Windsor Estates of St Charles

In the surveyor’s words

From the most serious findings on record at Windsor Estates of St Charles, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Oct 6, 2021

  Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a procedure to support and maintain breathing and circulation for a person who has stopped breathing and/or whose heart has stopped) for one resident (Resident #20) identified as having a full code status (CPR required in the event of cardiac or respiratory arrest). Staff found the resident unresponsive and without a pulse or respirations on [DATE] and failed to initiate CPR and call 911. The resident expired at the facility. The facility also failed to implement the facility policy addressing CPR requirements for staff and to monitor to ensure CPR certified staff were scheduled and present in the facility 24 hours a day, seven days a week. […]

• Immediate jeopardy, isolatedF600May 19, 2026

  Based on interview and record review, facility employees and service providers failed to provide services to a resident (Resident #79) that were necessary to avoid physical harm. Facility staff failed to follow facility policy and procedures, and physician orders for monitoring upon admission and when the resident, who had cardiac-related diagnosis, experienced a change in condition. Staff failed to follow physician's order to check the resident's blood pressure prior to administering blood pressure medication and failed to initiate orders for a muscle relaxer. […]

• Immediate jeopardy, isolatedF689Jun 28, 2023

  Based on interview and record review, the facility failed to secure Resident #1 with a seatbelt while in the facility bus for transport to an appointment. While driving, staff had to apply the brakes hard causing the resident to come out of the wheelchair and slide approximately 12 feet to the front of the bus sustaining injuries including facial fractures and fractured ribs. The facility census was 60. The administrator was notified on 6/28/23 at 1:00 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 6/16/23. On 6/16/23, the administrator became aware of the violation. The facility suspended the staff member driving the bus and in-serviced the staff on the proper way to transport a resident in the facility bus including the application of a seat belt. […]

• Immediate jeopardy, isolatedF600Oct 6, 2021

  Based on observation, interview, and record review, the facility failed to protect two residents (Resident #1 and #2) from physical abuse by Certified Nurse Aide (CNA) A. A camera in Resident #1's room recorded CNA A provide care and transfer the resident in an aggressive and abusive manner. The resident can be heard verbally expressing pain on the video by saying Ow several times during the incident. The resident sustained bruising to both arms and a skin tear to the left elbow. Resident #2 reported CNA A was rough while providing him/her with perineal care. Resident #2 told CNA A that it hurt, to which CNA A responded that is what the resident got for not helping with care. A sample of 12 residents was selected for review. The facility census was 56. […]

• Actual harm, isolatedF755Jun 29, 2026

  Based on record review and interview, the facility failed to implement procedures to accurately acquire and administer prescribed medications for one resident (Resident #1) upon admission, in a review of seven sampled residents. On admission, the facility involved a third-party provider, a group of physicians and nurse practitioners who review and issue orders after hours, to review the resident's medications listed on the resident's hospital discharge orders. The third-party provider placed medications to treat the resident's pain, anxiety, migraine headaches, and attention deficit hyperactivity disorder (ADHD, a disorder causing persistent patterns of inattention, hyperactivity, and impulsivity) on hold until the resident's physician reviewed and approved the orders. […]