were put in place to address the resident's safety and wandering tendencies. The lack of updates to the care plan and the absence of a policy for such updates contributed to the deficiency identified in the report.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a resident with wandering behaviors from leaving the skilled nursing unit without staff's knowledge or supervision. The resident, identified as R21, left the skilled nursing unit and was found in the independent living Bistro and later in the chapel, which was located past two closed double doors at the end of the hall. The resident had a history of Alzheimer's disease, cerebral infarction, and repeated falls, and was known to wander. Despite this, the care plan did not have updated interventions after the incidents, and staff were unsure of the specific interventions in place to supervise the resident. On two separate occasions, R21 was able to leave the skilled nursing unit without staff noticing. On the first occasion, the resident was found in the Bistro, and on the second occasion, the resident was missing for over two hours before being found in the chapel. Interviews with staff revealed that they were aware of the resident's wandering behavior but were unclear about the specific interventions to prevent it. The doors leading to the chapel did not have an effective alarm system, and there was no documentation of hourly monitoring after the resident was found. The Director of Nursing (DON) confirmed that there was no elopement assessment for R21 prior to the incidents and no root cause analysis or investigation into how the resident exited the unit. Additionally, there was no documentation of the 15-minute checks that were supposed to be implemented after the second incident. The facility's policy on elopements stated that all residents should be afforded adequate supervision and assessed for behaviors that put them at risk for elopement, but this was not followed in R21's case.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) changed gloves and performed hand hygiene when transitioning from a contaminated area to a clean area during catheter care for a resident. The facility's policy on Standard Precautions and Prevention of Catheter-Associated Urinary Tract Infections mandates that hand hygiene be performed immediately after any manipulation of or contact with the catheter site, catheter, tubing, drainage bag, or emptying container, even when gloves are worn. Additionally, gloves should be removed before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated. However, during an observation, CNA2 and CNA1 did not adhere to these protocols while providing catheter care to a resident diagnosed with neuromuscular dysfunction of the bladder, who had a recent urinalysis showing mixed pathogen growth. CNA2 and CNA1 failed to change gloves and perform hand hygiene at multiple points during the procedure, including after handling soiled linens and before touching clean items and areas of the resident's body. During the catheter care, CNA2 used the same gloves to remove bowel movement, handle soiled linens, and then touch clean items such as a new incontinence brief and a clean shirt. CNA1 also failed to change gloves after handling soiled linens and before assisting with clean tasks. Furthermore, CNA2 did not perform hand hygiene after removing gloves at the end of the procedure. Interviews with CNA2 and the Director of Nursing (DON) confirmed that gloves should be changed when moving from dirty to clean areas, indicating a clear deviation from the facility's established infection control policies.
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Illustrative
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Laurel Meadows Wellness & Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Lewis & Clark Gardens | 1.9 mi | ★★★★★ | 7 | 0 |
| Aspen Point Health And Rehabilitation | 2.3 mi | ★★★★★ | 9 | 0 |
| Nhc Healthcare, St Charles | 3.5 mi | ★★★★★ | 0 | 0 |
| Ssm Health Depaul Hospital - Anna House | 4.6 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.