Inspection Reports for
Camdenton Windsor Estates
2042 N BUSINESS ROUTE 5, CAMDENTON, MO, 65020-2611
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
46 residents
Based on a April 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 46
Deficiencies: 13
Date: Apr 10, 2025
Visit Reason
Routine inspection of Camdenton Windsor Estates nursing home to assess compliance with regulatory requirements including resident privacy, bed hold policy, PASRR notifications, medication management, activities program, safety, respiratory care, nursing coverage, psychotropic medication use, medication error rates, food service, infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy, failure to notify residents of bed hold policy, failure to notify appropriate authorities of PASRR changes, medication management errors including unavailable medications and incorrect dosages, lack of certified activity director, unsafe smoking material practices, improper oxygen therapy management, inadequate RN coverage, failure to implement psychotropic medication stop dates and gradual dose reductions, medication administration errors, failure to follow food preparation and storage standards, and inadequate infection prevention and control practices including hand hygiene and use of enhanced barrier precautions.
Deficiencies (13)
Failure to protect residents' personal information and privacy during medication administration and perineal care.
Failure to provide written bed hold policy information to residents or representatives at time of hospital transfer.
Failure to notify Central Office Medical Review Unit of significant change in mental health status for PASRR evaluation.
Failure to maintain professional standards in medication management including failure to notify physician of unavailable medications, incorrect medication dosages, and failure to document weights and food intake as ordered.
Failure to have certified activity director overseeing the activities program.
Failure to ensure residents did not retain smoking materials and failure to supervise smoking materials properly.
Failure to provide safe and appropriate respiratory care including oxygen delivery at prescribed flow rate and proper cleaning and maintenance of oxygen equipment.
Failure to provide RN coverage for at least eight consecutive hours per day, seven days a week.
Failure to implement psychotropic medication stop dates and gradual dose reductions as ordered.
Medication administration errors including incorrect dosages of medications given to residents.
Failure to serve food according to nutritional recipes and menus, failure to maintain proper food storage temperatures, failure to properly reheat pureed foods, and failure to perform proper hand hygiene in food service.
Failure to maintain infection prevention and control program including failure to implement enhanced barrier precautions, improper cleaning and disinfection of glucometers, failure to perform hand hygiene during blood sugar checks, insulin administration, toileting, and wound care.
Failure to designate a qualified infection preventionist with specialized training for the facility's infection prevention and control program.
Report Facts
Census: 46
Medication error rate: 5.26
Freezer temperature: 9
Freezer temperature: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in medication administration errors and infection control deficiencies |
| LPN D | Licensed Practical Nurse | Named in respiratory care and infection control deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding deficiencies and facility policies |
| Administrator | Facility Administrator | Named in multiple interviews regarding facility oversight and deficiencies |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies and facility policies |
| LPN E | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| Dietary Manager | Dietary Manager | Named in food service deficiencies |
| DA M | Dietary Aide | Named in food service hand hygiene deficiencies |
| CNA H | Certified Nurse Aide | Named in personal care and hand hygiene deficiencies |
| NA I | Nurse Aide | Named in personal care and hand hygiene deficiencies |
Inspection Report
Routine
Census: 49
Deficiencies: 2
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care plan development and revision requirements following resident falls, and to assess whether neurological checks were completed and documented for residents who had unwitnessed falls.
Findings
The facility failed to review and revise comprehensive care plans for three residents who sustained falls, and failed to complete and document neurological checks for two residents after unwitnessed falls, as required by facility policy. The deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Facility staff failed to review and revise the comprehensive care plan for three residents who sustained falls.
Facility staff failed to complete and document neurological checks for two residents who had unwitnessed falls as directed by facility policy.
Report Facts
Residents affected: 3
Residents affected: 2
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding updating care plans and neurological assessments | |
| Administrator | Interviewed regarding expectations for care plan updates and neurological assessments | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations and responsibility for care plan updates and neurological assessments |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding neurological check procedures |
| Certified Nurse Aide B | Certified Nurse Aide (CNA) | Interviewed regarding purpose of care plans and responsibilities |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of physical abuse involving one resident.
Complaint Details
The complaint involved an allegation that a Registered Nurse hit a resident and threw a sheet over the resident's head. The Certified Nurse Aide who witnessed the incident did not report it immediately, resulting in delayed notification to the Department of Health and Senior Services. The complaint was substantiated with findings of delayed reporting.
Findings
The facility failed to report an allegation of physical abuse by a staff member against a resident within the required two-hour timeframe. Interviews revealed lack of staff knowledge about immediate reporting requirements, and the facility subsequently educated the involved staff.
Deficiencies (1)
Failure to timely report suspected abuse of a resident within the two-hour required timeframe.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in allegation of physical abuse against resident |
| CNA A | Certified Nurse Aide | Witnessed abuse and delayed reporting |
Inspection Report
Routine
Census: 44
Capacity: 82
Deficiencies: 10
Date: Mar 21, 2024
Visit Reason
Routine inspection of Camdenton Windsor Estates nursing home to assess compliance with regulatory requirements including resident care, environment, medication management, infection control, and other standards.
Findings
The inspection identified multiple deficiencies including failure to maintain a clean environment, incomplete and inaccurate resident assessments and care plans, improper medication and chemical storage, inadequate respiratory care equipment handling, improper food temperature management, incomplete infection prevention policies, poor hand hygiene practices, and failure to document pneumococcal vaccinations for several residents.
Deficiencies (10)
Failure to maintain a clean, homelike, and comfortable environment with debris and dirty mop water used for cleaning.
Failure to document complete and accurate Minimum Data Set (MDS) assessments for residents using BiPAP, CPAP, and anticoagulants.
Failure to develop and implement comprehensive person-centered care plans for residents including oxygen use, BiPAP, hospice care, and risk factors.
Failure to provide necessary assistance with activities of daily living including hair care, facial hair care, and nail care for residents unable to perform these tasks.
Failure to ensure medication and treatment carts were locked and medications were not left unattended or unsecured; failure to lock housekeeping carts with chemicals.
Failure to store oxygen, nebulizer, CPAP, and BiPAP equipment properly to prevent contamination and infection; tubing and masks were often undated, uncovered, or on the floor.
Failure to accurately count controlled medications and failure to remove expired medications and supplies from storage.
Failure to ensure pureed food items were reheated to proper temperatures and held at safe temperatures during meal service; failure to follow puree recipes; failure to ensure hot food on room trays was maintained at 120°F at time of delivery.
Failure to develop and implement complete water management policies and procedures to inhibit growth of Legionella and other pathogens; failure to perform proper hand hygiene by staff.
Failure to document administration of pneumococcal vaccine for six of eight sampled residents despite signed consents.
Report Facts
Facility census: 44
Facility capacity: 82
Expired medication: 3
Controlled medication count discrepancy: 2
Food temperature: 118
Food temperature: 114
Food temperature: 111
Food temperature: 113
Food temperature: 117
Pureed food temperature: 124
Pureed food temperature: 130
Pureed food temperature: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN I | Licensed Practical Nurse | Named in medication count discrepancy and hand hygiene deficiencies |
| Housekeeping Supervisor | Named in deficiencies related to cleaning practices and chemical cart locking | |
| CMT G | Certified Medication Technician | Named in medication cart security deficiency |
| NA N | Nurse Assistant | Named in hand hygiene deficiency |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies and expectations |
| Administrator | Named in multiple interviews regarding deficiencies and expectations | |
| MDS Coordinator | Named in interviews regarding MDS assessments and care plans | |
| Dietary Manager | Named in interview regarding food preparation and temperature | |
| Medical Director | Named in interview regarding respiratory care and vaccination expectations | |
| CNA A | Certified Nurse Assistant | Named in interviews and observations regarding cleaning and hand hygiene |
| CNA O | Certified Nurse Assistant | Named in hand hygiene deficiency |
| NA K | Nurse Aide | Named in respiratory equipment handling deficiency |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jan 18, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide an appropriate 30-day discharge notice for one resident and failure to allow the resident to return to the facility after hospital discharge.
Complaint Details
The complaint investigation found that the facility did not provide the required discharge notice and did not accept the resident back after hospital transfer. The resident had a history of drug use, wound care needs, and behaviors unknown to the facility at admission. The hospital social worker confirmed placement had not been found for the resident after emergency room stay.
Findings
The facility failed to provide a 30-day discharge notice for Resident #1 and did not allow the resident to return after hospital discharge. The resident was admitted with IV antibiotics but was transferred to the emergency room due to adverse reactions, and the facility decided not to readmit the resident due to inability to meet care needs.
Deficiencies (1)
Failure to provide an appropriate 30 day discharge notice and failure to allow resident to return after hospital discharge.
Report Facts
Residents Affected: 1
Facility Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Designee (SSD) | Interviewed regarding resident admission and discharge | |
| Administrator | Interviewed regarding resident admission and hospital information | |
| Licensed Practical Nurse (LPN) | Interviewed regarding resident admission and care needs | |
| Hospital Social Worker | Interviewed regarding resident placement after emergency room stay |
Inspection Report
Census: 49
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding residents' access to communication methods, specifically the availability of internet access to residents.
Findings
The facility failed to provide internet access to residents despite the presence of younger residents who would benefit from it. Interviews with residents and staff confirmed the lack of internet availability, and management acknowledged requests for internet access were denied due to cost concerns.
Deficiencies (1)
Facility failed to offer internet access to residents, and no policy existed regarding resident internet usage.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Mentioned in interview regarding lack of internet access for residents |
| Director of Nursing | Director of Nursing | Interviewed about lack of internet access for residents |
| Administrator | Administrator | Interviewed about lack of internet access for residents and cost concerns |
Report
Dec 2, 2022
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