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Deficiency Records for Windsor Estates of St Charles
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.
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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-03-04 | 2025-03-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2025-02-21 | 2025-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-18 | 2024-10-10 | Y |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-03-21 | 2024-09-21 | 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 | 2024-03-21 | 2024-09-21 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2024-07-17 | 2024-08-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-30 | 2024-07-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-21 | 2024-05-05 | 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 | 2024-03-21 | 2024-05-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-03-21 | 2024-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-21 | 2024-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-21 | 2024-05-05 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-03-21 | 2024-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-21 | 2024-05-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-21 | 2024-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-21 | 2024-05-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-03-21 | 2024-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-21 | 2024-05-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-21 | 2024-05-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-21 | 2024-05-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-03 | 2024-01-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-03 | 2024-01-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-03 | 2023-12-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-20 | 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 enough food/fluids to maintain a resident's health. | 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-03 | 2023-11-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-11-15 | 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 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 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 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 |
| 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 | 2023-04-05 | 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 |
| 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 | 2023-01-18 | 2023-06-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-28 | 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 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 | 2023-01-18 | 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 |
| 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 |
| 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 |
| 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 |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) 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 |
| 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 |
| 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 |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-28 | 2023-03-30 | Y |
| Respond appropriately to all alleged violations. | 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-12-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-14 | 2022-12-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-14 | 2022-12-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-13 | 2022-12-30 | 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 |
| 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 |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-13 | 2022-12-06 | N |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-11 | 2022-12-06 | Y |
| Meet other general requirements. | Fire Safety | 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 | 2022-10-11 | 2022-12-06 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-07-13 | 2022-12-06 | N |
| 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 | 2022-07-13 | 2022-12-06 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2022-07-13 | 2022-12-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| 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 |
| 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 |
| 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 |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-13 | 2022-10-11 | Y |
| Develop Emergency Preparedness policies and procedures. | 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 |
| Meet requirements for the use of electrical equipment. | 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 |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-13 | 2022-10-11 | N |
| Provide activities to meet all resident's needs. | Health | 2022-07-13 | 2022-10-11 | N |
| 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 |
| 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 |
| Assess the resident when there is a significant change in condition | Health | 2022-07-13 | 2022-10-11 | N |
| 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 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 |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | 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 |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Provide properly protected cooking facilities. | 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 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-10-01 | N |
| Dispose of garbage and refuse properly. | 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 |
| 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 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | 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 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 |
| 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 |
| 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 care by qualified persons according to each resident's written plan of care. | 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 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 |
| 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 |
| 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 |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-08-22 | 2019-10-01 | N |
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