MissouriSaint Charles

Windsor Estates of St Charles

2150 West Randolph Street, Saint Charles, MO 63301 · St. Charles County · 81 certified beds · avg 73 residents/day · certified since Dec 3, 1992

Abuse citation flag (CMS)

Part of chain: TUTERA SENIOR LIVING & HEALTH CARE (25 facilities, chain avg rating 2.0★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
14
Serious findings on record
$364,413
Fines, last 3 years
3.45
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · May 19, 2026 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jul 7, 2026 (Deficient, Provider has plan of correction)

▲ Actual harm, one-off · Jun 29, 2026 · F-0755 · triggered by a complaint

The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.

Why it matters: Weak pharmacy services lead to medication mistakes, delays, and missed drug interactions that can seriously harm residents.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 7, 2026 (Deficient, Provider has plan of correction)

▲ Actual harm, one-off · May 19, 2026 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 7, 2026 (Deficient, Provider has plan of correction)

▲ Actual harm, one-off · Dec 15, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 19, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 3, 2025 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 1, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Aug 7, 2025 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 1, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · May 2, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 21, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 18, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 10, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jul 30, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 18, 2024 (Past Non-Compliance)

▲ Actual harm, one-off · Nov 20, 2023 · F-0697 · triggered by a complaint

The facility did not provide safe and appropriate pain management for a resident who needed it.

Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Dec 15, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (78)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 29, 2026▲ G · Actual harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
May 19, 2026▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 19, 2026▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 19, 2026E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
May 19, 2026E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
May 19, 2026E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
May 19, 2026E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 1, 2026E · Potential for harm, repeatedThe facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. · from a complaint
Dec 15, 2025▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 15, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 3, 2025▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 7, 2025▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 7, 2025E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Aug 7, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Aug 7, 2025D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jun 10, 2025E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
May 2, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 2, 2025F · Potential for harm, facility-wideThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint
May 2, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
May 2, 2025E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
May 2, 2025D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Mar 4, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Feb 21, 2025F · Potential for harm, facility-wideThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Sep 18, 2024▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 30, 2024▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 17, 2024E · Potential for harm, repeatedThe facility required residents to give up Medicare or Medicaid benefits or pay privately as a condition of moving in, or failed to tell residents which types of care it does not provide. Both practices are against the rules. · from a complaint
Mar 21, 2024F · Potential for harm, facility-wideThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Mar 21, 2024D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 21, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 21, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Mar 21, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 21, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 21, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 3, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Jan 3, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Nov 20, 2023▲ G · Actual harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Oct 3, 2023▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Oct 3, 2023▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 3, 2023▲ G · Actual harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Oct 3, 2023D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Oct 3, 2023D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Jul 13, 2022▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jul 13, 2022F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Jul 13, 2022E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jul 13, 2022E · Potential for harm, repeatedThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jul 13, 2022E · Potential for harm, repeatedThe facility did not have firmly secured handrails on both sides of its hallways.
Jul 13, 2022D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jul 13, 2022D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Jul 13, 2022D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 13, 2022C · Minimal risk, facility-wideThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jul 13, 2022B · Minimal risk, repeatedThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Aug 22, 2019F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 22, 2019E · Potential for harm, repeatedThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Aug 22, 2019E · Potential for harm, repeatedThe facility did not properly protect the personal money residents deposited with it for safekeeping.
Aug 22, 2019E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Aug 22, 2019E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Aug 22, 2019E · Potential for harm, repeatedThe facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive.
Aug 22, 2019E · Potential for harm, repeatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Aug 22, 2019E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 22, 2019E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Aug 22, 2019D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Aug 22, 2019D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Aug 22, 2019D · Potential for harm, one-offWhen a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care.
Aug 22, 2019D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Aug 22, 2019D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Aug 22, 2019D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Aug 22, 2019D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Aug 22, 2019D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (20 → 7).

YearCitationsSerious (G–L)Worst severity that year
2019170F
2022201G ▲
202364G ▲
2024122G ▲
2025154G ▲
202683J ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

8 fines totaling $364,413, plus 2 Medicare payment denial periods.

DateTypeAmount / length
May 19, 2026Fine$137,652
Dec 15, 2025Fine$86,190
Aug 7, 2025Fine$41,659
May 2, 2025Fine$12,425
May 2, 2025Payment Denial6 days from Jun 6, 2025
Feb 6, 2024Fine$9,032
Oct 3, 2023Fine$73,593
Oct 3, 2023Payment Denial29 days from Nov 16, 2023
Aug 28, 2023Fine$2,098
Aug 21, 2023Fine$1,764

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMissouri avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.453.663.95bottom 44% in Missouri; bottom 34% in the U.S.
Registered Nurse hours0.200.490.69bottom 9% in Missouri; bottom 2% in the U.S.
Weekend total nurse staffing3.003.223.50bottom 41% in Missouri; bottom 31% in the U.S.
Weekend RN hours (not acuity-adjusted)0.150.330.48bottom 14% in Missouri; bottom 5% in the U.S.
Total nursing staff turnover (%)71.456.045.8bottom 14% in Missouri; bottom 5% in the U.S.
RN turnover (%)0.047.842.9

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.53, RN 0.20, weekend 3.07. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Joseph Charles Tutera 2013 Family Irrevociable Trust AgreementOrganization5% or Greater Direct Ownership Interest13%08/01/2023
Marian Olander Tutera 2020 MRTL TrOrganization5% or Greater Direct Ownership Interest6%08/01/2023
St Charles Holdco Holdings LLCOrganization5% or Greater Direct Ownership Interest20%08/01/2023
Brooks, KileyIndividualCorporate OfficerNOT APPLICABLE08/01/2023
Brooks, KileyIndividualOperational/Managerial ControlNOT APPLICABLE08/01/2023
Tutera, JosephIndividualCorporate OfficerNOT APPLICABLE08/01/2023
Walnut Creek Management Company LLCOrganizationOperational/Managerial ControlNOT APPLICABLE08/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

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Laurel Meadows Wellness & Rehabilitation1.2 miSaint Charles, MO★★☆☆☆2/5
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Aspen Point Health and Rehabilitation2.4 miSaint Charles, MO★☆☆☆☆1/5
NHC Healthcare, St Charles3.5 miSaint Charles, MO★★★★☆4/5
SSM Health Depaul Hospital - Anna House4.5 miBridgeton, MO★★★☆☆3/5
Avenir at Mark Twain4.8 miBridgeton, MO★☆☆☆☆1/5
Life Care Center of Bridgeton4.8 miBridgeton, MO★★☆☆☆3/5
Parkwood Skilled Nursing and Rehabilitation Center5.2 miMaryland Heights, MO★☆☆☆☆1/5
Stonebridge Maryland Heights5.7 miMaryland Heights, MO★★☆☆☆2/5
McClay Senior Care6.0 miSaint Peters, MO★★★☆☆3/5
NHC Healthcare, Maryland Heights6.4 miMaryland Heights, MO★★★★☆4/5
St Peters Rehab and Healthcare Center6.4 miSaint Peters, MO★☆☆☆☆1/5abuseSFF

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Facility data as of CMS processing date 2026-08-01. CCN 265518.