A list of the most recent deficiencies for Windsor Estates of St Charles. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-20 | 2023-12-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-03 | 2023-12-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-03 | 2023-11-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-03 | 2023-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-11-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-03 | 2023-11-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-11-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-28 | 2023-07-31 | Y |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2023-06-28 | 2023-07-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-28 | 2023-06-18 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-04-05 | 2023-06-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-05 | 2023-06-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-05 | 2023-06-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-05 | 2023-06-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-28 | 2023-06-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-28 | 2023-06-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-28 | 2023-06-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-28 | 2023-06-01 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-18 | 2023-06-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-18 | 2023-06-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-18 | 2023-06-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-18 | 2023-06-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-18 | 2023-06-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-18 | 2023-06-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-18 | 2023-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-28 | 2023-03-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-28 | 2023-03-30 | Y |
| 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. | Health | 2023-02-28 | 2023-03-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-28 | 2023-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-28 | 2023-03-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-03-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-18 | 2023-03-30 | Y |
| 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. | Health | 2023-01-18 | 2023-03-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-18 | 2023-03-30 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-01-18 | 2023-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-18 | 2023-03-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-13 | 2022-12-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-14 | 2022-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-14 | 2022-12-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-13 | 2022-12-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-07-13 | 2022-12-06 | N |
| 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. | Health | 2022-07-13 | 2022-12-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-13 | 2022-12-06 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-07-13 | 2022-12-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-13 | 2022-12-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-13 | 2022-12-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-13 | 2022-12-06 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-11 | 2022-12-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-11 | 2022-12-06 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Meet other general requirements. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-13 | 2022-10-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-07-13 | 2022-10-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-07-13 | 2022-10-11 | N |
| Provide activities to meet all resident's needs. | Health | 2022-07-13 | 2022-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-10-11 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-13 | 2022-10-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-13 | 2022-10-11 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-13 | 2022-10-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-13 | 2022-10-11 | Y |
| 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. | Health | 2022-07-13 | 2022-10-11 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-13 | 2022-10-11 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-02-28 | 2022-03-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-28 | 2022-03-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-28 | 2022-03-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-15 | 2022-01-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-15 | 2022-01-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-04 | 2022-01-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-04 | 2022-01-26 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-11-04 | 2022-01-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-06 | 2022-01-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-06 | 2022-01-26 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-06 | 2022-01-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-04 | 2021-11-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-04 | 2021-11-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-04 | 2021-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-06 | 2021-11-30 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-10-06 | 2021-11-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-06 | 2021-11-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-06 | 2021-11-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-06 | 2021-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-06 | 2021-11-30 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-10-06 | 2021-11-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-06 | 2021-11-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-06 | 2021-10-06 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-10 | 2021-08-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-01 | 2021-07-27 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-22 | 2019-10-01 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-08-22 | 2019-10-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-08-22 | 2019-10-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-22 | 2019-10-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-08-22 | 2019-10-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-22 | 2019-10-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-08-22 | 2019-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-22 | 2019-10-01 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-10-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-22 | 2019-10-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-07-19 | 2019-01-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-07-19 | 2019-01-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-07-19 | 2018-08-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-19 | 2018-08-31 | N |
