Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WINDSOR ESTATES OF ST CHARLES
SAINT CHARLES, MO · 81 certified beds · Last Life Safety survey March 21, 2024
CMS Certification Number 265518 · first certified December 1992
Ownership
Operated by TUTERA SENIOR LIVING & HEALTH CARE · For profit - Limited Liability company
- Ownership changed August 1, 2023 (change of ownership)from WINDSOR ESTATES OF ST CHARLES SNAL LLC
Position within MO
41 citations — more than 93% of the 487 certified nursing homes in MO. Compared within MO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 11. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2025 to December 2025), and past the point by which nine in ten MO facilities have been surveyed. This facility’s last Life Safety survey was March 2024. Facilities in MO are typically surveyed 14–21 months after the last one (median 17), measured over 567 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 41 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
19 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 41 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0880 Provide and implement an infection prevention and control program.
- F-0924 Put firmly secured handrails on each side of hallways.
How that compares
Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 41 |
| Median facility in MO | 18 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 22, 2019 | 12 |
| July 13, 2022 | 20 |
| October 3, 2023 | 1 |
| March 21, 2024 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2024-03-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2023-10-03 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-03-21 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2022-07-13 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2022-07-13 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-03-21 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-03-21 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2022-07-13 |
What the citations cover
- Smoke Deficiencies 16
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Emergency Preparedness Deficiencies 5
- Miscellaneous Deficiencies 5
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Construction Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 21, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Waiver has been granted (September 21, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 5, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (May 5, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 5, 2024) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Waiver has been granted (September 21, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 5, 2024) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (May 5, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 5, 2024) |
October 3, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 15, 2023) |
July 13, 2022 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (October 11, 2022) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (December 6, 2022) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (December 6, 2022) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (December 6, 2022) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (December 6, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 6, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 6, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 6, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 6, 2022) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 6, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0932 | Meet other general requirements. | Deficient, Provider has date of correction (December 6, 2022) |
August 22, 2019 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 1, 2019) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 1, 2019) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 1, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.