Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Creve Coeur Manor during CMS and state inspections, most recent first.
A facility failed to transcribe and administer one resident’s ordered beta blocker and failed to hold another resident’s metoprolol when HR was below the ordered parameter. The DON and ADON said they were unaware of the missing order, and staff documented administration of the second resident’s medication despite low HR readings, with no documentation that the physician was notified.
A resident with dementia, prior stroke, and documented swallowing difficulties, who relied on a g-tube for more than half of their nutrition and fluids, did not receive ordered continuous Jevity 1.5 Cal tube feeding and scheduled water flushes. Observations showed the formula and water hanging at the bedside while the resident was seated in the hallway without the feeding attached, and later in bed with the feeding still not connected. Despite clear physician orders for 23-hour tube feeding at a set rate and water flushes every four hours, and facility policies requiring adherence to physician orders, the RN responsible did not restart the feeding when the resident was taken out of bed, resulting in the ordered g-tube regimen not being followed.
Staff did not consistently wear gowns during high-contact care activities for several residents with wounds or indwelling devices, despite EBP signage and care plans indicating the need. Multiple residents requiring EBP received care where only gloves were used, and PPE carts or supplies were not available in their rooms. Facility leadership confirmed insufficient PPE availability, leading to noncompliance with infection control standards.
The facility did not maintain RN coverage for at least eight hours daily, as the DON was administering medications while also fulfilling her role as DON. This dual role was due to staffing issues, and the Administrator was unaware of the requirement that the DON could not serve as the RN on duty while acting as the DON.
The facility did not ensure that the Dietary Manager (DM) met the required qualifications, as the DM was not certified. The Registered Dietician (RD) was only present one day a month and was aware of the DM's lack of certification. The Administrator knew about the DM's lack of training at hiring, expecting completion before the survey. The job description required a dietary management certificate.
The facility did not adhere to dietary menus and portion sizes, affecting 69 residents. A dietary aide served incorrect portions of vegetables and used visual estimation for meat portions due to lack of guidance. Mechanical soft diets were improperly served with whole pieces instead of chopped, and dinner rolls were omitted. The dietary manager confirmed these discrepancies and could not provide a policy.
The facility failed to maintain food safety and sanitation standards, affecting all 69 residents receiving dietary services. Observations revealed a malfunctioning dishwasher, significant cleanliness issues in the kitchen, and improper food handling practices. Staff did not change gloves between handling dirty and clean dishes, and food items were improperly stored, with some left uncovered and undated. The facility's policies were outdated and did not address critical aspects like sanitizing rinses and glove changes.
The facility failed to maintain cleanliness around the garbage dumpsters, affecting all 69 residents. Over four days, surveyors observed debris, including a broken refrigerator, plastic gloves, food debris, and more. One dumpster was often left open. The Administrator stated that cleaning occurs weekly, but lacked documentation. Facility policy assigns maintenance the responsibility to keep the area clean and lids closed.
The facility failed to maintain a large walk-in refrigerator in the dietary department, which has been inoperable since July 2024. This deficiency potentially affects all 69 residents receiving food from dietary. Observations confirmed the refrigerator was empty, and interviews with the Dietary Manager and Administrator provided details on the issue and an estimate for replacing the compressor.
The facility failed to complete TPL forms within 30 days for deceased residents with account balances and did not notify residents when their trust accounts neared the SSI resource limit. This affected several residents, with balances ranging from $610.61 to $10,357.35, and was attributed to a lack of awareness and a new BOM still learning their duties.
The facility failed to maintain a clean and homelike environment on the secured second floor, affecting 30 residents. Observations revealed food splatters, missing ceiling tiles, malfunctioning door handles, and unclean surfaces. Interviews with staff indicated a lack of awareness and communication regarding these issues, with no plan provided to address the concerns.
The facility failed to conduct CNA registry checks for seven newly hired employees, including non-nursing staff, as required by their Abuse Prevention Program. The Business Office Manager, responsible for these checks, was not trained to perform them for non-nursing staff, leading to this oversight.
The facility failed to provide prescribed therapeutic diets to several residents, including health shakes and specific meal items, as ordered by physicians. This affected residents with conditions such as Alzheimer's, diabetes, and malnutrition. The Dietary Manager and Registered Dietician were unaware of the omissions, and the facility lacked a policy to address the issue.
The facility did not follow its TB screening policy, failing to complete timely two-step and annual one-step TB tests for five employees. The policy requires a two-step TST upon hire and an annual one-step test. Staff Members A and B lacked documentation of an annual test, while Staff Members C, D, and E had no documentation of the two-step test. The Administrator noted that the DON or ADON administers the tests, and the HRM ensures completion, but both were out sick during the interview.
The facility failed to maintain the dignity and respect of four residents by not providing clean clothing and socks, and by staff standing while assisting two residents with meals. One resident wore dirty socks without assistance to change them, and another lacked adequate clothing, wearing a hospital gown since admission. Additionally, a CNA stood while feeding two residents, against protocol. These actions led to undignified care for the residents.
A non-verbal resident with multiple diagnoses, including cerebral palsy and multiple sclerosis, was not provided with a communication device, hindering his ability to express needs. Despite a BIMS score indicating an inability to communicate verbally, the care plan lacked strategies for alternative communication. Staff interviews confirmed the absence of a communication board or device, and the resident indicated that such a tool would be helpful.
A resident with a prescription for white petrolatum gel to treat dry skin on her feet and legs did not receive the treatment as prescribed. Despite the resident's cognitive awareness and request for care, observations confirmed the lack of treatment over several days. Interviews with staff revealed that the task was not included in the CNA's daily assignments, and the LPN was unaware of the oversight.
The facility's medication error rate was 6.67%, exceeding the acceptable threshold due to three errors in medication administration. A CMT administered Buspirone late to a resident, and an LPN gave a Daily-Vite with folic acid without a physician's order. Interviews confirmed the facility's policy on medication timing and orders, highlighting the errors' potential impact on accurate dosing.
The facility failed to maintain appetizing food temperatures, affecting all 69 residents. Observations showed food cooled significantly by the time it was served, with the pot roast at 106°F. Interviews revealed no food temperature logs were maintained, contrary to expectations.
The facility did not post the required daily nurse staffing report in a prominent place, instead keeping it in a notebook at the nurses' station. The document lacked essential details such as the facility name, date, census, and total hours worked by RNs, LPNs, and CNAs. The staffing coordinator was unaware of the posting requirement, and the Administrator confirmed the oversight.
The facility failed to provide a safe, comfortable, and homelike environment by not addressing plumbing and roofing issues, resulting in stained and bulging ceiling tiles in residents' rooms and a shower room. Residents expressed concerns about potential mold or fecal contamination, and the maintenance director indicated that approval for necessary repairs had not been granted by the corporate office.
A resident with severe cognitive impairment did not receive their prescribed Hydrocodone-acetaminophen for an extended period due to miscommunication and confusion among staff. The medication was documented as unavailable on multiple occasions, and there was no documentation of communication with the hospice company, physician, or pharmacy regarding the issue.
Failure to Follow Medication Orders and Hold Parameters
Penalty
Summary
The facility failed to ensure staff transcribed physician orders and administered medications as ordered for one resident and failed to hold a medication according to ordered parameters for another resident. The facility’s Physician’s Orders policy required new orders to be documented on the physician order sheet, MAR, and TAR, and newly prescribed medications to be transcribed onto the MAR or TAR. Surveyors reviewed records, observed documentation, and interviewed staff regarding the medication management issues. For one resident with diagnoses including high blood pressure, stroke, and heart failure, the POS contained an order for bisoprolol fumarate 5 mg, give 1/2 tablet via gastrostomy once daily after readmission. The MARs for multiple months showed no order for bisoprolol fumarate, and the resident’s progress notes contained no documentation about the medication. The resident’s MDS showed short- and long-term memory loss and total dependence for all ADLs. The care plan contained no documentation regarding high blood pressure medication. During interviews, the ADON and DON both stated they had passed medications to the resident several times and were unaware of the bisoprolol order, and the DON said she had never seen the medication on the cart. For another resident with diagnoses including high blood pressure, schizophrenia, and high cholesterol, the POS and MAR showed an order for metoprolol succinate 50 mg by mouth daily with instructions to hold for SBP less than 100, DBP less than 60, or HR less than 60. The MAR documented multiple dates when the resident’s HR was below 60, yet staff still documented the medication as administered on those dates. There was no documentation that the physician was notified of the below-parameter heart rates in the MAR or progress notes. The CMT stated he/she would hold the medication if the HR was below the parameter but did not recall whether the nurse was notified, and the DON stated the CMT should have notified the nurse and the nurse should have notified the physician and clarified the order.
Failure to Administer Ordered G-Tube Feeding and Water Flushes
Penalty
Summary
The deficiency involves the facility’s failure to provide gastrostomy tube (g-tube) feedings and water flushes as ordered for a resident who was dependent on tube feeding for nutrition and hydration. The resident had diagnoses including hypertension, stroke, dementia, short- and long-term memory loss, and required total staff assistance for all ADLs. The resident’s MDS indicated the presence of a feeding tube and that more than 51% of total calories and fluids were received via the tube. The care plan identified risk for altered nutrition and hydration related to difficulty swallowing and a history of failed swallow test, with approaches including providing tube feeding and water flushes as ordered. Physician orders directed Jevity 1.5 Cal at 45 ml/hr for 23 hours per day and g-tube water flushes of 150 ml every four hours. On the survey day, observations showed that at 10:38 A.M. the resident was not in the room while the Jevity and water were hanging on the IV pole next to the bed, and at 10:48 A.M. the resident was seated in the hallway across from the nurse’s station without the tube feeding or water attached, while an RN sat at the nurse’s station in full view of the resident. At 1:45 P.M., the resident was back in bed with the Jevity and water still hanging on the pole and not connected to the resident. A CNA reported getting the resident up around 9:00 A.M. and placing the resident at the nurse’s desk. The RN responsible for the resident initially stated the tube feeding was ordered to begin in the afternoon, but upon reviewing the physician orders acknowledged that the tube feeding should have been restarted when the resident was gotten out of bed. Facility policies required that tube feedings be administered according to physician orders and that any failure to implement an order be promptly reported to the physician and DON, but the ordered continuous tube feeding and scheduled water flushes were not provided during the observed period.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for residents with wounds or indwelling medical devices, such as urinary catheters. Observations revealed that staff did not consistently wear gowns during high-contact care activities, despite the presence of EBP signage and care plans indicating the need for such precautions. In multiple instances, staff provided wound care, catheter care, and assisted with transfers and hygiene for residents requiring EBP, but only wore gloves and not gowns as mandated by facility policy and CDC/CMS guidelines. Several residents with significant medical needs, including chronic wounds, indwelling catheters, and colostomies, were identified as requiring EBP. For these residents, care plans and physician orders often lacked specific instructions for EBP, and in some cases, the need for EBP was not addressed at all. Observations confirmed that staff failed to don appropriate PPE, such as gowns, during high-contact activities, and there was a lack of visible PPE carts or supplies in the rooms of affected residents. Staff interviews confirmed awareness of the requirement to wear gowns, but cited insufficient PPE availability as a barrier to compliance. Interviews with facility leadership, including the Assistant Director of Nursing and the Regional Nurse Manager, confirmed that EBP signage and PPE should be present and used for residents meeting the criteria. However, both acknowledged that the facility did not have enough PPE carts or supplies to meet the needs of all residents requiring EBP. This systemic failure to provide adequate PPE and ensure staff adherence to EBP protocols resulted in the facility not following acceptable infection control standards for multiple residents.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight hours daily, as required. Observations and interviews revealed that the Director of Nursing (DON) was performing dual roles by administering medications to residents while also fulfilling her responsibilities as the DON. This occurred despite the facility having an average daily occupancy of 68 residents. A review of the nurse schedule indicated that on seven out of fourteen days, there was no RN coverage for eight consecutive hours. The DON admitted to working as both the DON and charge nurse due to ongoing staffing issues, and the Administrator was unaware that the DON could not serve as the RN on duty while also acting as the DON.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) met the minimum qualifications required for the position when a Registered Dietician (RD) was not employed full-time at the facility. The DM admitted during an interview that he was not certified as a Dietary Manager. The RD, who was only present at the facility for eight hours one day a month, confirmed her awareness of the DM's lack of certification and stated that she was responsible for the clinical aspects of the facility, providing reports on sanitation and food service. The facility's Administrator acknowledged awareness of the DM's lack of training at the time of hiring, with the expectation that the training would be completed before the survey. The facility's job description for the Dietary Manager indicated that a certificate for dietary management was a minimum qualification.
Failure to Follow Dietary Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were followed for all four days of the survey, potentially affecting all 69 residents receiving food from dietary services. Observations on the first-floor food service revealed that a dietary aide used a three-ounce ladle to serve winter vegetables, contrary to the menu's specification of four ounces. Additionally, there was no method to measure double or single portions of pot roast. The dietary aide admitted to using visual estimation and serving tongs to determine meat portions, as portion sizes were not provided on the cards. Furthermore, mechanical soft diets were served with whole pieces of pot roast, vegetables, and scalloped potatoes instead of the required chopped form. Dinner rolls, which were indicated on the menu, were not served. The dietary manager confirmed that the items were not chopped, believing them to be soft enough, and acknowledged the omission of dinner rolls. The dietary manager was unable to provide a policy before the survey team's exit.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards, affecting all 69 residents receiving food from dietary services. Observations revealed that the dishwasher's temperature gauge was stuck at 105 degrees Fahrenheit, below the required minimum of 120 degrees Fahrenheit for sanitizing dishes. Despite this, the facility continued to use the dishwasher. Additionally, the kitchen had significant cleanliness issues, including dust and dirt accumulation on air vents, a cracked window with debris, and a walk-in freezer used for storage that was cluttered with dirty mopheads, food debris, and cleaning solutions. The Dietary Manager confirmed these issues and admitted to not having a cleaning schedule for the kitchen. Further observations showed improper food handling practices, such as staff not changing gloves between handling dirty and clean dishes. The dry storage area and back corridor had floors blackened with dirt and grease, and food items were improperly stored, with some left uncovered and undated. The refrigerator contained expired and moldy food items, and a pot roast was left at room temperature without refrigeration. The facility's policies on food labeling and machine ware washing were outdated and did not address critical aspects like sanitizing rinses and glove changes. The Registered Dietician's report also highlighted similar issues, indicating a pattern of non-compliance with food safety standards.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the cleanliness of the area around the garbage dumpsters, which has the potential to affect all 69 residents. Over the course of four days, surveyors observed the exterior garbage dumpster area littered with various debris, including a broken refrigerator, plastic gloves, food debris, medicine cups, fast-food bags, cardboard boxes, bottles of over-the-counter medicine, and other trash. Additionally, one of the dumpsters was consistently found with its lid open during multiple observations. An interview with the Administrator revealed that housekeeping and maintenance are responsible for cleaning the area once a week, but there was no documentation to confirm when the area was last cleaned. The facility's policy states that the maintenance department is responsible for ensuring the area is free of trash and that dumpster lids are kept closed.
Inoperable Walk-In Refrigerator in Dietary Department
Penalty
Summary
The facility failed to maintain essential equipment in working condition, specifically a large walk-in refrigerator in the dietary department. Observations on November 11, 2024, revealed that the refrigerator, measuring 15 feet deep by 10 feet wide, was empty of refrigerated food items. An interview with the Dietary Manager confirmed that the refrigerator has been inoperable since July 2024. This deficiency has the potential to affect all 69 residents who receive food from the dietary department. An interview with the Administrator provided an estimate to replace the refrigerator compressor.
Failure to Complete TPL Forms and Notify Residents of Account Balances
Penalty
Summary
The facility failed to complete third party liability (TPL) forms within 30 days for the final accounting of residents who had expired, affecting three residents who had money in their accounts. Specifically, Resident #104 had an ending balance of $4771.87, Resident #107 had an ending balance of $5833.00, and Resident #106 had an ending balance of $610.61, with no TPL forms completed for any of them. Additionally, the facility did not provide required notifications when residents' trust accounts reached $200 less than the Supplemental Security Income (SSI) resource limit, affecting four residents. These residents had significant balances in their accounts, ranging from $6196.57 to $10,357.35, without any documentation of Medicaid Resident Fund Notification. During an interview, the Administrator acknowledged that TPL and Resident Fund notifications had not been completed, attributing this oversight to a lack of awareness and the recent appointment of the Business Office Manager (BOM), who was still familiarizing themselves with their responsibilities. The facility's Resident's Rights Policy mandates that residents be notified when their account balance approaches the SSI resource limit and that funds be conveyed within 30 days upon a resident's discharge, eviction, or death. However, these requirements were not met, leading to the deficiencies identified in the report.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on the secured second floor, affecting 30 residents. During an initial tour, surveyors observed numerous deficiencies, including food splatters on walls, missing ceiling tiles, and malfunctioning door handles. Additionally, there were holes in bedroom and bathroom walls, unclean surfaces on tables, and dirty equipment, such as the ice container. These conditions were confirmed through interviews with staff, including a certified nursing assistant who noted that the tables had always been in poor condition. Specific rooms on the second floor exhibited various issues. For instance, some rooms had broken window blinds, missing wardrobe drawers, and bathroom doors without handles, making them inaccessible. Other rooms had gaps around air conditioning units, allowing outside air and pests to enter, and wall damage exposing pipes and supports. The clean linen room also had missing ceiling tiles, exposing ductwork and wires, and lacked a doorknob, leaving a hole in the door. Interviews with the Administrator and Maintenance Director revealed a lack of awareness regarding these conditions. The Maintenance Director admitted to not having a communication system in place for staff to report needed repairs. Despite acknowledging the need for window cleaning and repairs, the Administrator did not provide a plan or documentation to address the identified concerns before the survey exit.
Failure to Conduct CNA Registry Checks for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees were screened to rule out the presence of a Federal Indicator, specifically by checking the Certified Nurse Aide (CNA) Registry. This deficiency was identified during a review of employee files, where it was found that seven out of ten sampled employees did not have a CNA registry check performed. These employees included a housekeeper, an activity director, two additional housekeepers, a dietary aide, a maintenance director, and a medical records staff member. The facility's Abuse Prevention Program mandates pre-employment screening, including checking the CNA Registry to ensure no findings of abuse, neglect, or misappropriation of property are present. During an interview, the facility's administrator acknowledged that the Business Office Manager (BOM), who also handles Human Resources (HR), was responsible for conducting these checks but had not been trained to do so for non-nursing staff. The BOM/HR person was out sick at the time of the interview, and the administrator confirmed that the oversight was due to a lack of training. This lapse in procedure indicates a failure to adhere to the facility's established policies for preventing abuse and neglect through proper employee screening.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were prepared and distributed as prescribed by the residents' physicians for several residents. Specifically, seven residents did not receive the diets ordered by their physicians, which included specific items such as health shakes, power potatoes, and cheesy eggs. These dietary components were crucial for managing their medical conditions, which included Alzheimer's disease, dementia, diabetes, and malnutrition, among others. The absence of these prescribed dietary items was observed over several days during the survey period. For instance, one resident with Alzheimer's disease and diabetes was prescribed a pureed diet with specific items like power potatoes and health shakes, but these were not provided. Another resident with traumatic subdural hematoma and anorexia was supposed to receive health shakes with each meal, but these were not served until the issue was highlighted during the survey. Similarly, other residents with conditions such as cerebral palsy, multiple sclerosis, and severe protein-calorie malnutrition also did not receive their prescribed health shakes and other dietary items. Interviews with the Dietary Manager and the Registered Dietician revealed a lack of awareness and preparation of the prescribed dietary items. The Dietary Manager admitted to not preparing or serving the required items, and the Registered Dietician was unaware of the omissions. The facility's failure to provide the prescribed diets was further compounded by the absence of a policy to address the issue, as the requested policy was not provided by the time the survey team exited the facility.
Failure to Follow TB Screening Policy for Employees
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) screening policy for employees, resulting in a deficiency. The policy, dated 2005, mandates that all healthcare workers undergo a two-step tuberculin skin test (TST) upon hire, with the first dose administered within seven days of employment and the second dose one to three weeks later if the first test is negative. Additionally, an annual one-step test is required. However, the facility did not complete these screenings in a timely manner for five employees. Specifically, Staff Members A and B, hired on 10/1/22 and 7/18/23 respectively, lacked documentation of an annual one-step test. Staff Members C, D, and E, hired on 2/22/24, 3/7/24, and 9/12/24 respectively, had no documentation of the required two-step test. During an interview, the Administrator stated that the Director of Nursing (DON) or Assistant Director of Nursing (ADON) administers the TB test, and the Human Resource Manager (HRM) is responsible for ensuring completion and documentation. However, the DON and HRM were out sick at the time of the interview.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of four residents by not providing adequate assistance and care. One resident, who was severely cognitively impaired, was observed multiple times wearing dirty non-skid socks, and despite acknowledging the issue, did not receive assistance from staff to change them. Another resident, who was cognitively intact, reported wearing a hospital gown since admission due to a lack of clothing. Despite having a few items in her closet, she expressed a desire for more clothing, but staff had not noticed her need, and the facility's administrator was unaware of the situation. Additionally, during meal service, two residents were assisted by a CNA who stood while feeding them, contrary to the facility's protocol of sitting and making eye contact with residents during meals. One of these residents was moderately cognitively impaired, while the other was severely cognitively impaired. The CNA admitted to standing for convenience, and the Director of Nursing confirmed that staff should sit while assisting residents with meals. These actions and inactions contributed to an undignified manner of care for the residents involved.
Failure to Provide Communication Device for Non-Verbal Resident
Penalty
Summary
The facility failed to provide an alternative communication device for a non-verbal resident, identified as R35, which hindered his ability to express his needs and wants. R35 was admitted with multiple diagnoses, including cerebral palsy, generalized anxiety disorder, mood disorder, conversion disorder with seizures or convulsions, dysphagia, and multiple sclerosis. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of zero, confirming his inability to verbally communicate. Despite this, the resident's care plan did not include any strategies or devices to facilitate communication. Interviews with facility staff, including the Administrator and a certified nursing assistant (CNA), revealed that R35 had never been provided with a communication board or device. The Administrator acknowledged that a communication board would be beneficial, yet no such device was in place. During an interaction with R35, he confirmed through non-verbal gestures that he had never used a communication board or device and indicated that such a tool would be helpful for communication. This lack of provision for an alternative communication method constitutes a deficiency in the facility's care for R35.
Failure to Administer Prescribed Skin Care Treatment
Penalty
Summary
The facility failed to provide necessary care in accordance with a resident's preferences and physician orders, specifically regarding skin care. The resident, who was admitted with acute kidney failure, generalized muscle weakness, and obesity, was observed to have extremely dry and flaking skin on her feet and legs. Despite having a prescription for white petrolatum gel to be applied daily, the resident reported that the ointment was not being applied, and this was confirmed through multiple observations over several days. Interviews with facility staff, including a CNA and an LPN, revealed that the task of applying the prescribed cream was not included in the CNA's daily assignment sheet, and the LPN was unaware of why the cream had not been used. The Director of Nursing expressed an expectation for the nursing staff to be more attentive to the resident's skin condition and to apply the ointment as prescribed, indicating a lapse in communication and task assignment within the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.67%. This was due to three errors out of 30 opportunities for error during medication administration. One resident did not receive their medication on time, and another resident received a medication without a physician's order. Specifically, a Certified Medical Technician administered Buspirone to a resident at 9:55 AM, which was ordered for 7:30 AM, exceeding the acceptable administration window of one hour before to one hour after the scheduled time. Additionally, a Licensed Practical Nurse administered a Daily-Vite with folic acid to a resident without a corresponding physician's order. Interviews with the LPN, CMT, and the Director of Nursing confirmed the facility's policy that medications should be administered within one hour before or after the scheduled time and that medications should not be given without a physician's order. The failure to adhere to these protocols resulted in the medication errors observed during the survey, which had the potential to affect the accurate dosing of medication administered to the residents.
Deficiency in Maintaining Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at an appetizing temperature, as observed during one of three meals on one of four survey days. This deficiency potentially affected all 69 residents receiving food from the dietary department. Observations revealed that the pot roast, scalloped potatoes, and winter vegetables were initially at high temperatures on the steam table, but by the time the food was served, the pot roast had cooled to 106 degrees Fahrenheit, which was considered cold by both the Dietary Manager and a resident. The lunch was scheduled for 12:00 PM, but the food cart left the kitchen at 12:40 PM and arrived at the first floor at 12:42 PM, with the test tray temperatures being taken at 1:10 PM. Interviews with the Dietary Manager and Registered Dietician indicated that there were no food temperature logs maintained either in the kitchen or on the unit prior to food service, which was against the facility's expectations. The facility policy regarding food temperature logs was requested but not provided before the survey team exited the facility.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing report in a prominent place accessible to residents and visitors. Observations from 11/12/24 to 11/14/24 revealed that the nurse staffing information was not posted anywhere in the facility but was instead kept in a notebook at the nurses' station. This document lacked essential details such as the facility name, date, census, and the total number and actual hours worked per shift for RNs, LPNs, and CNAs responsible for resident care. During an interview, the staffing coordinator admitted to being unaware of the requirement to post the nurse staffing sheets prominently. She confirmed that the daily nurse documents were kept in a notebook at the nurse's station and did not include the necessary information for proper staffing posting. The Administrator also confirmed that the staffing sheets had not been posted in a prominent place in the facility.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment by not addressing plumbing and roofing issues that resulted in bulging, brown, and rust-colored ceiling tiles in three residents' rooms and a shower room used daily by another resident. Observations and interviews revealed that the ceiling tiles in these areas had been in disrepair for several weeks to months, causing concern among residents about potential mold or fecal contamination. The maintenance director acknowledged the issues but indicated that approval for necessary repairs had not been granted by the corporate office, despite plans and proposals being submitted. Resident #10, who is cognitively intact and has diagnoses including heart disease and diabetes, reported that the ceiling tiles in their bathroom and above their door had been stained and bulging for a couple of months. Resident #11, with mild cognitive impairment and diagnoses including heart failure and diabetes, also reported a stained ceiling tile above their bed that had been present for several weeks. Resident #12, with severe cognitive impairment and multiple diagnoses, had a ceiling tile above their closet that was stained and bent out of place. Additionally, Resident #1, who is cognitively intact and has a history of scoliosis and frequent falls, expressed concerns about the stained ceiling tiles and light fixture cover in the 100 hall shower room, which they used daily. The facility's main entrance lobby hallway also had visible disrepair, with partially painted walls and a clear dried film flaking off in some areas. The maintenance director and administrator both acknowledged the poor condition of the facility and the need for repairs, but indicated that corporate approval had not been received to proceed with the necessary renovations. The overall appearance and maintenance issues were not in line with providing a homelike environment for the residents.
Failure to Obtain Prescribed Narcotic in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not obtaining the resident's prescribed narcotic in a timely manner. The resident, who had severe cognitive impairment and was on a scheduled pain medication regimen, did not receive their prescribed Hydrocodone-acetaminophen for an extended period. The medication was documented as not administered due to unavailability on multiple occasions from 2/13/24 to 3/6/24. There was no documentation of communication with the hospice company, physician, or pharmacy regarding the resident's Hydrocodone during this period. Interviews with staff revealed that there was confusion and miscommunication regarding the responsibility for obtaining the medication. The LPN was unaware of the medication's unavailability, and the CMT noticed the issue after a week and informed the DON. The DON assumed the hospice nurse was handling the prescription and was unaware of the medication's absence until informed by the CMT. The facility's emergency kit was also not functioning properly, and staff failed to document their attempts to resolve the issue in the resident's progress notes.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Villa Wellness & Rehabilitation | 1.1 mi | ★★★★★ | 4 | 0 |
| Brooking Park | 2.9 mi | ★★★★★ | 3 | 0 |
| River Crossing Rehab And Healthcare Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Surrey Place St Lukes Hospital Skilled Nursing | 3.3 mi | ★★★★★ | 0 | 0 |
| Westchester House, The | 3.7 mi | ★★★★★ | 0 | 0 |
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