F53

WINDSOR ESTATES OF ST CHARLES

Grade F 53/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

81

Ownership

For profit - Limited Liability company

Total Fines

$133,015

Last Survey

N/A

2150 WEST RANDOLPH STREET, SAINT CHARLES, MO 63301
6369464966

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.21h
LPN
1.25h
CNA
2.24h
Total
3.70h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

JOSEPH CHARLES TUTERA 2013 FAMILY IRREVOCIABLE TRUST AGREEMENT

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Aug 2023

13%

MARIAN OLANDER TUTERA 2020 MRTL TR

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Aug 2023

6%

ST CHARLES HOLDCO HOLDINGS LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Aug 2023

20%

TUTERA INVESTMENTS, LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Aug 2023

18%

TUTERA, JOSEPH

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Aug 2023

13%

WALNUT CREEK MANAGEMENT COMPANY LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Aug 2023

BROOKS, KILEY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Aug 2023

BROOKS, KILEY

IndividualCORPORATE OFFICERSince Aug 2023

TUTERA, JOSEPH

IndividualCORPORATE OFFICERSince Aug 2023

Penalties & Fines (11)

$133,015total fines
DateTypeDescriptionAmount
May 2, 2025Fine$19,115
May 2, 2025Payment Denial
Feb 6, 2024Fine$9,032
Oct 3, 2023Fine$73,593
Oct 3, 2023Payment Denial
Aug 28, 2023Fine$2,098
Aug 21, 2023Fine$1,764
Jul 31, 2023Fine$3,145
Jun 28, 2023Fine$14,518
Jan 18, 2023Fine$9,750
Jan 18, 2023Payment Denial

Health Inspection Deficiencies (97)

September 3, 2025Health1 deficiency1 severe
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Oct 1, 2025
August 7, 2025Health4 deficiencies1 severe
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Aug 27, 2025
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 1, 2025
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Oct 1, 2025
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Aug 27, 2025
June 10, 2025Health1 deficiency
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jun 12, 2025
May 2, 2025Health5 deficiencies1 severe
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jun 12, 2025
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 21, 2025
0801FMinimal harm, Widespread

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.

Nutrition and Dietary Deficiencies

Corrected May 21, 2025
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected May 21, 2025
0908DMinimal harm, Isolated

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected May 21, 2025
March 4, 2025Health1 deficiency
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 19, 2025
February 21, 2025Health1 deficiency
0919FMinimal harm, Widespread

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected Mar 3, 2025
September 18, 2024Health1 deficiency1 severe
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Oct 10, 2024
July 30, 2024Health1 deficiency1 severe
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jul 18, 2024
July 17, 2024Health1 deficiency
0620EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Aug 12, 2024
March 21, 2024Health7 deficiencies
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected May 5, 2024
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected May 5, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 5, 2024
0801FMinimal harm, Widespread

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.

Nutrition and Dietary Deficiencies

Corrected May 5, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 5, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 5, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 5, 2024
January 3, 2024Health2 deficiencies
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jan 31, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jan 31, 2024
November 20, 2023Health1 deficiency1 severe
0697GActual harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Dec 15, 2023
October 3, 2023Health5 deficiencies3 severe
0697GActual harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Dec 15, 2023
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 15, 2023
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Nov 15, 2023
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Nov 15, 2023
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Nov 15, 2023
June 28, 2023Health3 deficiencies1 severe
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jun 18, 2023
0835EMinimal harm, Pattern

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Corrected Jul 31, 2023
0920EMinimal harm, Pattern

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.

Environmental Deficiencies

Corrected Jul 31, 2023
April 5, 2023Health4 deficiencies
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Jun 1, 2023
0585EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Jun 1, 2023
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2023
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Jun 1, 2023
February 28, 2023Health9 deficiencies
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 30, 2023
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2023
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jun 1, 2023
0692EMinimal harm, Pattern

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Mar 30, 2023
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Jun 1, 2023
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Mar 30, 2023
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 30, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 30, 2023
0919EMinimal harm, Pattern

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected Jun 1, 2023
January 18, 2023Health13 deficiencies
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 30, 2023
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Jun 1, 2023
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Jun 1, 2023
0585EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Jun 1, 2023
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 30, 2023
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 1, 2023
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jun 1, 2023
0692EMinimal harm, Pattern

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Mar 30, 2023
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Jun 1, 2023
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Mar 30, 2023
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 30, 2023
0838FMinimal harm, Widespread

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.

Administration Deficiencies

Corrected Mar 30, 2023
0919EMinimal harm, Pattern

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected Jun 1, 2023
July 13, 2022Health20 deficiencies1 severe
0558EMinimal harm, Pattern

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Dec 6, 2022
0578DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Oct 11, 2022
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Dec 6, 2022
0585EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Oct 11, 2022
0602EMinimal harm, Pattern

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Oct 11, 2022
0623CNo harm, Widespread

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Oct 11, 2022
0625BNo harm, Pattern

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.

Resident Rights Deficiencies

Corrected Oct 11, 2022
0637DMinimal harm, Isolated

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Corrected Oct 11, 2022
0638EMinimal harm, Pattern

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 6, 2022
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 30, 2022
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Dec 6, 2022
0679EMinimal harm, Pattern

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Oct 11, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 30, 2022
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 6, 2022
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 11, 2022
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Oct 11, 2022
0803EMinimal harm, Pattern

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.

Nutrition and Dietary Deficiencies

Corrected Dec 6, 2022
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Dec 6, 2022
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 11, 2022
0924EMinimal harm, Pattern

Put firmly secured handrails on each side of hallways.

Environmental Deficiencies

Corrected Dec 6, 2022
August 22, 2019Health17 deficiencies
0561EMinimal harm, Pattern

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Oct 1, 2019
0570EMinimal harm, Pattern

Assure the security of all personal funds of residents deposited with the facility.

Resident Rights Deficiencies

Corrected Oct 1, 2019
0578DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Oct 1, 2019
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Oct 1, 2019
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Oct 1, 2019
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 1, 2019
0659EMinimal harm, Pattern

Provide care by qualified persons according to each resident's written plan of care.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 1, 2019
0661DMinimal harm, Isolated

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 1, 2019
0686EMinimal harm, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Oct 1, 2019
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Oct 1, 2019
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Oct 1, 2019
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Oct 1, 2019
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Oct 1, 2019
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 1, 2019
0814DMinimal harm, Isolated

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Oct 1, 2019
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 1, 2019
0883EMinimal harm, Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Oct 1, 2019

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Frequently Asked Questions

What is the CareGrader rating for WINDSOR ESTATES OF ST CHARLES?

WINDSOR ESTATES OF ST CHARLES in SAINT CHARLES, Missouri has a CareGrader grade of F (Poor), with a composite score of 53.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WINDSOR ESTATES OF ST CHARLES?

WINDSOR ESTATES OF ST CHARLES has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WINDSOR ESTATES OF ST CHARLES have?

WINDSOR ESTATES OF ST CHARLES has 97 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has WINDSOR ESTATES OF ST CHARLES been fined?

Yes. WINDSOR ESTATES OF ST CHARLES has $133,015 in total fines from CMS enforcement actions across 11 penalties.

How many beds does WINDSOR ESTATES OF ST CHARLES have?

WINDSOR ESTATES OF ST CHARLES has 81 certified beds with approximately 70 current residents (86% occupancy). The facility is located at 2150 WEST RANDOLPH STREET, SAINT CHARLES, Missouri 63301. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.