Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to maintain
resident dignity by failing to properly cover urinary catheter (tube to drain urine from
the bladder) bag for one resident (Resident #13), failed to sit while assisting three
residents (Resident #48, #81, and #195) with meals, and failed to cover exposed skin in
public areas for one resident (Resident #81). Additionally, facility staff failed to
ensure the availability of undergarments for one resident (Resident #44). The facility
census was 99.
1. Review of the facility’s Resident’s Rights policy, undated, showed staff are directed
to treat residents with consideration, respect and full recognition of his/her dignity and
individuality, including privacy in treatment and in care for his/her personal needs.
Review of the facility’s Indwelling Catheter policy, dated (MONTH) 2001, showed staff are
directed to promote dignity by making sure the catheter bag is covered.
Review of the facility’s Feeding Dependent Residents policy, dated (MONTH) 2001, showed
staff are directed to sit at the same level as the resident when possible and converse
with the resident in an appropriate manner.
Review of the facility’s policy for the duties of the Social Services Director (SSD),
undated, showed he/she is to ensure residents have appropriate and proper fitting
clothing, shoes, socks, and undergarments in good repair, to present a well-groomed
appearance.
2. Review of Resident #13’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 3/9/18, showed staff assessed the resident with an indwelling catheter.
Review of the resident’s care plan, updated 6/15/18, showed the resident had a Suprapubic
catheter (tube surgically inserted into the abdomen and the bladder to drain urine) and
staff are directed to do the following:
-Change catheter as ordered;
-Drainage bag at proper height;
-Offer fluids frequently.
Observation on 4/24/18 at 8:54 A.M., showed the resident in bed. Further observation
showed his/her catheter bag contained urine and staff did not cover the urinary catheter
bag. Observation showed the catheter bag in view from the hallway and residents and staff
walked past the resident’s room.
Observation on 4/25/18 at 9:22 P.M., showed the resident in bed. Further observation
showed his/her catheter bag contained urine and staff did not cover the urinary catheter
bag. Observation showed the catheter bag in view from the hallway and residents and staff
walked past the resident’s room.
Observation on 4/25/18 at 10:01 A.M., showed the resident in bed. The resident’s catheter
bag contained urine and staff did not cover the urinary catheter bag. Observation showed
the catheter bag in view from the hallway and residents and staff walked past the
resident’s room. Further observation showed Licensed Practical Nurse (LPN) K provided
catheter care to the resident and did not place the catheter bag in a dignity bag.
Observation on 4/26/18 at 9:18 A.M., showed the resident in bed. Further observation
showed his/her catheter bag contained urine and staff did not cover the urinary catheter
bag. Observation showed the catheter bag in view from the hallway and residents and staff
walked past the resident’s room.
During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) L said
residents’ catheter bags should be kept covered in a dignity bag so the urine is not

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
visible. CNA L said he/she is not sure why staff did not place the resident’s catheter in
a dignity bag.
During an interview on 4/26/18 at 11:16 A.M., LPN M said staff are expected to place
residents’ catheter bags in a dignity bag so the urine is not visible. LPN M said he/she
is not sure why staff did not place the resident’s catheter bag in a dignity bag.
During an interview on 4/26/18 at 11:52 A.M., CNA D said residents’ catheter bags should
be kept covered in a dignity bag so the urine is not visible to others.
During an interview on 4/2618 at 6:56 P.M., the Director of Nursing (DON) said staff
should keep residents’ catheter bags covered in a dignity bag so the urine is not visible
to others. The DON said he/she is not sure why staff did not place the resident’s catheter
bag in a dignity bag.
3. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff are directed to provide
assistance with dressing.
Review of the resident’s inventory sheet, dated 12/01/17, showed the resident entered the
facility with two coats.
Review of the residents’ MDS, a federally mandated assessment instrument, dated 12/04/17,
showed staff assessed the resident as follows:
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s MDS, a federally mandated assessment tool, dated 02/15/18, showed
staff assessed the resident as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
-Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene;
-Antidepressant medication seven days a week.
Observation on 04/25/18 at 9:11 A.M., showed the resident sat alone on the couch at the
end of the hall.
Observation on 04/25/18 at 10:54 A.M., showed the resident sat alone on the couch at the
end of the hall.
Observation on 04/25/18 at 3:18 P.M., showed the resident sat alone on the couch at the
end of the hall.
Observation on 04/26/18 at 10:00 A.M., showed the resident awake in bed.
During an interview on 04/24/18 at 10:10 A.M., the resident said he/she is not wearing
underpants today because he/she does not have any clean. He/She said he/she only has one
pair and they are in laundry. He/She said not wearing underpants makes him/her feel
uncivilized.
During an interview on 04/26/18 at 10:00 A.M., the resident said the Social Services
brought him/her one pair of underpants yesterday but they are dirty and stained. He/She
said he/she had to wear them last night because he/she has to wear something at night but
he/she did not want to because they were gross.
During an interview on 04/25/18 at 4:25 P.M., Social Services said the resident asked for
undergarments the other day and staff provided him/her with more. He/She said the facility
provides clothing to all needy residents and staff are expected to list those clothing
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
items on the inventory sheet.
During an interview on 04/26/18 at 3:24 P.M., the Administrator said they provide clothing
to all indigent residents. He/She said they have a lot of donated clothes they keep in the
Orphan Room. He/She said they have sizes to fit just about anybody. He/She said if they
need to, they also buy clothes for residents. He/She said they buy undergarments new.
He/She said the Activities Director and the Housekeeping Supervisor are responsible for
making sure residents have all the clothes they need. He/She said all a resident has to do
is tell a staff member and it will be discussed in the morning meeting. He/She said he/she
was not aware of any resident being without undergarments. He/She said staff should never
provide residents with used undergarments.
During an interview on 04/26/18 at 3:37 P.M., the Housekeeping Supervisor said he/she
tries to make sure the residents have what they need. He/She provided the resident with
about five outfits when he/she arrived. He/She is unsure about the undergarments. He/She
said he/she will check on the resident. He/She said if the resident reported needing
undergarments to any staff member (CNA/Laundry) he/she expects the staff to report it to
him/her.
During an interview on 04/26/18 at 6:59 P.M., the DON said all staff are responsible to
ensure a resident has clothing and if not, staff should report it to him/her so he/she can
take care of it. He/She said they do have a lot of nice clothing. He/She said the
housekeeping supervisor checks to make sure residents have what they need upon admission.
He/She said he/she had no idea Resident #44 did not have undergarments and no one ever
reported it to him/her.
4. Review of Resident #48’s significant change MDS, dated [DATE], showed staff assessed
the resident with moderate cognitive impairment, and required limited assistance of one
person with eating.
Review of the resident’s care plan last updated (YEAR), showed staff are directed to
assist with meals, and offer finger foods.
Observation on 4/23/18 at 1:15 P.M., showed CNA G served the resident his/her meal, stood
next to the resident and assisted with the meal.
Observation on 4/23/18 at 1:18 P.M., showed the CNA G continued to stand next to the
resident and assisted him/her to eat.
Observation on 4/23/18 at 1:22 P.M., showed the CNA G continued to stand next to resident
and assisted him/her to eat.
5. Review of Resident #81’s quarterly MDS, dated [DATE], showed staff assessed the
resident with severe cognitive impairment, required limited assist of one with eating, no
behaviors or rejection of care.
Review of the resident’s care plan for ADLs last updated (YEAR), showed staff are directed
to assist with meals.
Observation on 4/23/18 at 1:00 P.M., showed the resident sat in his/her wheelchair at the
dining table. Observation showed the resident used his/her right hand to raise his/her
shirt to his/her cheek, and exposed his/her abdomen. Further observation showed five other
residents (2 females, 3 males) sat at the table in line of sight, and staff present in the
dining room did not offer redirection to assist the resident maintain his/her dignity.
Observation on 4/23/18 at 1:33 P.M., showed CNA K stood next to the resident at the dining
table and fed him/her a few bites of turkey. The CNA did not assist the resident to eat
his/her meal in a dignified manner.
Observation on 4/23/18 at 1:35 P.M., showed the resident continued to use his/her right
hand to raise his/her shirt to his/her cheek, and exposed his/her abdomen. Further
observation showed five other residents sat at the table in line of sight, and CNA N or
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
other staff present in the dining room did not offer any redirection to the resident.
Observation on 4/23/18 at 1:49 P.M., showed the resident continued to use his/her right
hand to raise his/her shirt to his/her cheek, and exposed his/her abdomen. Further
observation showed five other residents sat at the table in line of sight, and CNA N or
other staff present in the dining room did not offer any redirection to the resident.
Observation on 4/24/18 at 1:43 P.M., showed CNA N sat next to the resident and assisted
him/her to eat. The CNA did not communicate with the resident as he/she assisted the
resident to eat his/her meal.
During an interview on 04/26/18 at 5:50 P.M., CNA I said if staff see a resident in a
public area with exposed skin they should cover them up and notify the nurse to see if
they need to be taken back to their room.
6. Review of Resident #195’s Quarterly MDS, a federally mandated assessment tool, dated
03/01/18, showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-Independent with transfers and eating.
Review of the resident’s care plan, dated 04/02/18, showed staff are directed to assist
with tray setup, encourage the resident to complete meals, and assist the resident with
meals.
Observation on 04/23/18 at 12:43 P.M., showed CNA G stood beside the resident while he/she
fed him/her. Further observation showed CNA G did not communicate with the resident during
the meal. The CNA did not assist the resident to eat his/her meal in a dignified manner.
During an interview on 04/25/18 at 3:54 P.M., CNA H said they sit the feeders at the first
table and staff are expected to sit down at the table and assist them.
During an interview on 04/26/18 at 9:18 A.M., CNA D said all residents on the special care
unit need some help with meals. He/She said some just need cueing and supervision but
others need help to eat their meals. The CNA said he/she was trained to sit down and speak
to residents when assisting them with meals but said he/she has noticed some staff stand
while they feed residents.
During an interview on 04/26/18 at 9:48 A.M., LPN F said staff should sit down beside
residents and explain what they are eating when assisting them with meals. He/She said
he/she has not attended any in-services on assisting residents with meals.
During an interview on 4/26/18 at 5:51 P.M., LPN B said staff are expected to sit at eye
level and converse with the resident when they assist with feeding. Staff are also
expected to ensure the resident’s skin is covered (whether male or female), and offer
redirection to protect privacy and dignity.
During an interview on 4/26/18 06:19 PM CNA C said there should always be at least one
staff in the dining room when residents are eating, and staff are expected to sit next to
the resident while they assist the resident to eat to provide a dignified dining
environment.
During an interview on 04/26/18 at 6:59 P.M., the DON said he/she expects staff to sit
next to the resident (not across the table, or stand), when they assist the resident to
eat. Staff should also cover the resident’s skin if exposed, whether male or female.

F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Reasonably accommodate the needs and preferences of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
Based on observation, interview, and record review, facility staff failed to provide
reasonable accommodations of individual needs and preferences by failing to ensure call
lights were left in reach for two residents (Resident #10 and #38) and by failing to clean
wheelchairs for two residents (Residents#10 and #81). The census was 99.
1. Review of Resident #10’s quarterly Minimum Data Set (MDS), dated [DATE], showed staff
assessed the resident as follows:
-Rarely or never understood;
-Physical and verbal behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of urine and occasionally incontinent of bowel.
Review of the resident’s care plan, dated 12/19/17, showed staff are directed to keep the
call light within reach, answer the call light promptly, ensure clean appearance at all
times, and ensure assistive devices are appropriate.
Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated assessment,
dated 03/08/18, showed staff assessed the resident as follows:
-Rarely or never understood;
-Physical and verbal behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of urine and occasionally incontinent of bowel.
Observation on 04/23/18 at 11:51 A.M., showed the resident in bed with a soiled brief
around his/her knees. There was a strong odor of feces and urine in the room. Further
observation showed the resident’s call light coiled on the floor under the bedside table
outside the reach of the resident. Additional observation showed the seat of the
resident’s wheelchair soiled with brown debris with an odor of feces.
Observation on 04/23/18 at 12:10 P.M., showed the resident in bed naked. There was a
strong odor of feces and urine in the room. Further observation showed the resident’s call
light coiled on the floor under the bedside table outside the reach of the resident.
Observation on 04/23/18 at 1:10 P.M., showed the resident in his/her wheelchair in the
dining room. There was a strong odor of feces near the resident.
Observation on 04/23/18 at 3:04 P.M., showed the resident in his/her wheelchair in the TV
room. There was a strong odor of feces and urine.
Observation on 04/24/18 at 3:26 P.M., showed the resident lie in bed in a brief. There was
a strong odor of feces in the room. Further observation showed the resident’s call light
coiled on the floor under the bedside table outside the reach of the resident. Additional
observation showed the seat of the resident’s wheelchair with brown debris with an odor of
feces.
Observation on 04/24/18 at 3:41 P.M., showed staff entered the resident’s room, provided
care, and left the resident’s room. Further observation showed the resident’s call light
remained coiled on the floor under the bedside table outside the reach of the resident.
Staff did not place the call light within the resident’s reach.
Observation on 04/25/18 at 2:50 P.M., showed the resident in bed. Further observation
showed the resident’s call light coiled on the floor under the bedside table outside the
reach of the resident.
2. Review of Resident #38’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment;
-No behaviors;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of bladder and bowel.
Review of the resident’s care plan, dated 07/21/16, showed staff are directed to keep the
call light within reach and answer the call light promptly.
Observation on 04/25/18 at 2:14 P.M., showed the resident in his/her wheelchair at the
foot of his/her bed near the door. He/She was alone in the room with no television or
radio. Further observation showed the call light under the blanket near the head of the
bed outside the resident’s reach.
Observation on 04/26/18 at 9:44 A.M., showed the resident in his/her wheelchair at the
foot of his/her bed near the door. He/She was alone in the room with no television or
radio. Further observation showed the call light near the head of the bed outside the
resident’s reach.
During an interview on 04/25/18 at 3:54 P.M., Certified Nursing Assistant (CNA) H said
he/she makes sure the resident doesn’t have any additional needs before he/she leaves the
room. He/She said the call light should be left within reach before staff leave a
resident’s room.
3. Review of Resident #81’s quarterly MDS, dated [DATE], showed staff assessed the
resident with severe cognitive impairment, did not ambulate, and used a wheelchair.
Observation on 4/23/18 at 12:20 P.M., showed the resident in his/her broda chair (an
adjustable tilt and recline wheelchair) in the dining room with multiple colored dried
debris to both sides of the chair.
Observation on 4/24/18 at 1:06 P.M., showed the resident in his/her broda chair in the
dining room with multiple colored dried debris to both sides of the chair.
Observation on 4/26/18 at 6:15 P.M., showed the resident in his/her broda chair in the
dining room with multiple colored dried debris to both sides of the chair.
4. During an interview on 4/26/18 at 5:51 P.M., Licensed Practical Nurse (LPN) B said
staff are expected to place call lights near the bed, and within the resident’s reach at
all times. Residents’ wheelchairs are cleaned by the night shift staff or as needed by any
other staff if obviously dirty, but he/she was not sure if staff had a specific schedule
for cleaning the wheelchairs.
During an interview on 04/26/18 at 5:50 P.M., CNA I said staff should attend to the
resident’s needs and let them know to call if they need anything before they leave a room.
He/She said the resident’s call light light should be left within reach. He/She said if
they are in bed he/she makes sure the call light is close to them and if they are in their
wheelchair he/she hands it to them. He/She said he/she would clean and sanitize a
resident’s wheelchair and check their cushion before he/she transferred the resident into
the wheelchair.
During an interview on 04/26/18 at 5:57 P.M., LPN J said staff should make sure the call
light and water is in reach and any positioning devices are in place before they leave a
resident’s room. He/She said if they are up in a chair staff often pin the call light to
them so they can reach it. He/She said he/she would clean off any noticeable debris before
he/she transferred a resident into their wheelchair.
During an interview on 04/26/18 at 6:59 P.M., the DON said when a resident is in their
room, their call light should be left within reach. He/She said a call light should not
ever be coiled under the bed or under the bedside table. He/She said some residents may
not be physically or mentally able to use their call light but staff checks on them when
they make their rounds. He/She said whether or not a resident may be able to use a call
light it should still be within reach. He/She said night shift CNAs clean wheelchairs
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
monthly. He/She said the housekeeping supervisor goes around and checks wheelchairs and
cleans them in the shower room. He/She said staff should clean any noticeable debris from
wheelchairs immediately.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to manage his or her financial affairs.

Based on interview and record review, facility staff failed to ensure residents have
appropriate access to their trust fund account, including on weekends. The facility census
was 99.
1. Review of the facility’s policy on availability of funds, undated, showed staff are
directed:
-All funds maintained in the Trust Fund must be made available to participating residents
during normal business hours;
-The funds must be available to residents no less than 10 hours a week, and no less then 3
days a week;
-Standard policy would dictate that the funds be available during regular business hours
Monday through Friday;
-The residents must be fully informed of the time and days in which funds may be received.
2. During an interview on 4/24/18 at 9:30 A.M., the Bookkeeper said residents are not able
to receive their funds on the weekends as no one is in the facility to access the funds on
Saturday or Sunday. He/She said if the residents need money they need to let him/her know
on Friday before he/she leaves.
3. During a group meeting on 4/24/18 at 10:54 A.M., residents in attendance said they are
not able to get any of their funds on the weekends, they have to either ask for it on
Friday or wait until Monday.
4. During an interview on 4/26/18 at 6:50 P.M. the Administrator said resident funds are
only offered Monday through Friday. He/She said staff check with residents on Friday
evenings to ensure no one needs money for the weekend. He/She was not aware residents
should have access to funds on the weekends.
5. During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said funds
are not offered to residents on the weekends. He/She said residents know they have to
request funds for the weekend by 5:00 P.M. on Friday evenings.

F 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, facility staff failed to purchase a surety bond in
an amount sufficient to assure security of all personal funds the facility holds for
residents. The census was 99.
1. Review of the facility’s policy on Surety Bond, undated, showed the following:
-The Surety bond liability amount should always be adequate to cover one and one half
times (1 1/2 times) the highest balance of the Resident Trust Fund, per the bank
statement;
-The monthly balance should be viewed against the amount on the surety bond;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-The Operations Manager must be notified anytime the Trust Fund balance (multiplied by 1
1/2) exceeds the surety bond liability limit.
2. Review of the resident trust fund account for (MONTH) (YEAR) through (MONTH) (YEAR),
showed an average monthly balance of $ 44,375.55, which requires a surety bond of
$66,000.00. The current ledger amount is $ 37,601.00.
3. Review of the Department of Health and Senior Services (DHSS) database, showed the
facility has an approved non-cancelable Escrow Agreement Account in the amount of
$60,000.00.
4. During an interview on 4/24/18 at 09:30 A.M., The Business Office Manager said the
administrator is responsible to ensure the bond amount is sufficient.
During an interview on 04/26/18 at 6:30 P.M., the Administrator said the corporate office
is responsible to ensure the bond is sufficient. He/She said the corporate office advised
them they were over their bond about a week ago and told them to spend it down.

F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on observation, interview and record review the facility failed to ensure fifteen
residents’ (Resident #10, #22, #26, #32, #37, #38, #44, #48, #52, #81, #83, #188, #191,
#195, #197) who live on the 200 hall right to private communication when they failed to
repair the resident phone in a timely manner. The facility census was 99.
1. Review of the facility’s Resident Rights policy, undated, showed staff are directed to
ensure residents are free to communicate freely and privately with persons of their
choice, receive their mail unopened, and be allowed private telephone conversations.
2. Observation on 04/23/18 at 12:12 P.M., showed the 200 hall resident phone plugged in
but without a dial tone.
Observation on 04/24/18 at 9:35 A.M., showed Resident #26 used the phone at the nurse’s
station to speak to family and the ADON interrupted him/her many times during the call.
3. During an interview on 04/23/18 at 11:59 A.M., Resident #44 said he/she is not allowed
to use the phone. He/She has not been able to use the phone in four months. He/She said
he/she complained to the state in Jefferson City and then his/her phone rights were shut
off. He/She said staff took the phone out of the phone room so he/she could not use it.
During an interview on 04/24/18 at 9:44 A.M., Resident #197 said he/she used the phone at
the nurse’s desk one time and got yelled at for using it.
During an interview on 04/24/18 at 9:53 A.M., Resident # 83 said he/she usually uses the
phone at the nurse’s desk but today he/she was told he/she could use the phone in the
phone room. The resident said the phone did not work before. He/She said he/she can not
remember how long the phone was broken.
During an interview on 04/25/18 at 2:17 P.M., Resident #12 said the resident phone has
been down for two or three months because someone cut the phone line.
During an interview on 04/25/18 at 3:54 P.M., CNA H said he/she did not know the resident
phone was broken. He/She said sometimes the residents break the phone but staff usually
replace it the next day.
During an interview on 04/25/18 at 4:25 P.M., the Social Services Director said the
residents on the locked unit broke the phone and it happens often. He/She said he/she is
unsure of how long the phone was broken. He/She said the residents are able to use the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
phone at the nurse’s station.
During an interview on 04/26/18 at 9:18 A.M., CNA D said the phone on the 200 hall was
down for a week or two. He/She said all the residents are allowed to use the phone.
During an interview on 04/26/18 at 6:30 P.M., the Administrator said a resident ripped the
phone out of the wall and maintenance staff tried to fix it but could not. He/She said
he/she called the phone provider but they were unable to fix it so it was down about a
month.
During an interview on 04/26/18 at 6:59 P.M., the DON said the phone was down for a week
because residents are always breaking the phone. He/She said no resident is restricted
from using the phone. He/She said the residents usually break the phone but this time the
resident pulled out the line and it took them a while to get it fixed.

F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Keep residents’ personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, facility staff failed to ensure residents’ rights to
personal privacy was protected, when they stored 12 boxes of pharmacy records and shower
sheets in an unlocked and unattended location near a public hallway. Additionally, staff
failed to ensure a resident’s right to privacy when they included the resident’s personal
mail communications in his/her medical record for one resident (Resident #44). Facility
census was 99.
1. Observation on 04/23/18 at 2:25 P.M., showed 12 boxes of resident pharmacy records and
shower sheets stored in an unlocked closet near the resident scale across from the DON’s
office. The closet was open to the public hallway and near resident rooms. There were no
staff in the area.
Observation on 04/24/18 at 10:48 A.M., showed 12 boxes of resident pharmacy records and
shower sheets stored in an unlocked closet near the resident scale across from the DON’s
office. The closet was open to the public hallway and near resident rooms. There were no
staff in the area.
Observation on 04/25/18 at 9:39 A.M., showed 12 boxes of resident pharmacy records and
shower sheets stored in an unlocked closet near the resident scale across from the DON’s
office. The closet was open to the public hallway and near resident rooms. There were no
staff in the area.
During an interview on 04/26/18 at 5:57 P.M., LPN J said medical records should be stored
in the locked medical records office. He/She said medical records should be locked up or
out of reach.
During an interview on 04/26/18 at 6:59 P.M., the DON said resident medical records are
kept locked next door in medical records. He/She said there are medical records kept in a
closet across from his/her office. He/She said there should be a lock on the door and
he/she said he/she asked maintenance for a lock in (MONTH) but they have not installed it
yet.
2. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff are directed to provide
assistance with dressing.
Review of the residents’ Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 12/04/17, showed staff assessed the resident as follows:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s Quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 02/15/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
-Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s medical records showed a large stack of personal correspondence
from the resident to the president was included with the resident’s stored medical record.
Staff did not store the resident’s private correspondence appropriately to protect the
resident’s right to privacy.
During an interview on 04/24/18 at 10:10 A.M., the resident said he/she wants to go
somewhere else. He/She said he/she tried to talk to Social Services but he/she is just too
busy. He/She said he/she feels like he/she is in prison. He/She said no one here likes
him/her because of the letters to the president. He/She said he/she wrote letters to the
president and the staff have them in his/her chart.
During an interview 04/26/18 at 3:00 P.M., the Administrator said the resident was placed
at the facility on an emergency basis by the state. He/She said he/she found the letters
from the resident to the president in his/her chart in medical records storage. He/She
said the letters came over with the resident from the hospital. He/She said he/she does
not know if the letters were ever in the resident’s chart or not. He/She said he/she does
not know why the letters were not given back to the resident. He/She said he/she thought
the state wanted staff to keep the letters to help with the guardianship case.
During an interview on 04/26/18 at 6:59 P.M., the DON said he/she does not think the
resident is lucid. He/She said the resident seems ok at times but if you read the letters
he/she wrote to the president you would know otherwise.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to complete the Care Area
Assessment (CAA) Section (section V0200) of the Minimum Data Set (MDS), a federally
mandated resident assessment tool, for 15 residents (Residents #10, #13, #20, #26, #31,
#38, #44, #48, #52, #53, #63, #68, #76, #83, and #191) and failed to complete
comprehensive assessments for four residents (Resident #5, #8, #11, and #22). The facility
census was 99.
1. Review of the Centers for Medicare & Medicaid Services (CMS) MDS database showed
Resident #5’s last submitted quarterly assessment with an assessment reference date (ARD)
of 11/02/17.
Review of the facility’s MDS software showed a quarterly assessment with an ARD of
04/19/18 finalized, not transmitted, and the completion date on Section Z0500B as

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 10)
04/19/18.
Review of the facility’s MDS software showed an annual assessment due on 02/09/18, the
assessment was not validated, finalized, transmitted, or completed.
2. Review of the CMS MDS database showed Resident #8’s last submitted quarterly assessment
with an ARD of 02/16/18.
Review of the CMS MDS database showed the resident’s previous submitted quarterly
assessment with an ARD of 11/17/17.
Review of the CMS MDS database showed the resident’s previous submitted quarterly
assessment with an ARD of 05/11/17.
Review of the CMS MDS database showed the resident’s previous submitted quarterly
assessment with an ARD of 02/11/17.
Review of the CMS MDS database showed the resident’s previous submitted quarterly
assessment with an ARD of 11/11/16.
Review of the facility’s MDS software showed a quarterly assessment due on 05/19/18.
Review of the facility’s MDS software showed a comprehensive (admission, annual, or
significant change) assessment has not been a validated, finalized, transmitted, or
completed from 11/11/16 to 2/16/18.
3. Review of the CMS MDS database showed Resident #11’s last submitted quarterly
assessment with an ARD of 12/11/17.
Review of the facility’s MDS software showed an annual assessment due 03/13/18, the
assessment was not validated, finalized, transmitted, or completed.
4. Review of the facility’s MDS software showed Resident #22’s quarterly assessment with
an ARD of 04/06/18 transmitted with the completion date on Section Z0500B as 04/06/18.
Review of the CMS MDS database showed the resident’s last submitted quarterly assessment
with an ARD of 01/03/18.
Review of the CMS MDS database showed the resident’s previous quarterly assessment with an
ARD of 10/02/17.
Review of the CMS MDS database showed the resident’s submitted entry-tracking assessment
with an ARD of 09/22/17.
Review of the CMS MDS database showed the resident’s submitted discharge with return
anticipated assessment with an ARD of 09/21/17.
Review of the CMS MDS database showed the resident’s submitted entry-tracking assessment
with an ARD of 08/04/17.
Review of the CMS MDS database showed the resident’s submitted discharge with return
anticipated assessment with an ARD of 08/03/17.
Review of the CMS MDS database showed the resident’s submitted entry-tracking assessment
with an ARD of 07/20/17.
Review of the CMS MDS database showed the resident’s submitted discharge with return
anticipated assessment with an ARD of 07/19/17.
Review of the CMS MDS database showed the resident’s previous quarterly assessment with an
ARD of 07/15/17.
Review of the CMS MDS database showed the resident’s previous quarterly assessment with an
ARD of 01/15/17.
Review of the facility’s MDS software showed a comprehensive (admission, annual, or
significant change) assessment has not been a validated, finalized, transmitted, or
completed from 1/15/17 to 4/6/18.
5 Review of the CAA summary section of the Resident Assessment Instrument (RAI) Manual
showed the following:
-Check section A (Care Area Triggered) if Care area is triggered;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 11)
-For each triggered care area, indicate whether a new care plan, care plan revision, or
continuation of current care plan is necessary to address the problem(s) identified in
your assessment of the care area. The care plan decision column must be completed within
seven days of completing the RAI (MDS and CAA’s). Check column B (Care Planning Decision)
if the triggered area is addressed in the care plan;
-Indicate in the location and date of CAA Documentation column where information related
to the CAA can be found. CAA documentation should include information on the complicating
factors, risks, and any referrals for this resident for this care area;
-Signature of Registered Nurse (RN) Coordinator for CAA process and date signed;
-Signature of Person completing care plan decision and date signed.
6 Review of Resident #10’s MDS, dated [DATE], showed staff documented the following
information in Section V of the Care Area Assessment:
– The areas which triggered in Care Area A are [MEDICAL CONDITION], Cognitive
Loss/Dementia, Visual Function, Communication, ADL Functional/Rehabilitation Potential,
Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Behavioral
Symptoms, Activities, Falls, Nutritional Status, Pressure Ulcer, and [MEDICAL CONDITION]
Drug Use;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
7.Review of Resident #13’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Visual Function, Activities of Daily Living (ADL) functional/rehabilitation potential;
urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid
maintenance, pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in
section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
8. Review of Resident #26’s MDS, dated [DATE], showed staff documented the following
information in Section V of the Care Area Assessment:
-The areas which triggered in Care Area A are Cognitive Loss/Dementia, ADL
Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls,
Pressure Ulcer, and [MEDICAL CONDITION] Drug Use;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
9. Review of Resident #31’s MDS, dated [DATE], showed staff documented the following
information in Section V of the Care Area Assessment:
-The areas which triggered in Care Area A are Cognitive Loss/Dementia, Psychosocial
Well-Being, Behavioral Symptoms, Falls, Nutritional Status, and [MEDICAL CONDITION] Drug
Use;
-No section triggered as care planning decisions in section B;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 12)
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
10. Review of Resident #38’s MDS, dated [DATE], showed staff documented the following
information in Section V of the Care Area Assessment:
-The areas which triggered in Care Area A are [MEDICAL CONDITION], Cognitive
Loss/Dementia, Visual Function, Communication, ADL Functional/Rehabilitation Potential,
Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Behavioral
Symptoms, Activities, Falls, Nutritional Status, Pressure Ulcer, and [MEDICAL CONDITION]
Drug Use;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
11. Review of Resident #44’s MDS, dated [DATE], showed staff documented the following
information in Section V of the Care Area Assessment:
-The areas which triggered in Care Area A are [MEDICAL CONDITION], Cognitive
Loss/Dementia, Visual Function, Communication, Urinary Incontinence and Indwelling
Catheter, Psychosocial Well-Being, Falls, Nutritional Status, and [MEDICAL CONDITION] Drug
Use;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
12. Review of Resident #48’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive Loss/Dementia, Communication, Urinary Incontinence and Indwelling Catheter,
Psychosocial well-being, Behavioral Symptoms, Activities, Falls, Nutritional Status,
Dehydration/fluid maintenance, Pressure ulcer, and [MEDICAL CONDITION] drug use triggered
as care areas in section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
13. Review of Resident #52’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive Loss/Dementia, ADL functional/rehabilitation potential, Psychosocial
well-being, Falls, Nutritional Status, Dehydration/fluid maintenance, Pressure ulcer, and
[MEDICAL CONDITION] drug use triggered as care areas in section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
14. Review of Resident #53’s MDS, dated [DATE], showed staff documented the following
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 13)
information in the CAA:
-Cognitive loss/dementia, visual function, urinary incontinence and indwelling catheter,
falls, dehydration/fluid maintenance, pressure ulcer, and [MEDICAL CONDITION] drug use
triggered as care areas in section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
15. Review of Resident #63’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence
and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, and
pressure ulcer triggered as care areas in section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
16. Review of Resident #68’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive loss/dementia, urinary incontinence and indwelling catheter, psychosocial
well-being, mood state, activities, falls, nutritional status, dehydration/fluid
maintenance, pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in
section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
17. Review of Resident #76’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive loss/dementia, ADL functional/rehabilitation potential, falls, feeding tube,
dehydration/fluid maintenance, and [MEDICAL CONDITION] drug use triggered as care areas in
section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
18. Review of Resident #83’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive Loss/Dementia, Communication, ADL functional/rehabilitation potential,
Psychosocial well-being, Mood state, Activities, Falls, Dehydration/fluid maintenance, and
[MEDICAL CONDITION] drug use triggered as care areas in section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 14)
-No signature of person completing care plan decision and date signed.
19. Review of Resident #191’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive Loss/Dementia, ADL functional/rehabilitation potential, Behavioral Symptoms,
Falls, Nutritional Status, and [MEDICAL CONDITION] drug use triggered as care areas in
section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
20. Review of Resident #199’s MDS, dated [DATE], showed staff documented the following
information in the CAA:
-Cognitive loss//dementia, urinary incontinence and indwelling catheter, psychosocial well
being, behavioral symptoms, falls, nutritional status, pressure ulcer, and [MEDICAL
CONDITION] drug use triggered as care areas in section A;
-No section triggered as care planning decisions in section B;
-Nothing documented in the location and date of CAA documentation on where information
could be found;
-No signature of the RN Coordinator for CAA process and date signed;
-No signature of person completing care plan decision and date signed.
21. During an interview on 4/26/18 at 6:30 P.M., the Program Manager said he/she and the
Administrator are both responsible to complete the MDS assessments and expects them to be
completed per the RAI guidelines. He/She said she was not aware that they had to complete
section V on the comprehensive MDSs.
22. During an interview on 4/26/18 at 6:30 P.M., the Administrator said she and the
Program Manager are responsible to complete the MDS. The Administrator said she expects
them to be completed per the RAI guideline. The Administrator said she was told they did
not have to complete section V if they did a hand written manual’ care plan.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview facility staff failed to complete a Comprehensive
Significant Change Minimum Data Set (MDS), a federally mandated resident assessment tool,
for three residents (Resident #26, #32, and #81) out of 20 sampled residents. The facility
census was 99.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, showed
direction for staff as follows:
-Comprehensive Assessments are required comprehensive assessments include the completion
of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as
care planning. Comprehensive assessments are completed upon admission, annually, and when
a significant change in a resident’s status has occurred or a significant correction to a
prior comprehensive assessment is required. They consist of:
-Admission Assessment;
-Annual Assessment;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-Significant Change in Status Assessment;
-Significant Correction to Prior Comprehensive Assessment.
-The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a
resident that must be completed when the interdisciplinary team (IDT) has determined that
a resident meets the significant change guidelines for either major improvement or
decline. It can be performed at any time after the completion of an Admission assessment,
and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s
determination was made that the resident had a significant change. A significant change is
a major decline or improvement in a resident’s status that:
-Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, the decline is not considered
self-limiting;
-Impacts more than one area of the resident’s health status; and
-Requires interdisciplinary review and/or revision of the care plan.
-A Significant Change in Status MDS is required when:
-A resident enrolls in a hospice program; or
-A resident changes hospice providers and remains in the facility; or
-A resident receiving hospice services discontinues those services; or
-A resident experiences a consistent pattern of changes, with either two or more areas of
decline or two or more areas of improvement, from baseline (as indicated by comparison of
the resident’s current status to the most recent CMS-required MDS).
-A Significant Change in Status MDS is considered timely when the RN Assessment
Coordinator signs the MDS as complete at section Z0500B & V0200B2 by the 14th calendar
day after the determination that a significant change has occurred (determination date +
14 calendar days).
-Assessment Completion refers to the date that all information needed has been collected
and recorded for a particular assessment type and staff have signed and dated that the
assessment is complete.
-For required Comprehensive assessments, assessment completion is defined as completion of
the CAA process in addition to the MDS items, meaning that the registered nurse (RN)
assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item
V0200B) completion attestations. Since a Comprehensive assessment includes completion of
both the MDS and the CAA process, the assessment timing requirements for a comprehensive
assessment apply to both the completion of the MDS and the CAA process.
The facility did not have a written policy for completing Significant Change MDS
assessments.
2. Review of Resident #26’s Admission Minimum Data Set (MDS), a federally mandated
assessment tool, dated 07/22/17, showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-No behaviors;
-Hallucinations and delusions;
-Limited assistance of one or more staff with bed mobility, dressing, eating, toileting,
and hygiene;
-No assistive devices;
-No pressure ulcers or risk of pressure;
-Antipsychotic 7 days a week.
Review of the resident’s Quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Moderate cognitive impairment;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-No behaviors;
-Hallucinations and delusions;
-Limited assistance of one or more staff with bed mobility, dressing, eating, toileting,
and hygiene;
-No assistive devices;
-No pressure ulcers or risk of pressure;
-No antipsychotic medications.
Review of the resident’s physician’s orders [REDACTED]. The resident was ordered the
antipsychotic after the Quarterly MDS.
Review of the resident’s nurse’s note, dated 03/30/18, showed the resident yelled at staff
and accused them of trying to kill him/her. The resident displayed verbal behaviors after
the Quarterly MDS.
Review of the resident’s Physical Therapy notes, dated 03/27/18, showed the resident was
issued a walker on 03/27/18 to assist with mobility. The resident used the assistive
device after the Quarterly MDS.
Review of the resident’s POS, dated 04/13/18, showed the resident was diagnosed with
[REDACTED]. The resident developed a pressure ulcer after the Quarterly MDS.
Observation on 04/25/18 at 11:12 A.M., showed the resident sit on the couch at the end of
the hall with his/her walker next to him/her.
During an interview on 04/25/18 at 10:34 A.M., Licensed Piratical Nurse (LPN) F said the
resident just received his/her walker from therapy recently. He/She said the resident
could walk on his/her own prior to getting the walker.
Staff did not complete a significant change MDS, as directed by the RAI manual, after the
resident declined in areas of antipsychotic medications, behaviors, pressure ulcers, and
assistive devices.
3. Review of Resident #32’s quarterly MDS, dated [DATE], showed staff assessed the
resident with [DIAGNOSES REDACTED].
-Moderate cognitive impairment;
-Delusions;
-Verbal behaviors towards others;
-Wandering behaviors, and rejection of care.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as:
-discharged to acute hospital;
-Moderate cognitive impairment;
-Displayed hallucinations and delusions;
-Physical and verbal behaviors towards other;
-Wandering behaviors, and rejection of care.
Review of the resident’s medical records showed he/she had significant changes in at least
two behavioral areas, was discharged to an inpatient Psychiatric hospital on [DATE] for
treatment, and returned to the facility on [DATE]. Further review of the records on
4/26/18, showed staff did not complete a significant change MDS assessment, within 14 days
as directed by the RAI manual, after staff identified a significant change in his/her
mental health condition.
4. Review of Resident #81’s quarterly MDS, dated [DATE], showed staff assessed the
resident with severe cognitive impairment, and received Hospice Care.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
with severe cognitive impairment, and did not receive Hospice Care.
Further review of the records showed staff did not complete a timely significant change
MDS assessment within 14 days after the resident was discharged from Hospice services, as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
directed by the RAI manual.
During an interview on 4/23/18 at 11:30 A.M., Certified Nursing Assistant (CNA) O said
staff had provided hospice care to the resident, but not at the moment.
During an interview on 4/24/18 at 10:47 A.M., the Assistant Director of Nursing (ADON)
said staff discharged the resident from Hospice services on 1/5/18.
During an interview on 4/24/18 at 3:31 P.M., the Program Manager said he/she was new to
completing MDS assessments and did not know that he/she needed to complete a significant
change MDS when a resident is discharged from Hospice services. He/She said Resident #81
was discharged from Hospice on 1/5/18, and he/she found out on 3/6/18 that he/she should
complete a significant change MDS.
5. During an interview on 04/26/18 at 6:30 P.M., the Program Manager said he/she and the
Administrator are responsible to complete the MDS assessments. He/She said staff should
complete the MDS assessments according to RAI guidelines. He/She said he/she knows
significant change MDS assessments should be done whenever a resident goes on and off
hospice or has changes in three or more areas.
During an interview on 04/26/18 at 6:30 P.M., the Administrator said they complete the MDS
assessments according to RAI guidelines. He/She said staff should complete a significant
change MDS assessment with every significant change. He/She said a significant change is
either improvement or decline in three or more areas.

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

Based on interview and record review, facility staff failed to transmit required Minimum
Data Set (MDS) assessments for 16 residents (Residents #1, #2, #3, #4, #6, #7, #9, #10,
#12, #13, #14, #15, #16, #17, #18, and #19 ). The facility census was 99.
1. Review of the Resident Assessment Insturment (RAI) Manual, dated 10/1/17, directs
assessments must be sumitted:
-Comprehensive assessments must be transmitted electronically within 14 days of the Care
Plan Completion Date (V0200C2 + 14 days);
-All other MDS assessments must be submitted within 14 days of the MDS Completion Date
(Z0500B + 14 days).
2. Review of the Centers for Medicare & Medicaid Services (CMS) MDS database showed
Resident #1’s last submitted quarterly assessment with an assessment reference date (ARD)
of 11/01/17.
Review of the facility’s MDS software showed a quarterly assessment with an ARD of
04/17/18 finalized, not transmitted, and the completion date on Section Z0500B is
04/17/18.
Review of the facility’s MDS software showed an annual assessment due on 02/01/18, not
validated, not finalized, not transmitted, and not completed.
3. Review of the CMS MDS database showed Resident #2’s last submitted quarterly assessment
with an ARD of 11/02/17.
Review of the facility’s MDS software showed a quarterly assessment with an ARD of
04/17/18 finalized, not transmitted, and the completion date on Section Z0500B is
04/17/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 18)
Review of the facility’s MDS software showed an annual assessment due on 02/02/18, not
finalized, not transmitted, and not completed.
4. Review of the CMS MDS database showed Resident #3’s last submitted quarterly assessment
with an ARD of 11/09/17.
Review of the CMS MDS data base showed Resident #3’s last submitted discharge with no
return anticipated assessment with an ARD of 01/09/18.
Review of the CMS MDS database showed Resident #3’s last submitted entry tracking record
with an ARD of 02/13/18.
Review of the facility’s MDS software showed an annual assessment with an ARD of 02/14/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B is
02/14/18.
Review of the facility’s MDS software showed an entry assessment due on 02/26/18, not
validated, not finalized, not transmitted, and not completed.
5. Review of the CMS MDS database showed Resident #4’s last submitted quarterly assessment
with an ARD of 11/09/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 02/13/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B is
02/13/18.
6. Review of the CMS MDS database showed Resident #6’s last submitted quarterly assessment
with an ARD of 11/16/17.
Review of the CMS MDS data base showed Resident #6’s last submitted discharge return
anticipated assessment with an ARD of 12/08/17.
Review of the CMS MDS database showed Resident #6’s last submitted entry tracking
assessment with an ARD of 12/18/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 02/15/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
02/15/18.
7. Review of the CMS MDS database showed Resident #9’s last submitted quarterly assessment
with an ARD of 12/08/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 03/09/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/09/18.
8. Review of the CMS MDS database showed Resident #10’s last submitted quarterly
assessment with an ARD of 12/08/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 03/08/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/08/18.
9. Review of the CMS MDS database showed Resident #12’s last submitted quarterly
assessment with an ARD of 12/11/17.
Review of the facility’s MDS software shows an annual assessment with an ARD of 03/13/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/13/18.
10. Review of the CMS MDS database showed Resident #13’s last submitted quarterly
assessment with an ARD of 12/11/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 03/09/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/09/18.
11. Review of the CMS MDS database showed Resident #14’s last submitted quarterly
assessment with an ARD of 12/11/17.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 19)
Review of the facility’s MDS software showed an annual assessment with an ARD of 03/12/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/12/18.
12. Review of the CMS MDS database showed Resident #15’s last submitted quarterly
assessment with an ARD of 12/13/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 03/14/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/14/18.
13. Review of the CMS MDS database showed Resident #16’s last submitted quarterly
assessment with an ARD of 12/14/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 03/16/18
not properly validated, not finalized, not transmitted, and the completion date on Section
Z0500B 03/16/18.
14. Review of the CMS MDS database showed Resident #17’s last submitted quarterly
assessment with an ARD of 12/15/17.
Review of the facility’s MDS software shows an annual assessment with an ARD of 03/16/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/16/18.
15. Review of the CMS MDS database showed Resident #18’s last submitted quarterly
assessment with an ARD of 12/15/17.
Review of the facility’s MDS software showed an annual assessment with an ARD of 03/23/18
validated, not finalized, not transmitted, and the completion date on Section Z0500B
03/23/18.
16. Review of the CMS MDS database showed Resident #19’s last submitted quarterly
assessment with an ARD of 12/18/17.
Review of the facility’s MDS software shows an annual assessment with an ARD of 03/23/18
not properly validated, not finalized, not transmitted, and the completion date on Section
Z0500B 03/23/18.
17. During an interview on 4/24/18 at 3:31 P.M., the Program Manager said he/she does not
know when the MDS assessments are transmitted because the Administrator is responsible to
submit the MDS assessments.
During an interview on 04/26/18 at 10:56 A.M., the Administrator said the staff did not
complete the Section V on the comprehensive MDS assessments so they were initially
validated but not finalized or accepted.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to document a complete and
accurate Minimum Data Set (MDS) assessment (a federally mandated assessment) when they did
not accurately code an assistive/mobility device for two residents (Resident #22, and
#48), behaviors for one resident (Resident #44), a psychiatric/mood disorder [DIAGNOSES
REDACTED].#44), injections and antipsychotic medication for one resident (Resident #44), a
fall with injury for one resident (Resident #83), Preadmission Screening and Resident
Review (PASRR) and Antipsychotic medication review for one resident (Resident #191), of 20
sampled residents. The facility census was 99.
1. Review of Resident #22’s quarterly change Minimum Data Set (MDS), dated [DATE], showed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
staff assessed the resident as follows:
-Unable to complete cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices;
-Hospice care.
Review of the resident’s medical record showed hospice staff provided the resident a
walker on 09/28/17.
Observation on 04/24/18 at 4:03 P.M., showed the resident in the dining room in his/her
wheelchair at a table.
Observation on 04/25/18 at 10:52 A.M., showed the resident in his/her wheel chair and
watch television (TV) in the TV in room.
Staff did not accurately code the resident’s walker use, wheelchair use or hospice care.
2. Review of Resident #44’s Quarterly Minimum Data Set (MDS), a federally mandated
assessment tool, dated 02/15/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
-Limited one-person assist with transfers, dressing, toileting, and hygiene;
-No Psychiatric/Mood Disorder diagnosis;
-No injections;
-No antipsychotic medication;
-Antidepressant medication seven days a week.
Review of the resident’s POS, dated 02/07/18, showed staff were directed to inject a 20mg
antipsychotic into the resident daily PRN (as needed) for aggressive behavior for 90 days.
Staff did not accurately code the resident’s antipsychotic medication.
3. Review of Resident #48’s quarterly MDS dated [DATE], showed staff assessed the resident
as follows:
-Severe cognitive impairment;
-Extensive assist of one person with ambulation, locomotion on and off unit;
-Did not use any mobility devices.
Review of the resident’s care plan for fall intervention, last updated 6/15/17, showed
staff documented the resident has impaired ambulation, and directed staff the resident
needs assistance, uses a wheelchair for mobility as a result of Dementia, and uses a high
back wheelchair with two foot rests.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Severe cognitive impairment;
-Extensive assist of one person with ambulation, locomotion on and off unit;
-Did not use any mobility devices.
Review of the resident’s comprehensive MDS dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment;
-Extensive assistance of one person with ambulation, locomotion on and off unit;
-Did not use any mobility devices.
Observation on 4/23/18 at 1:15 P.M., showed the resident sat in a high back wheelchair at
the dining table.
Observation on 4/23/18 at 3:55 P.M., showed the resident sat in a high back wheelchair at
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
the dining table.
Observation on 4/26/18 at 10:45 A.M., showed Certified Nursing Assistant (CNA) E Patricia
propelled the resident in his/her high back wheelchair from the dining room to his/her
room.
Observation on 4/26/18 at 10:54 A.M., showed CNA D and CNA E transferred the resident from
the high back wheelchair to the bed, provided perineal care, and transferred the resident
back to the wheelchair. CNA D said staff are expected to push the resident in his/her
wheelchair with the foot pedals.
Staff did not accurately code the resident’s use of a wheelchair for mobility, as required
on section G0600 of the MDS.
4. Review of Resident #83’s admission MDS showed staff documented the resident was
admitted on [DATE], and assessed the resident with:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS-test for cognitive impairment) score of seven,
indicates severe cognitive impairment;
-Independent with bed mobility, transfer, ambulation and locomotion on unit.
Review of the resident’s Baseline Care Plan, undated, showed staff documented the resident
had no skin issues, and had intact skin. Further review of the Comprehensive Care Plan,
dated 3/12/18, showed staff are directed:
-[DIAGNOSES REDACTED].
-Orient resident to surroundings and routine activities;
-Needs assist of all ADLs;
-Ambulatory fall risk.
Review of the nurses’ notes, dated 3/22/18 at 9:00 P.M., showed staff documented the
resident fell in the hall on the way to answer the phone. The resident said he/she got
dizzy. Staff cleansed a skin tear to the back of the resident’s head, applied dressing,
and administered Tylenol for comfort.
Review of the nurses’ notes, dated 3/23/18 showed staff documented the resident stumbled
and was lowered to the floor. The resident said he/she felt dizzy since the day before.
The physician and resident representative were notified. Resident was transferred to the
emergency room for evaluation.
Review of the resident’s discharge return anticipated MDS dated [DATE], showed staff
documented the resident was admitted on [DATE], and assessed the resident with:
-Modified independence-some difficulty in new situations only;
-No falls since admission or the prior assessment (prior assessment date 3/12/18).
Review showed staff did not document the resident’s fall with injury on 3/22/18 as
required on section J1800 and J1900 of the MDS.
Review of the nurses’ notes, dated 3/29/18 showed staff documented the resident returned
from the hospital via ambulance from a fall related to dizziness.
Observation and interview on 4/23/18 at 2:04 P.M., showed the resident in a wheelchair in
his/her room, with scabs to his/her left elbow, and a small hematoma (swelling) to his/her
right forehead. The resident said he/she fell due to dizzy spells, and staff sent him/her
to the hospital for treatment.
During an interview on 4/24/18 at 11:04 A.M., Certified Medication Technician (CMT) A said
the resident fell about a month or so ago, and thinks he/she was sent to the emergency
room for treatment.
5. Review of Resident #191’s PASRR Level II screening review, dated 2/2/18, showed
facility staff are directed:
-The Department of Mental Health (DMH) has determined the applicant has met the federal
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
definition of Serious Mental Illness (SMI) but does not require specialized services;
-It has been determined that this client meets facility admission requirements;
-This information must be reflected on the resident’s current MDS.
Review of the resident’s admission MDS, dated [DATE], and electronically signed as
completed on 2/26/18, showed staff assessed the resident as follows:
-admitted [DATE] with a [DIAGNOSES REDACTED].
-BIMS score of 12, indicates moderate cognitive impairment;
-Is not currently considered by the state level II PASRR process to have serious mental
illness and/or intellectual disability or related condition;
-Received Antipsychotic and Antidepressant for seven days during the seven-day review
period;
-Did not receive antipsychotic medications since admission/entry/re-entry or prior
assessment.
Staff did not accurately complete sections A1500 (PASRR) and N0450 (Antipsychotic
medication review) as required on the MDS.
6. During an interview on 4/26/18 at 6:30 P.M., the Administrator said he/she and the
Program Manager completes the MDS assessments. He/She expects the MDS to be completed per
the RAI guidelines. He/She said if a resident’s PASSR screening was completed, he/she
expects that information to be reflected on the MDS, and did not know why Resident #191’s
MDS was not accurate. The Administrator also said Resident #83’s fall with injury should
have been documented on the MDS, it was just missed.

F 0644

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Coordinate assessments with the pre-admission screening and resident review program;
and referring for services as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to accurately complete the
Pre-Admission Screening and Resident Review (PASRR) process prior to admission for one
resident (Resident #44). The facility census was 99.
1. Review of the Central Office Medical Review Unit (COMRU) Instructional Guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASRR process:
-The DA-124 application will assist in identifying a client that requires a Level II
screening. The DA-124 C form must be completed prior to admitting the client to a nursing
facility to ensure the client does not trigger a Level II screening. A level II screening
refers to clients with the [DIAGNOSES REDACTED].
-A client that requires a Level II screening cannot be admitted to the nursing facility
prior to the determination of the Level II.
-The triggers for the level II screening are:
-the client has had inpatient psychiatric treatment in the past two years;
-the client was suicidal or homicidal (includes Dementia clients);
-the client has very aggressive behavior (includes Dementia clients);
-the client has a [DIAGNOSES REDACTED].
2. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
to the facility on [DATE].
Review of the resident’s PASRR Level I, dated 11/21/17, showed the resident did not have a
major mental illness diagnosis, did not display signs or symptoms of a mental illness, and
did not have serious problems in level of functioning in the last six months.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0644

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
Review of the resident’s POS, dated 11/21/17, showed staff are directed to administer a
25mg [MEDICATION NAME] (antidepressant) to the resident daily for depression.
Review of the resident’s POS, dated 02/07/18, showed staff are directed to administer by
injection a 20mg [MEDICATION NAME] (antipsychotic) to the resident daily PRN (as needed)
for aggressive behavior for 90 days.
Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by
injection a 1mg [MEDICATION NAME] (antipsychotic) to the resident daily in the morning.
Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by
injection a 2.5mg [MEDICATION NAME] (antipsychotic) to the resident daily at bedtime.
Review of the resident’s Quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 02/15/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
-Limited one-person assist with transfers, dressing, toileting, and hygiene;
-No Psychiatric/Mood Disorder diagnosis;
-No injections;
-No antipsychotic medication;
-Antidepressant medication seven days a week.
During an interview on 04/25/18 at 4:25 P.M., the Social Services Director said nursing
staff completes the PASRRs and he/she just submits them. He/She said PASRRs do not ever
need to be updated or resubmitted as far as he/she knows. He/She said he/she is unsure if
Resident #44 has a mental illness but he/she said the resident does not have any signs or
symptoms of mental illness. He/She said the state is referring the resident for
Guardianship due to him/her not being able to make responsible life decisions on his/her
own. The Social Services Director also said he/she has not received any training on
completing PASSR assessments.
During an interview on 04/26/18 at 6:59 P.M., the DON said Level I and Level II PASRR
screenings should be completed accurately prior to admission. He/she said the resident
displays signs symptoms of mental illness and has a [DIAGNOSES REDACTED].

F 0646

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Notify the appropriate authorities when residents with MD or ID services has a
significant change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review facility staff failed to complete the Pre-Admission
Screening and Resident Review (PASRR) process prior to admission, and failed to notify the
appropriate mental health authority for a referral/screening, after an acute inpatient
Psychiatric hospital stay for one sampled resident (Resident #32). The facility census was
99.
1. Review of the facility’s records showed it did not contain a policy to address the
PASRR screening and referral process.
2. Review of the Central Office Medical Review Unit (COMRU) Instructional Guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASRR process:
-The DA-124 application will assist in identifying a client that requires a Level II
screening;
-The DA-124 C (form for the screening) must be completed prior to admitting the client to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0646

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
a nursing facility to ensure the client does not trigger a Level II screening. A level II
screening refers to clients with the [DIAGNOSES REDACTED].
-A client that requires a Level II screening cannot be admitted to the nursing facility
prior to the determination of the Level II;
-The triggers for the level II screening are:
-the client has had inpatient psychiatric treatment in the past two years;
-the client was suicidal or homicidal (includes Dementia clients);
-the client has very aggressive behavior (includes Dementia clients);
-the client has a [DIAGNOSES REDACTED].
-If the resident has a [DIAGNOSES REDACTED].
-If a verbal consent is obtained, the guardian’s name must appear on the line and be
witnessed by two people;
-Section F: must include the physician’s discipline and license number, and the date of
the physician’s signature.
-A significant change in status is defined as a change in two or more areas on the Minimum
Data Set (MDS) 3.0 (a federally mandated assessment), regarding a client’s needs. It can
be either physical or mental changes;
-Changes in Status are completed by the nursing home in which the resident is residing. It
is not completed by the hospital. A change in status will be completed in conjunction with
the MDS. It is the responsibility of the nursing facility to identify the change in status
for a mentally ill or intellectually impaired client. The MDS coordinator and the person
who completes the DA 124 forms should work closely together to ensure they are completed;
-A DA-124 A/B and a DA-124 C form must be completed and submitted to COMRU for a change in
status. The nursing facility should indicate Change in Status on the client’s DA 124
application. If not indicated the application will be processed as a Pre-admission Level
II screening and payment could be affected. The facility should attach a short summary
indicating the reason.
-Example: The initial application does not indicate a client as a Level II, however after
nursing facility admission the client has now admitted to inpatient psychiatric treatment
and/or a Level II was never completed when one should have been completed. The trigger for
a Level II MI screening is inpatient psychiatric treatment in the past 2 years. The client
has now triggered the need for a Level II screening. The DA-124 application must be
completed and submitted to COMRU.
2. Review of Resident #32’s medical records showed his/her first admission to the facility
was 7/28/08. Additional review showed he/she had at least two inpatient Psychiatric
treatments in (YEAR).
Review of the resident’s Level I PASSR screen for Mental Illness/Mental [MEDICAL
CONDITION] or Related Condition, undated, showed staff documented:
-The resident showed signs and symptoms of major mental disorder;
-The person has been diagnosed as having major mental disorder;
-The person has had serious problems in levels of functioning in the last six months;
-The person has received intensive psychiatric treatment in the past two years.
Further review of the form showed the resident representative did not sign or date section
E of the form, and the physician signed section F, but did not date the form. The Level II
referral was not completed/submitted as directed by the COMRU instructional guide.
Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident with
[DIAGNOSES REDACTED].
-Not evaluated by Level II PASRR and determined to have a serious mental illness and/or
mental [MEDICAL CONDITION] or a related condition;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0646

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
-Brief Interview for Mental Status (BIMS-test for cognitive impairment) score of 12:
indicates moderate cognitive impairment;
-No signs and symptoms of [MEDICAL CONDITION];
-Delusions;
-Verbal behaviors towards others;
-No wandering behaviors;
-Rejection of care;
-Change in behaviors, not assessed.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
with [DIAGNOSES REDACTED].
-BIMS score of 9: indicates moderate cognitive impairment;
-No signs and symptoms of [MEDICAL CONDITION];
-Delusions;
-Verbal behaviors towards others;
-Wandering behaviors, and rejection of care;
-Change in behaviors, not assessed.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as:
-discharged to acute hospital;
-Moderate cognitive impairment;
-No signs and symptoms of [MEDICAL CONDITION];
-Displayed hallucinations and delusions;
-Physical and verbal behaviors towards other;
-Wandering behaviors, and rejection of care;
-Change in behaviors, not assessed.
Review of the resident’s medical records showed the resident was discharged to an
inpatient Psychiatric hospital on [DATE], and returned to the facility on [DATE]. Further
review of the records showed staff did not notify the appropriate state mental health
authority of the increased behavioral and psychiatric symptoms in a resident previously
diagnosed with [REDACTED].
During an interview on 4/25/18 at 4:26 P.M., the Social Services Director (SSD) said
he/she started working at the facility about two years ago, and is responsible to submit
PASRR referrals to COMRU. The SSD said the resident’s level I PASRR screen was undated, so
he/she was unsure when it was completed. The SSD said he/she did not receive any training
from COMRU, and was not instructed by the corporate office to review or submit PASRR
screens/referrals any other time except on admission of a resident. The SSD said if a
resident has a mental illness diagnosis, that is an indicator for a Level II PASSR
screen/referral. He/She said facility staff does not normally re-submit PASRR screens for
Level II referrals once a prior Level I was submitted. The SSD said since Resident #32 was
admitted with a [DIAGNOSES REDACTED].
During an interview on 4/25/18 at 4:40 P.M., the SSD said the resident receives
psychological therapy at the facility from a Licensed Psychologist several times a week.
During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said he/she
expects PASRR screens to be completed correctly and prior to a resident’s admission to the
facility. The DON said a Level II screen should have been completed.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to develop and
implement measurable goals and interventions for comprehensive care plans for four sampled
residents (Residents #10, #22, #44, and #195) related to eating assistance, fall
preventions, and individualized non pharmacological behavior interventions. The facility
census was 99.
1. Review of Resident #10’s annual Minimum Data Set (MDS), dated [DATE], showed staff
assessed the resident as follows:
-Rarely or never understood;
-Physical and verbal behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of urine and occasionally incontinent of bowel.
Review of the resident’s care plan, dated 05/19/16, showed staff are directed to:
-Set up the resident’s tray and assist him/her during meals;
-Offer the resident alternatives for known food dislikes if he/she is not eating well;
-Report any refusals to eat to the charge nurse and document the refusal in the
consumption book.
Review of the resident’s care plan, dated 08/07/16, showed staff are directed to attempt
to address the resident’s dementia related behaviors with non pharmacological
interventions prior to utilizing any PRN medications. Staff did not specify what
individualized non pharmacological interventions to use for the resident.
Observation on 04/24/18 at 1:10 P.M., showed staff did not assist or encourage the
resident at lunch.
Observation on 04/24/18 at 1:28 P.M., showed the resident left the dining room and did not
eat any of his/her meal.
2. Review of Resident #22’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices.
Review of the resident’s medical record showed hospice gave the resident a walker on
09/28/17.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Unable to complete cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices;
-Hospice.
Review of the resident’s care plan, dated 08/07/16, showed staff are directed to attempt
to address the resident’s dementia related behaviors with non pharmacological
interventions prior to utilizing any PRN medications. Staff did not specify what
individualized non pharmacological interventions to use for the resident.
3. Review of Resident #38’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of bladder and bowel.
Review of the resident’s care plan, dated 07/21/16, showed staff are directed to keep the
call light within reach and answer the call light promptly.
Review of the resident’s care plan, dated 02/23/17, showed staff are directed to assist
the resident with meals as needed. Staff did not specify what level or type of assistance
the resident may need.
Observation on 04/24/18 at 1:06 P.M., showed staff did not assist the resident at lunch.
Observation on 04/25/18 at 2:14 P.M., showed the resident in his/her wheelchair at the
foot of his/her bed near the door. He/She was alone in the room with no television or
radio. Further observation showed the call light under the blanket near the head of the
bed out of the resident’s reach.
Observation on 04/26/18 at 9:44 A.M., showed the resident in his/her wheelchair at the
foot of his/her bed near the door. He/She was alone in the room with no television or
radio. Further observation showed the call light near the head of the bed out of the
resident’s reach.
4. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff did not address the
resident’s [MEDICAL CONDITION] medication.
Review of the residents’ Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 12/04/17, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 02/15/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
-Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene;
-Antidepressant medication seven days a week.
5. Review of Resident #195’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Moderate cognitive impairment;
-Verbal behaviors;
-Independent with transfers, dressing, eating, and toileting;
-Antipsychotic medication seven days a week and antianxiety medication one day a week.
Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory
but a fall risk and staff are directed to:
-Administer medication as ordered;
-Pharmacist and physician to review medications monthly and PRN;
-Monitor gait and transfer and alert nurse with changes;
-Supervise resident outdoors;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
-Observe for effects of medication such as: drowsiness, restlessness, nervousness,
abnormal movements, [DIAGNOSES REDACTED] (persistent or intermittent muscle contractions),
muscle cramps, increase in falls, and change in mood or behavior;
-Complete labs as ordered and report to Medical Director.
Staff did not incorporate appropriate interventions for the resident who has a history of
multiple falls with injury.
6. During an interview on 04/26/18 at 5:50 P.M., CNA I said a care plan has something to
do with the resident’s needs and should be individualized because needs differ from person
to person. He/She said a resident’s fall risk should be listed on the care plan.
During an interview on 04/26/18 at 5:57 P.M., LPN J said care plans have to be
individualized because residents all have different needs. He/She said he/she has noticed
the care plans are generic.
During an interview on 04/26/18 at 6:30 P.M., the Administrator said the DON is
responsible to update the care plans to meet the resident’s need. He/She said they have a
cheat sheet with standard interventions to add if a resident falls or develops a pressure
sore. He/She said all staff can update the care plans. He/She said MDSs and care plans
should adequately reflect the resident and the care plan should be updated with the MDS.
During an interview on 04/26/18 at 6:59 P.M., the DON said he/she and the Administrator
update care plans. He/She said the care plans are updated with falls, wounds, and with any
individualized changes to the resident. He/She said the facility’s care plans are pretty
general and could be more specific. He/she said staff get care directions from the care
plan so they should be individualized and updated so staff will know how to appropriately
care for residents.
MO 773

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review facility staff failed to update the plan
of care with changes in the resident’s needs for nine residents (Resident #22, #26, #32,
#44, #48, #52, #81, #191, and #195) out of 20 sampled residents. The facility census was
99.
1. Review of the facility’s records showed it did not contain a policy to address
resident’s care plans.
2. Review of Resident #22’s Quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 1/03/18, showed staff assessed the resident as follows:
-Unable to complete cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices;
-Hospice.
Review of the resident’s care plan, dated 10/24/16, showed staff did not update the care
plan when the resident could no longer ambulate on his/her own and began to use a
wheelchair.
Observation on 4/24/18 at 4:03 P.M., showed the resident in the dining room in his/her

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
wheelchair at a table.
Observation on 4/25/18 at 10:52 A.M., showed the resident in his/her wheelchair in the TV
in room.
3. Review of Resident #26’s Quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Moderate cognitive impairment;
-No mood;
-No behaviors;
-Hallucinations and delusions;
-Limited assistance of one or more staff with bed mobility, dressing, eating, toileting,
and hygiene;
-No assistive devices;
-No pressure or risk of pressure;
-No antipsychotic medications.
Review of the resident’s care plan, dated 1/05/18, showed staff did not update the care
plan when the resident could no longer ambulate on his/her own and began to use a walker.
Observation on 4/25/18 at 11:12 A.M., showed the resident sat on the couch at the end of
the hall with his/her walker.
4. Review of Resident #32’s medical records showed staff documented the resident
re-admitted to the facility on [DATE].
Review of the resident’s care plan for [MEDICAL CONDITION] and Behavior Management, last
updated 5/4/17, showed staff are directed:
-Resident has [DIAGNOSES REDACTED].
-Staff will document behaviors as they occur, and document noted behaviors in chart as
needed;
-The consultant pharmacist and physician will evaluate and document continued use of
medications and taper medications at least monthly as indicated;
-Staff will attempt to address behaviors with non-pharmacological interventions prior to
utilizing any PRN meds;
-Staff will monitor for any side effects or Extrapyramidal Symptoms (EPS) (drug-induced
movement disorders/side effects);
-Resident begs staff for soda, if staff refuse, he/she yells out and says he hit me,
please re-direct resident.
Review of the resident’s comprehensive annual MDS, dated [DATE], showed staff assessed the
resident with [DIAGNOSES REDACTED].
-Not evaluated by Level II PASRR screening;
-Brief Interview for Mental Status (BIMS-test for cognitive impairment) score of 12:
indicates moderate cognitive impairment;
-No signs and symptoms of [MEDICAL CONDITION];
-Delusions;
-Verbal behaviors towards others;
-No wandering behaviors;
-Rejection of care;
-Change in behaviors, not assessed.
Staff did not update the care plan within seven days after completion of the comprehensive
annual MDS assessment dated [DATE].
Review of the Social Services Director (SSD) notes, dated 1/10/18, showed he/she
documented the resident did not have any significant changes in his/her behavior, but
needed re-direction for behavioral outburst.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
with [DIAGNOSES REDACTED].
-BIMS score of 9: indicates moderate cognitive impairment;
-No signs and symptoms of [MEDICAL CONDITION];
-Delusions;
-Verbal behaviors towards others;
-Wandering behaviors, and rejection of care;
-Change in behaviors, not assessed.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-discharged to acute hospital;
-Moderate cognitive impairment;
-No signs and symptoms of [MEDICAL CONDITION];
-Displayed hallucinations and delusions;
-Physical and verbal behaviors towards others;
-Wandering behaviors, and rejection of care;
-Change in behaviors, not assessed.
Further review of the records showed the resident was discharged to an inpatient
Psychiatric hospital on [DATE], and returned to the facility on [DATE].
Staff did not document any updates to the resident’s care plan after he/she had changes in
behaviors to include hallucinations, wandering, physical behaviors towards others, and had
at least one inpatient psychiatric stay. Further review showed staff did not update the
comprehensive care plan after 5/4/17.
5. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff did not update the care
plan to direct staff to provide individualized interventions in response to resident
behaviors or monitor for side effects of [MEDICAL CONDITION] medications. Further review
showed staff did not update the care plan within seven days after completion of the
comprehensive admission MDS assessment, dated 12/04/17.
Review of the resident’s POS, dated 11/21/17, showed staff are directed to administer a
25mg [MEDICATION NAME] (antidepressant) to the resident daily for depression.
Review of the resident’s POS, dated 02/07/18, showed staff are directed to administer by
injection a 20mg [MEDICATION NAME] (antipsychotic) to the resident daily PRN (as needed)
for aggressive behavior for 90 days.
Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by
injection a 1mg [MEDICATION NAME] (antipsychotic) to the resident daily in the morning.
Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by
injection a 2.5mg [MEDICATION NAME] (antipsychotic) to the resident daily at bedtime.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
-Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene;
-Antidepressant medication seven days a week.
6. Review of Resident #48’s medical records, showed staff documented the resident was
admitted to the facility on [DATE], with a [DIAGNOSES REDACTED].
Review of the resident’s care plan for [MEDICAL CONDITION], last updated 8/8/16, showed
staff documented the resident had [DIAGNOSES REDACTED].
-Administer [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] and [MEDICAL
CONDITION] disorder), [MEDICATION NAME] (medication to treat depression), and [MEDICATION
NAME] (medication to treat [MEDICAL CONDITIONS] disorder, and depression);
-Document behaviors as they occur;
-Abnormal Involuntary Movement Scale (AIMS) assessment on admission, quarterly and with
signficant changes;
-Pharmacist and Physician will evaluate and document continued use of meds, and taper meds
monthly as indicated.
Review of the resident’s comprehensive significant change MDS, dated [DATE], showed staff
assessed the resident as follows:
-Severe cognitive impairment;
-Daily wandering and rejection of care;
-Behaviors improved since prior assessment (prior assessment date 2/27/18);
-[DIAGNOSES REDACTED].
-Received Antipsychotics and Antidepressant medications daily during the seven-day review
period;
-Received Antipsychotics on a routine basis only, with last attempted GDR 2/6/18.
Review of the resident’s POS, dated 3/1/18 through 4/26/18, showed staff did not document
an order for [REDACTED].>Staff did not update the care plan within seven days after
completion of the comprehensive significant change MDS assessment dated [DATE]. Further
review showed staff did not make any updates to the resident’s comprehensive care plan
after 6/15/17.
7. Review of Resident #52’s medical records showed the resident was admitted [DATE], and
re-entered the facility on 3/1/17 after an acute hospital stay.
Review of the resident’s care plan, last updated 4/11/17, showed staff assessed the
resident at risk for falls, required assistance with ADL’s as needed, and directed staff
to encourage the resident to do as much for himself/herself as possible.
Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as
follows:
-Moderate cognitive impairment;
-[DIAGNOSES REDACTED].
-Very important to have books, newspapers and mazazines to read, listen to music, and keep
up with the news;
-Required supervision with eating, toilet use, personal hygiene, and bathing;
-Uses a walker;
-Received antidepressant and diuretic medications for seven days during the seven-day
review period.
Staff did not update the care plan within seven days after completion of the comprehensive
annual MDS assessment dated [DATE]. Additional review showed staff did not document any
updates to the resident’s comprehensive care plan after 4/11/17.
During an interview on 4/23/18 at 3:09 P.M., the resident said he/she has gotten weaker
and needs assistance with bathing. He/She said staff used to send a letter out for care
plan meetings, but they haven’t in a long time, so if they are still having the meetings,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
he/she does not know about it.
8. Review of Resident #81’s medical records showed staff documented the resident
re-admitted to the facility on [DATE].
Review of the resident’s care plan, for Behavior management, [MEDICAL CONDITION], and
[MEDICAL CONDITION], last updated 8/8/16, showed staff documented [DIAGNOSES REDACTED].
-If the resident exhibits behaviors, staff will attempt to assess the cause for behaviors
and address cause promptly;
-If behaviors are not caused by medical factors, staff will attempt to manage behaviors
with non pharmacological interventions first;
-Resident starting Hospice care, begin 7/15/16;
-[MEDICAL CONDITION] medication due to the following conditions: Dementia, [MEDICAL
CONDITIONS], Anxiety, and combativeness;
-Following medications per physician’s orders [REDACTED].
-Staff will document behaviors as they occur, and all noted behaviors and interventions;
-The consultant pharmacist and physician will evaluate and document continued use of
medications and taper medications at least monthly as indicated
-Staff will attempt to address behaviors with non-pharmacological interventions prior to
utilizing any PRN meds;
-Staff will monitor for any side effects or EPS.
Review of the resident’s significant change MDS, dated [DATE] on paper, and electronically
signed as completed on 3/6/18, showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-No behaviors, or rejection of care, with improved behaviors;
-Received antipsychotic, antidepressant, and hypnotic medications for seven days during
the seven day review period;
-Last attempted GDR on 10/6/17.
Staff did not update the care plan within seven days after completion of the comprehensive
significant change MDS assessment completed 3/6/18.
Review of the resident’s POS, dated 4/1/18 through 4/30/18, showed staff did not document
an order for [REDACTED].>Further review showed staff did not make any updates to the
resident’s comprehensive care plan after the physician discontinued several [MEDICAL
CONDITION] medications.
9. Review of Resident #191’s admission MDS, dated [DATE], and electronically signed as
complete 2/26/18, showed staff assessed the resident as follows:
-admitted [DATE] with a [DIAGNOSES REDACTED].
-BIMS score of 12, indicates moderate cognitive impairment;
-Feeling down, depressed, or hopeless (nearly every day);
-No physical, verbal, or other behavioral symptoms directed towards others;
-Daily wandering that did not impact others;
-Received antipsychotic and antidepressant medications for seven days during the seven-day
review period;
-Did not receive antipsychotic medications since admission/entry/re-entry or prior
assessment.
Review of the resident’s care plan, dated 2/6/18, showed staff are directed:
-Has history of [MEDICAL CONDITION], delusions, paranoia, disheveled, disorganized, social
withdrawal;
-Remind resident of scheduled activity that involve memory challenge;
-Encourage to walk with reliable buddy to dining room, chapel, etc.,
-Place resident on locked unit;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
-Resident wanders to smoking area with intent to smoke;
-Resident is very withdrawn and quiet to self at times. Other times resident is aggressive
and anxious with unstable mood.
Review of the resident’s records showed the resident was involved in a physical
altercation with another resident on 2/11/18. Further review showed the resident was sent
to the hospital on [DATE] for medical and psychiatric evaluation related to behaviors.
Staff did not update the resident’s care plan after his/her involvement in a physical
altercation with another resident on 2/11/18.
During an interview on 4/25/18 at 4:40 P.M., the Social Services Director (SSD) said there
is a Licensed Psychologist that sees residents at the facility, but he/she does not think
the Psychologist sees the resident. The SSD said he/she does one-on-one visits with the
resident. The SSD said he/she normally gives recommendations to the Administrator to
update care plans, but had not given/offer any specific psychological services to the
resident.
10. Review of Resident #195’s Quarterly MDS, a federally mandated assessment tool, dated
03/01/18, showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-Verbal behaviors;
-Independent with transfers, dressing, eating, and toileting;
-Antipsychotic medication seven days a week and antianxiety medication one day a week.
Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory
but a fall risk and staff are directed to:
-Administer medication as ordered;
-Pharmacist and physician to review medications monthly and PRN;
-Monitor gait and transfer and alert nurse with changes;
-Supervise resident outdoors;
-Observe for effects of medication such as:
-drowsiness, restlessness, nervousness, abnormal movements, [DIAGNOSES REDACTED], muscle
cramps, increase in falls, and change in mood or behavior;
-Complete labs as ordered and report to Medical Director.
Review of the resident’s incident report, dated 04/10/18, showed housekeeping staff found
the resident on the floor. Further review showed the resident had no bleeding or swelling.
Additional review showed the resident said his/her leg gave way.
Review of the resident’s Post Incident report, dated 04/10/18, showed staff assessed the
resident’s skin clear with no bruises on day, evening, and night shifts.
Review of the resident’s Post Incident report, dated 04/11/18, showed staff assessed the
resident’s skin clear with no bruises on day, evening, and night shifts.
Review of the resident’s Post Incident report, dated 04/12/18, showed staff assessed the
resident’s skin clear with no bruises on day, evening, and night shifts.
Staff did not update the care plan after the resident fell on [DATE].
11. During an interview on 04/26/18 at 5:50 P.M., CNA I said a care plan has something to
do with the resident’s needs and should be individualized because needs differ from person
to person. He/She said the nurses update the care plans so he/she notifies the nurse.
He/She said a resident’s fall risk should be listed on the care plan.
During an interview on 04/26/18 at 5:57 P.M., LPN J said care plans have to be
individualized because residents all have different needs. He/She said he/she has noticed
the care plans here are generic. He/She said the Program Manager usually updates the care
plans but nurses can update them after falls or incidents. He/She said new interventions
should be listed on a resident’s care plan after a fall.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
During an interview on 04/26/18 at 6:30 P.M., the Administrator said the DON is
responsible to update the care plans to meet the resident’s needs. He/She said they have a
cheat sheet with standard interventions to add if a resident falls or develops a pressure
sore. He/She said all staff can update the care plans. He/She said MDS assessments and
care plans should adequately reflect the resident and the care plan should be updated with
the MDS.
During an interview on 04/26/18 at 6:59 P.M., the DON said he/she and the Administrator
update care plans. He/She said the care plans are updated with falls, wounds, behaviors,
and with any individualized changes to the resident. He/She said the facility’s care plans
are pretty general and could be more specific. He/she said staff get care directions from
the care plan so they should be individualized and updated so staff will know how to
appropriately care for residents. He/She said Resident #191’s care plan should have been
updated after the physical altercation occurred, particularly since the resident did not
have a history of physical behaviors towards others.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to meet
professional standards when they failed to follow the physician’s order regarding oxygen
administration for one resident (Resident #68). Additionally staff failed to obtain x-ray
results in a timely manner and follow physician’s orders to administer PRN (as needed)
pain medication for one resident (#195). The facility census was 99.
1. Review of the facility’s Oxygen Administration policy, dated (MONTH) 2001, showed
facility staff are directed to check the physician’s order for liter flow and method of
administration.
2. Review of Resident #68’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 3/16/18, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Required extensive assist of two or more staff for bed mobility and bathing;
-Required total assistance of one staff for locomotion, dressing, and personal hygiene;
-Required total assistance of two or more staff for transfers, and toilet use;
-Had shortness of breath with exertion, rest, and lying flat;
-No oxygen therapy.
Review of the resident’s care plan, undated showed the resident was on oxygen as needed
and the resident is very confused when the resident needs his/her oxygen.
Review of the resident’s Physician Order Sheet (POS), dated (MONTH) (YEAR), showed a
telephone order, dated 2/21/18, directed staff to discontinue oxygen of two liters
continuously and start two liters via nasal cannula as need to keep saturation above 90
percent (%).
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
Observation on 4/24/18 at 9:03 A.M. showed the resident in his/her room in bed. The
resident had his/her oxygen on and set at six liters per nasal cannula.
Observation on 4/24/18 at 2:58 P.M. showed the resident in his/her room in bed. The
resident had his/her oxygen on and set at six liters per nasal cannula.
Observation on 4/25/18 at 9:57 A.M. showed the resident in his/her room in bed. The

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 35)
resident had his/her oxygen on and set at six liters per nasal cannula.
Observation on 4/25/18 at 2:48 P.M. showed the resident in his/her room in bed. The
resident had his/her oxygen on and set at six liters per nasal cannula.
During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) AL said the
nurse lets us know how much oxygen a resident should be on. CNA AL said the nurse is the
only person to change the level the oxygen is on. CNA AL said he/she is not sure how many
liters the resident’s oxygen should be set on.
During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said staff
should follow the physician’s orders regarding oxygen administration levels. LPN M said
he/she is not sure what level the resident’s oxygen should be set at. LPN M said if staff
notice the oxygen is not being administered per the physician’s orders the nurse should
change it to the ordered rate.
During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said said staff
should follow the physician’s orders regarding oxygen administration levels. The DON said
he/she is not sure what level the resident’s oxygen should be set at. The DON said if
staff notice the oxygen is not being administered per the physician’s orders the nurse
should change it to the physician’s ordered rate. The DON said he/she does not know why
the resident’s oxygen was not set per the physicians orders. The DON said the charge nurse
is expected to monitor oxygen setting for accuracy every shift.
3. Review of Resident #195’s Quarterly MDS, a federally mandated assessment tool, dated
03/01/18, showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-Verbal behaviors;
-Independent with transfers, dressing, eating, and toileting;
-Antipsychotic medication seven days a week and antianxiety medication one day a week.
Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory
but a fall risk and staff are directed to:
-Administer medication as ordered;
-Pharmacist and physician to review medications monthly and PRN;
-Monitor gait and transfer and alert nurse with changes;
-Supervise resident outdoors;
-Observe for effects of medication such as: drowsiness, restlessness, nervousness,
abnormal movements, [DIAGNOSES REDACTED], muscle cramps, increase in falls, and change in
mood or behavior;
-Complete labs as ordered and report to Medical Director.
Additional review showed staff did not implement fall prevention measures appropriate for
a resident with a history of falls with injury and did not review or update the care plan
after the resident fell on [DATE].
Review of the resident’s nurse’s notes, dated 04/02/18, showed staff documented the
resident arrived at the facility very confused with a soft cast on his/her left arm for a
fracture from a fall.
Review of the resident’s POS, dated 04/10/18, showed staff are directed to administer
650mg of Tylenol every six hours PRN (as needed).
Review of an incident report, dated 04/10/18, showed staff found the resident on the floor
and the resident said his/her legs gave way.
Review of the resident’s POS, dated 04/19/18, showed staff obtained an order for
[REDACTED].
Review of the resident’s nurse’s notes, dated 04/21/18, showed staff documented they found
a large greenish bruise on the resident’s right arm, a greenish bruise on the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
right shoulder, and a dark greenish bruise on the resident’s right ankle. Further review
showed staff documented they notified the physician and an x-ray was ordered and
completed.
Review of the resident’s nurse’s notes, dated 04/24/18, showed staff contacted the x-ray
agency for results. Further review showed the x-ray results showed the resident had a
right humeral head and neck (upper arm bone) fracture.
Additional review of the resident’s medical record showed five days passed between the
date of the ordered x-ray and the date staff obtained the x-ray results.
Review of the medication administration report (MAR), dated 04/01/18-04/30/18 showed staff
did not document the resident’s PRN pain medication.
During an interview on 04/25/18 at 10:23 A.M., the ADON said he/she noticed a bruise on
the resident’s right hand on 04/19/18 that he/she thought was from a blood draw. He/She
said the Nurse Practitioner (NP) assessed the resident and ordered an x-ray which came
back negative for breaks or fractures. He/She said the NP did not see any other bruises.
He/She said he/she did not know how the resident fractured his/her arm.
During an interview on 04/25/18 at 10:25 A.M., LPN F said the resident fell sometime this
month. He/She said when a resident falls staff complete an incident report and they are
kept in the DON’s office until completed and then returned to the resident’s chart. He/She
said the resident had x-ray results come back yesterday that showed the resident had an
arm fracture.
During an interview on 04/25/18 at 11:09 A.M., the DON said the resident’s arm fracture
was due to a fall on 04/10/18 and the incident report should have been back in the
resident’s chart.
During an interview on 04/25/18 at 3:08 P.M., LPN F said the resident’s PRN Tylenol should
be on the MAR and he/she does not know why it is not listed on there. He/She said they do
not do routine pain assessments only admission, quarterly, and post incident for 72 hours
unless the physician wants them to do it longer. He/She said the resident only complained
of pain once on his/her shift on Friday 04/20/18 when the resident’s sister came out and
told the LPN he/she was hurting. He/She said he/she asked the medication technician to
give the resident his/her Tylenol.
During an interview on 04/26/18 at 6:59 P.M., the DON said there are no interventions on
the resident’s care plan because he/she had not triggered yet. He/She said a resident
triggers for the fall prevention program after two falls. He/She said the resident had a
history of [REDACTED]. He/She said the resident’s care plan should have had more detailed
fall interventions due to his/her history of falls at their sister facility. The DON also
said the resident’s care plan should have been updated after he/she fell on [DATE] and all
medications should be listed on the MAR.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review facility staff failed to provide an
ongoing program of activities designed to meet the residents’ interest during the weekend
for 10 sampled residents (Residents #10, #13, #22, #26, #38, #44, #48, #63, #68, and #83).
The facility census was 99.
1. Review of the facility’s policy for the Director of Activity (AD), undated, showed the
AD is to assure that an ongoing program of activities is designed to meet, in accordance

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
with the comprehensive assessment, the interests and the physical, mental and psychosocial
well-being of each resident is maintained.
2. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the
following:
-Saturday, 1/6/18: family visits, movies available;
-Sunday, 1/7/18: family visits, movies available;
-Saturday, 1/13/18: family visits, movies available;
-Sunday, 1/14/18: family visits, movies available;
-Saturday, 1/20/18: family visits, movies available;
-Sunday, 1/21/18: family visits, movies available;
-Saturday, 1/27/18: family visits, movies available;
-Sunday, 1/28/18: 2 P.M. family visits, movies available.
Staff did not plan weekend activities other than church (not listed on calendar), family
visits, and movies available.
3. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the
following:
-Saturday, 2/3/18: family visits, movies available;
-Sunday, 2/4/18: family visits, movies available;
-Saturday, 2/10/18: family visits, movies available;
-Sunday, 2/11/18: family visits, movies available;
-Saturday, 2/17/18: family visits, movies available;
-Sunday, 2/18/18: family visits, movies available;
-Saturday, 2/24/18: family visits, movies available;
-Sunday, 2/25/18: 2 P.M. family visits, movies available.
Staff did not plan weekend activities other than church (not listed on calendar), family
visits, and movies available.
4. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the
following:
-Saturday, 3/3/18: family visits, movies available;
-Sunday, 3/4/18: family visits, movies available;
-Saturday, 3/10/18: family visits, movies available;
-Sunday, 3/11/18: family visits, movies available;
-Saturday, 3/17/18: family visits, movies available;
-Sunday, 3/18/18: family visits, movies available;
-Saturday, 3/24/18: family visits, movies available;
-Sunday, 3/25/18: P.M. family visits, movies available;
-Saturday, 3/31/18: family visits, movies available.
Staff did not plan weekend activities other than church (not listed on calendar), family
visits, and movies available.
5. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated assessment
tool, dated 03/08/18, showed staff assessed the resident as follows:
-Rarely or never understood;
-Physical and verbal behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of urine and occasionally incontinent of bowel.
Review of the resident’s care plan, dated 03/08/16, showed staff are directed to:
-Orient the resident to surroundings, routine, and environment;
-One on One interaction with the Activities Director;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
-Offer activities in the resident’s interest;
-Encourage attendance in activities.
Review of the resident’s medical record showed no Individual Resident Daily Activities
sheet for (MONTH) (YEAR).
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th,
10th, 11th, 12th, 14th, 15th, 17th, 18th, 20th, 22nd, 24th, 25th, 26th, 28th, 29th, 30th,
and 31st. Further review showed these dates were the weekend and the resident did not
attend activities on the weekends. Additional review showed the only resident activities
staff marked for the month were 11 room visits.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th,
8th, 10th, 11th, 12th, 14th, 15th, 17th, 18th, 20th, 22nd, 24th, 25th, 26th, 28th, 29th,
and 31st . Further review showed these dates were the weekend and the resident did not
attend activities on the weekends.
Observation on 04/23/18 at 11:51 A.M., showed the resident in bed. Staff did not engage
the resident in any activities.
Observation on 04/23/18 at 12:10 P.M., showed the resident in bed. Staff did not engage
the resident in any activities.
Observation on 04/23/18 at 1:10 P.M., showed the resident in his/her wheelchair in the
dining room. Staff did not engage the resident in any activities.
Observation on 04/23/18 at 3:04 P.M., showed the resident in his/her wheelchair in the TV
room. Staff did not engage the resident in any activities.
Observation on 04/24/18 at 3:26 P.M., showed the resident in bed. Staff did not engage the
resident in any activities.
Observation on 04/25/18 at 2:50 P.M., showed the resident in bed. Staff did not engage the
resident in any activities.
6. Review of Resident #13’s MDS, dated [DATE], showed facility staff assessed the resident
as follows:
-Cognitively intact;
-Required extensive assistance of two or more staff for bed mobility, transfers,
locomotion, dressing, toileting, and personal hygiene.
Review of the resident’s care plan, undated, showed staff are directed to do the
following:
-Encourage to attend activities for socialization;
-Explain to me about activities and make sure I understand;
-Continue to ask what he/she would like to do;
-Resident loves to participate and be included.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 6th, 7th, 13th,
14th, 20th, 21st, 27th, and 28th. Further review showed these dates were the weekend and
the resident did not attend activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 4th, 10th,
11th, 17th 18th, 24th, 25th. Further review showed these dates were the weekend and the
resident did not attend activities on the weekends.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd 4th, 10th, 11th,
17th, 18th, 24th, 25th, and 31st. Further review showed these dates were the weekend and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 39)
the resident did not attend activities on the weekends.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Very important to go outside;
-Somewhat important to participate in reading, music, be around animals, keep up with
news, do things with groups of people, and do his/her favorite activities;
-Required extensive assistance of two or more staff for bed mobility;
-Required total assistance of one staff for locomotion and dressing;
-Required total assistance of two or more staff for transfer, toilet use, and personal
hygiene.
During an interview on 4/24/18 at 8:48 A.M., the resident said there is noting to do on
the weekends and he/she wished there was something for him/her to do on the weekends. The
resident said he/she would like bingo or something like that. The resident said he/she
gets bored on the weekends especially if no family comes to visit him/her.
7. Review of Resident #22’s quarterly change Minimum Data Set (MDS), dated [DATE], showed
staff assessed the resident as follows:
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices.
Review of the resident’s care plan, dated 10/24/16, showed staff are directed:
-Encourage to attend all activities;
-Explain activities and make sure he/she understands;
-Continue to ask him/her what activities he/she enjoys.
Review of the resident’s quarterly change MDS, dated [DATE], showed staff assessed the
resident as follows:
-Unable to complete cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-Hospice care.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 1st, 2nd, 4th, 6th,
7th, 8th, 10th, 13th, 16th, 17th, 19th, 20th, 21st, 24th, 27th, 28th, and 30th. Further
review showed these dates were the weekend and the resident did not attend activities on
the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th,
10th, 11th, 13th, 15th, 17th, 18th, 20th, 22nd, 24th, 25th, 27th, 29th, 30th, and 31st.
Further review showed these dates were the weekend and the resident did not attend
activities on the weekend. Additional review showed the only resident activities marked
for the month were 13 room visits and one family visit.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th,
8th, 10th, 11th, 12th, 14th, 15th, 17th, 18th, 20th, 21st, 22nd, 24th, 25th, 26th, 28th,
29th, and 31st . Further review showed these dates were the weekend and the resident did
not attend activities on the weekend. Additional review showed the only resident
activities marked for the month were eight room visits and one family visit.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
Observation on 04/24/18 at 4:03 P.M., showed the resident in the dining room in his/her
wheelchair at a table.
Staff did not engage the resident in any activities.
Observation on 04/26/18 at 9:47 A.M., showed the resident in bed. Staff did not engage the
resident in any activities.
8. Review of Resident #26’s Quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Moderate cognitive impairment;
-No mood;
-No behaviors;
-Hallucinations and delusions;
-Limited assistance of one or more staff with bed mobility, dressing, eating, toileting,
and hygiene;
-No assistive devices;
-No antipsychotic medications.
Review of the resident’s care plan, dated 01/05/18, showed staff were directed to:
-Encourage to attend all activities;
-Explain activities and make sure he/she understands;
-Continue to ask him/her what activities he/she enjoys.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th,
7th, 9th, 12th, 13th, 14th, 16th, 17th, 19th, 20th, 21st, 23nd, 25th, 27th, 30th, and 31st
. Further review showed these dates were the weekend and the resident did not attend
activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 1st, 3rd, 4th, 6th,
7th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 22nd, 24th,
25th, 27th, 29th, 30th, and 31st. Further review showed these dates were the weekend and
the resident did not attend activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 6th, 8th, 10th,
11th, 14th, 15th, 16th, 17th, 18th, 21tst, 23rd, 24th, 25th, 28th, 29th, 30th, and 31st .
Further review showed these dates were the weekend and the resident did not attend
activities on the weekend.
Observation on 04/25/18 at 11:12 A.M., showed the resident sat on the couch at the end of
the hall with his/her walker. Staff did not engage the resident in any activities.
Observation on 04/26/18 at 9:48 A.M., showed the resident lay on his/her bed. Staff did
not engage the resident in any activities.
9. Review of Resident #38’s quarterly Minimum Data Set (MDS), dated [DATE], showed staff
assessed the resident as follows:
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Frequently incontinent of bladder and bowel.
Review of the resident’s care plan, dated 07/21/16, showed staff did not provide any
direction or interventions to address or encourage activities.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of bladder and bowel.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 1st, 2nd, 4th, 6th,
7th, 10th, 12th, 13th, 16th, 17th, 19th, 20th, 21st, 22nd, 24th, 25th, 26th, 27th, 28th,
29th, 30th, and 31st . Further review showed these dates were the weekend and the resident
did not attend activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th,
10th, 11th, 13th, 14th, 15th, 18th, 20th, 22nd, 24th, 25th, 27th, 29th, 30th, and 31st.
Further review showed these dates were the weekend and the resident did not attend
activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 6th, 8th, 10th,
11th, 12th, 15th, 17th, 20th, 22tst, 23rd, 24th, 25th, 26th, 28th, 29th, 30th, and 31st .
Further review showed these dates were the weekend and the resident did not attend
activities on the weekend.
Observation on 04/25/18 at 2:14 P.M., showed the resident in his/her wheelchair near
his/her room door. Further observation showed the resident alone and the TV off. Staff did
not engage the resident in any activities.
Observation on 04/26/18 at 9:44 A.M., showed the resident sit in his/her wheelchair near
his/her room door. Further observation showed the resident alone and the TV off. Staff did
not engage the resident in any activities.
10. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff are directed to:
-Encourage to attend all activities;
-Explain activities and make sure he/she understands;
-Continue to ask him/her what activities he/she enjoys.
Review of the resident’s Quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
-Limited one-person assist with transfers, dressing, toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 2nd, 4th, 6th, 7th,
9th, 11th, 12th, 14th, 16th, 17th, 19th, 20th, 21st, 23th, 25th, 27th, 28th, and 30th.
Further review showed these dates were the weekend and the resident did not attend
activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th,
10th, 11th, 13th, 15th, 17th,18th, 20th, 22nd, 24th, 25th, 27th, 29th, 30th, and 31st.
Further review showed these dates were the weekend and the resident did not attend
activities on the weekend.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 42)
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th,
7th, 9th, 11th, 13th, 15th, 16th,17th,18th 20th, 21st, 23rd, 24th, 25th, 27th, 28th, 29th,
30th, and 31st . Further review showed these dates were the weekend and the resident did
not attend activities on the weekend.
Observation on 04/25/18 at 9:11 A.M., showed the resident sat alone on the couch at the
end of the hall. Staff did not engage the resident in any activities.
Observation on 04/25/18 at 10:54 A.M., showed the resident sat alone on the couch at the
end of the hall. Staff did not engage the resident in any activities.
Observation on 04/25/18 at 3:18 P.M., showed the resident sat alone on the couch at the
end of the hall. Staff did not engage the resident in any activities.
Observation on 04/26/18 at 10:00 A.M., showed the resident in bed. Staff did not engage
the resident in any activities.
11. Review of Resident #48’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-[DIAGNOSES REDACTED].>-Severe cognitive impairment;
-Rarely or never understood;
-Trouble concentrating on things, such as reading newspaper or watching TV (nearly
everyday);
-Extensive assistance of one person with transfers, ambulation, and locomotion on/off
unit.
Review of the resident’s care plan, last updated 6/15/17, showed staff did not document
any specific interventions for activities.
Review of the resident’s significant change MDS, dated [DATE], showed staff assessed the
resident as follows:
-[DIAGNOSES REDACTED].
-Severe cognitive impairment;
-Unclear speech (slurred or mumbled words);
-Rarely or never understood;
-Trouble concentrating on things, such as reading newspaper or watching TV (nearly
everyday);
-Extensive assistance of one person with transfers, ambulation, and locomotion on/off
unit;
-Resident prefers snacks between meals.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document any weekend activities on the 3rd, 4th, 10th, 11th, 17th,
18th, 24th, and the 25th.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document any weekend activities on the 3rd, 4th, 10th, 11th, 17th,
18th, 24th, 25th, and the 31st.
Observation on 4/23/18 at 3:55 P.M., showed the resident sat in his/her wheelchair at the
dining table, mumbling words to him/herself and moved his/her hands back and forth across
the table. Staff did not engage the resident in any activities.
During an interview on 4/26/18 at 10:54 A.M., CNA D said the resident does not attend any
activities on the first floor. He/She said staff sometimes give the resident towels to
fold to keep his/her hands busy, but he/she cannot really participate in scheduled
activities.
12. Review of Resident #63’s MDS, dated [DATE], showed staff assessed the resident as
follows:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 43)
-Moderate cognitive impairment;
-Somewhat important to read, listen to music, keep up with the news, participate in
his/her favorite activities, and go outside;
-Required extensive assistance of two or mores staff for bed mobility, transfers,
locomotion, dressing and personal hygiene.
Review of the residents care plan, undated, showed staff are directed to do the following:
-Encourage to attend all activities;
-Explain activities and make sure he/she understands;
-Continue to ask him/her what activities he/she enjoys.
Review of the residents (MONTH) (YEAR), Individual Resident Daily Activities sheet, showed
staff did not document the resident attended activities on the 6th, 7th, 13th, 14th, 20th,
21st, 27th, and 28th. Further review showed these dates were the weekend and the resident
did not attend activities on the weekend.
During an interview on 4/24/18 at 9:15 A.M., the resident said there is not much to do on
the weekends and it gets boring.
13. Review of Resident #68’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severe cognitive impairment;
-Somewhat important to read, listen to music, keep up with the news, and participate in
religious services;
-Required limited assistance of one staff for transfers, toileting, and personal hygiene.
Review of the resident’s care plan, undated, showed staff were directed to do the
following:
-Encourage to attend all activities;
-Explain activities and make sure he/she understands;
-Ask what activities he/she would enjoy;
-Encourage resident to participate as much as possible;
Review of the resident’s Annual Activity Progress notes, dated (MONTH) (YEAR), showed the
resident usually enjoys bingo, socializing, television/radio, movies, pet visits, unit
activities, entertainment, trivia/current, and music.
Review of the residents (MONTH) (YEAR), Individual Resident Daily Activities sheet, showed
staff did not document the resident attended activities on the 6th, 7th, 13th, 14th, 20th,
21st, 27th, and 28th. Further review showed these dates were the weekend and the resident
did not attend activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd, 4th, 10th,
11th, 17th 18th, 24th, 25th. Further review showed these dates were the weekend and the
resident did not attend activities on the weekend.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document the resident attended activities on the 3rd 4th, 10th, 11th,
17th, 18th, 24th, 25th, and 31st. Further review showed these dates were the weekend and
the resident did not attend activities on the weekend.
14. Review of Resident #83’s admission MDS, dated [DATE], showed staff assessed the
resident as follows:
-[DIAGNOSES REDACTED].
-Modified independence-some difficulty in new situations only;
-No behaviors or rejection of care;
-Somewhat important to have books, newspapers, and magazines to read, and listen to music;
-Independent with all ADL’s;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 44)
-Requires supervision of one person with locomotion off unit.
Review of the resident’s care plan, dated 3/12/18, showed staff are directed:
-Remind resident of scheduled activity that involve memory challenge;
-Orient to surroundings, routine activities;
-Resident cannot care for himself/herself, confused, depressed, suicidal, tearful and
[MEDICAL CONDITION];
-Needs assist of all ADLs;
-Encourage to attend all activities;
-Continue to ask what activities the resident would enjoy;
-Isolative to room, please try to get him/her to join in.
Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR),
showed staff did not document any weekend activities on the 17th, 18th, and the 31st.
During an interview on 4/23/18 at 2:10 P.M., the resident said he/she has been at the
facility for about three weeks now, and there is not much to do around here.
Observation and interview on 4/23/18 at 3:54 P.M., showed the resident sat in his/her
wheelchair at the dining table. The resident said he/she is an outdoors person, so
anything outside would be great for him/her to enjoy, even just the courtyard.
15. During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) L said
on the weekends there is church in the activity rooms and television. CNA L said CNAs help
set up the activities, but they do not document activities are provided on the weekends.
During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said he/she
believes there are activities on the weekend but he/she is not sure if staff document
them.
During an interview on 4/26/18 at 11:30 A.M., LPN F said there are activities on the
weekends and it depends on the activity as to if the CNAs are responsible or the nurses.
He/She said they are not sure if they document that activities are done but he/she does
not document on the activity part in the chart.
During an interview on 4/26/18 at 11:52 A.M., CNA D said staff do not provide activities
on the weekends. He/She said sometimes the CNAs put on the TV for the resident but he/she
is not sure if they document activities anywhere.
During an interview on 4/26/18 at 6:06 P.M., LPN B said he/she has worked every other
weekend for the past year, and has never seen any weekend activities held for the
residents on the second floor.
During an interview on 4/26/18 at 6:19 P.M., CNA C said there are no scheduled activities
on the weekends, but staff does stuff with the residents because they need something to
do. He/She said the AD is only at the facility Monday through Friday.
During an interview on 04/26/18 at 6:26 P.M., the AD said the Restorative Aide conducts
activities on the second floor. The AD said there are no staff-led activities on the
weekends, but the nurses and CNAs help with activities, and provide coloring materials,
cards, and movies for residents to watch. The AD said he/she leaves lots of games out on
the weekends, but does not know if the residents play them. The AD said all residents are
allowed downstairs for activities if they want to participate. Church services are held on
Sundays, and the volunteers document on paper which residents attended.
During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said he/she
expects staff to document activities on the activity documentation form.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to ensure
residents’ environment remained free from accident hazards, when they propelled two
residents (Resident #29 and #48) without foot pedals, failed to properly transfer one
resident (Resident #81), and failed to put fall prevention measures in place for one
resident (Resident #195) of 20 sampled residents in a manner to prevent accidents.
Facility staff also failed to ensure the residents’ environment remained free of accident
hazards when they failed to ensure razors and chemicals were not accessible to residents.
The facility census was 99.
1. Review of the facility’s policy on Wheelchair use, updated 11/2001, showed staff are
directed:
-The purpose is to provide mobility for the non-ambulatory resident with safety and
comfort;
-Fold foot rests up out of the resident’s way for safety, and do not remove foot rests
unless the resident uses feet on floor to enable mobility;
-Lower foot rests and place resident’s feet on foot rest if used. Position feet and legs
in good body alignment. Elevate legs as ordered;
-Encourage and instruct resident in proper procedures for safely propelling the
wheelchair.
2. Review of Resident #48’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 5/13/17, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Limited assistance of one person with bed mobility, and transfer;
-Extensive assist of one person with ambulation, locomotion on/off unit, dressing, toilet
use, and personal hygiene;
-Did not use any mobility devices.
Review of the resident’s care plan for fall intervention, last updated 6/15/17, showed
staff are documented the resident has impaired ambulation, and directed staff:
-Use wheelchair for mobility as a result of Dementia;
-Resident uses high back wheelchair with two foot rests;
-Resident needs assistance.
Review of the resident’s comprehensive MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment;
-Extensive assistance of one person with ambulation, locomotion on and off unit, dressing,
toilet use, and personal hygiene;
-Did not use any mobility devices.
Observation on 4/26/18 at 10:45 A.M., showed Certified Nursing Assistant (CNA) E propelled
the resident in his/her high back wheelchair without foot pedals from the dining room to
his/her room, while his/her feet slid along the floor.
Observation and interview on 4/26/18 at 10:54 A.M., showed CNA D and CNA E transferred the
resident from the chair to the bed, provided perineal care, and transferred the resident
back to the wheelchair. CNA D began to propel the resident back to the dining room. CNA D
said the resident does have foot rests for his/her wheelchair, but staff did not know
where to find them at the moment. The CNA said staff are expected to push the resident in
his/her wheelchair with the foot pedals to prevent an accident from his/her feet jamming
on the floor.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 46)
3. Observation on 4/24/18 at 10:09 A.M., showed the Director of Nursing (DON) propelled an
unidentified resident down the 100 hallway without foot pedals. Observation showed the
resident’s feet slid on the floor.
4. Review of Resident #29’s quarterly Minimum Data Set (MDS), dated [DATE], showed staff
assessed the resident as follows:
-Resident is rarely/never understood;
-No behaviors;
-Limited assistance of one or more staff for transfers, dressing, eating, toileting, and
hygiene;
-Always incontinent of bladder and bowel.
Observation on 4/24/18 at 12:47 P.M., showed CNA D propelled Resident #29 down the 200
hallway without foot pedals. Observation showed the residents feet slid on the floor.
5. During an interview on 4/25/18 at 3:54 P.M., CNA H said staff have been trained to make
sure the wheelchair is locked before they propel residents in wheelchairs but that is it.
He/She said if he/she was pushing a resident and his/her feet dragged the floor he/she
would stop and get foot pedals because if not the residents feet could get caught.
During an interview on 4/26/18 at 9:18 A.M., CNA D said staff should make sure the
wheelchair is locked when a resident sits down and unlocked before staff starts pushing.
He/She said you should not push a resident without foot pedals. He/She said staff has not
had any training about pushing residents without foot pedals. He/She said he/she has
pushed residents without foot pedals because he/she wants to help them and was never told
not to do it.
During an interview on 4/26/18 at 9:48 A.M., LPN F said staff should not propel a resident
in a wheelchair without foot pedals because their feet could get caught and they could
fall out. He/She said all staff was in-serviced on the dangers of pushing a resident
without foot pedals.
During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said residents
should have foot pedals on when staff propel them.
6. Review of the facility’s records showed the facility did not have a policy on resident
transfers via mechanical lifts (hoyer or sit-to-stand).
7. Review of Resident #81’s quarterly MDS dated [DATE], showed staff assessed the resident
as follows:
-Moderate cognitive impairment;
-Independent with bed mobility;
-Limited assistance of one person with transfers, and toilet use;
-Uses wheelchair.
Review of the resident’s care plan for fall interventions, last updated 4/2018, showed
staff are directed:
-Resident is on the falling star program (usually implemented after a resident falls
twice);
-Requires hoyer lift (mechanical sling style lift) with two-person assistance;
-Resident uses geri/Broda chair (an adjustable tilt and recline wheelchair);
-Geri/Broda chair reclined when resident is up;
-Resident takes [MEDICAL CONDITION] medications;
-Fall mat at bedside;
-Wear non-skid footwear.
Observation and interview on 4/25/18 at 9:03 A.M., showed CNA D and CNA O transferred the
resident from his/her Broda chair with a sit-to-stand mechanical lift. Observation showed
the resident did not hold on to the lift during transfer, and pulled both his/her legs
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 47)
upwards behind him/her. Observation showed the resident’s torso (chest, upper abdomen, and
back) hung from the sling on the lift, while the CNAs instructed him/her to help them and
stand. The CNAs said the resident requires assistance of two staff for quite some time
now, due to a decline in his/her activities of daily living (ADLs). The CNAs did not
properly transfer the resident as directed by the care plan to prevent accident hazards.
During an interview on 4/25/18 at 10:30 A.M., Licensed Practical Nurse (LPN) F said the
resident has not been able to ambulate since he/she started working at the facility back
in 2/2017.
Observation on 4/26/18 at 10:32 A.M., showed the resident lay on his/her right side on the
floor in his/her room next to the Broda chair, with his/her feet under the bed.
Observation showed the Broda chair in the upright position.
During an interview on 4/26/18 at 10:38 A.M., CNA O said staff had left the resident
sitting upright in his/her Broda chair inside the room unattended.
During an interview on 4/26/18 at 5:51 P.M., LPN B said the CNAs have a booklet that
instructs them on the care and level of assistance residents need. The LPN said staff are
expected to transfer the resident with a hoyer lift and two staff because he/she cannot
stand. The LPN said staff should not use a sit-to-stand lift to transfer the resident.
During an interview on 4/26/18 at 6:19 P.M., CNA C said staff should transfer the resident
with two staff and a gaitbelt because he/she stands with transfers.
During an interview on 4/26/18 at 7:00 P.M., the DON said staff are expected to use two
people to transfer the resident with a gaitbelt, but he/she can be transferred with a
hoyer lift because he/she does not always bear weight. The DON said if the care plan
directs staff to use a hoyer, then he/she expects staff to use a hoyer lift.
8. Review of Resident #195’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Moderate cognitive impairment;
-Verbal behaviors;
-Independent with transfers, dressing, eating, and toileting;
-Antipsychotic medication seven days a week and antianxiety medication one day a week.
Review of the resident’s nurse’s notes, dated 04/02/18, showed the resident arrived at the
facility very confused with a soft cast on his/her left arm for a fracture from a fall.
Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory
but a fall risk and staff are directed to:
-Administer medication as ordered;
-Pharmacist and physician to review medications monthly and PRN;
-Monitor gait and transfer and alert nurse with changes;
-Supervise resident outdoors;
-Observe for effects of medication such as: drowsiness, restlessness, nervousness,
abnormal movements, [DIAGNOSES REDACTED], muscle cramps, increase in falls, and change in
mood or behavior;
-Complete laboratory tests as ordered and report to Medical Director.
Additional review of the care plan showed staff did not implement fall prevention measures
appropriate for a resident with a history of falls with injury or update the care plan
after the resident fell on [DATE].
Review of an incident report, dated 04/10/18, showed staff documented they found the
resident on the floor and he/she said his/her legs gave way.
Review of the resident’s POS, dated 04/19/18, showed staff obtained an order for
[REDACTED].>Review of the resident’s nurse’s notes, dated 04/21/18, showed staff found
a large greenish bruise on the resident’s right arm, a greenish bruise on the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 48)
right shoulder, and a dark greenish bruise on the resident’s right ankle. Further review
showed the physician was notified and an x-ray was ordered and completed.
Review of the resident’s nurse’s notes, dated 04/24/18, showed staff contacted the x-ray
agency for results. Further review showed the x-ray results showed the resident had a
humeral head and neck fracture (upper arm fracture).
During an interview on 04/25/18 at 10:25 A.M., LPN F said the resident fell sometime this
month. He/She said when a resident falls, staff complete an incident report and they are
kept in the Director of Nursing (DON’s) office until completed and then returned to the
resident’s chart. He/She said the resident did report pain in his/her arm to him/her on
04/19/18 and he/she told the medication technician to check on him/her. He/She said staff
received an x-ray report yesterday (4/24/18) that showed the resident had an arm fracture.
During an interview on 04/26/18 at 6:59 P.M., the DON said there are no interventions on
the resident’s care plan because he/she had not triggered yet. He/She said a resident
triggers for the fall prevention program after two falls. He/She said the resident had a
history of [REDACTED]. He/She said the resident’s care plan should have had more detailed
fall interventions due to his/her history of falls at their sister facility. He/She said
the resident’s care plan should have been updated after he/she fell on [DATE].
9. Review of the facility’s Director of Housekeeping and Laundry Services job discription,
undated, showed the director of housekeeping and laundry services is directed to do the
following:
-To make daily rounds to assure that facility is maintained in a clean and safe manner;
-Assure that housekeeping and laundry personnel follow established safety regulations in
used of equipment and supplies at all times.
10. Observation on 4/23/18 at 12:05 P.M., showed the room across from resident room [ROOM
NUMBER] unlocked and unattended. Further observation showed the room contained one gallon
of floor polishing solution, spray bottles of floor cleaner, spray bottles of floor finish
restoring solution, three one gallon jugs of multisurface cleaner, one unlabeled chemical
spray bottle with clear liquid, one unlabeled chemical spray bottle with blue liquid, one
unlabeled chemical spray bottle with green liquid, three spray bottles of spray floor buff
solution, one bottle of cleaner and disinfectant. Further observation showed all labeled
bottles with a warning to keep out of reach of children. Observation showed residents
walked past the room.
Observation on 4/24/18 at 11:38 A.M., showed the room continued to be unlocked and
unattended. Further observation showed the room continued to contain the same chemicals
and residents walked by the room.
Observation on 4/24/18 at 4:25 P.M., showed the room continued to be unlocked and
unattended. Further observation showed the room continued to contain the same chemicals
and residents walked by the room.
Observation on 4/25/18 at 2:50 P.M., showed the room continued to be unlocked and
unattended. Further observation showed the room continued to contain the same chemicals
and residents walked by the room.
Observation on 4/26/18 at 9:25 A.M., showed the room continued to be unlocked and
unattended. Further observation showed the room continued to contain the same chemicals
and residents walked by the room.
11. Observation on 04/23/18 at 3:25 P.M., showed the shower room on the 200 hall unlocked
and unattended. Further observation showed the cabinet was unlocked and the sharps
container overflowed with used razors. Additional observation showed residents in their
rooms with their doors open across the hall.
12. During an interview on 04/25/18 at 3:54 P.M., CNA H said sharps and chemicals should
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 49)
be stored in the dirty utility room and sharps container. He/She said the dirty utility
room is left locked up.
During an interview on 4/26/18 at 11:10 A.M., CNA L said chemicals and sharps should be
stored behind locked doors inaccessible to residents. CNA L said he/she was not sure why
the chemicals were not locked up.
During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said
chemicals and sharps should be stored behind locked doors inaccessible to residents. LPN M
said he/she was not sure why the chemicals were not locked up.
During an interview on 4/26/18 at 11:30 A.M. LPN F said sharps and chemicals are to be
stored behind locked doors.
During an interview on 4/26/18 at 11:52 A.M. CNA D said sharps and chemicals should be
kept in the dirty utility room and locked.
During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said sharps and
chemicals should be kept in the housekeeping closets and behind a locked door.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review facility staff failed to complete
required assessments and maintain proper documentation for the use of side rails for three
residents (Resident’s #13, #63, and #68). The facility census was 99.
1. Review of the facility’s Restraints and Enabler policy and procedure, reviewed (YEAR),
showed staff are directed to do the following:
-Complete the Device Decision Guide to determine if it is appropriate to place the
resident in a restraint or enabler;
-Any resident that is identified to have a need for a enabler is to be referred to therapy
department;
-If it is determined there is a need for a enabler the resident and/or responsible party
will meet for a care plan meeting to allow for informed consent regarding the type of
device to be used, when the device will be used, what medical symptom is being treated,
and what way the device will improve the resident’s quality of life;
-A physician order [REDACTED]. of life;
-On a quarterly basis, the care plan team will meet to determine if a restraint reduction
and elimination is appropriate. The Device Decision Guide will be repeated during this
time;
-Any trial reductions will be addressed in the care plan and the nursing department will
document the resident’s response to the reduction a minimum of daily until the care plan
team determines the success or failure of the reduction attempt.
2. Review of Resident #13’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 3/9/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Required extensive assistance of two or more staff for bed mobility;
-Required total assistance of one staff for locomotion and dressing;
-Required total assistance of two or more staff for transfer, toilet use, and personal

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 50)
hygiene.
Review of the resident’s side rail screening, dated 3/9/18, showed staff documented the
resident will have two side rails to be used as an enabler to promote independence and the
resident has expressed a desire to have the side rails raised while in bed.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s medical record showed it did not contain an entrapment assessment
or an informed consent for the use of side rails.
Review of the resident’s nurse’s notes, dated (MONTH) (YEAR) through (MONTH) (YEAR),
showed staff did not document information related to the resident’s use of side rails or
wish for side rails.
Observation on 4/24/18 at 8:57 A.M., showed the resident in bed with two full side rails
raised.
Observation on 4/25/18 at 9:22 A.M., showed the resident in bed with two full side rails
raised.
Observation on 4/26/18 at 9:18 A.M., showed the resident in bed with two full side rails
raised.
3. Review of the Resident #63’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Moderate cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility, transfers,
locomotion, dressing, and personal hygiene.
Review of the resident’s side rail screen, dated 4/24/18, showed staff documented the
resident will have one side rail to assist the resident in reposition and transfer.
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order to have one side rail
to promote independence as an enabler with an order date of 4/24/18. Further review showed
the order for side rails did not contain a [DIAGNOSES REDACTED].
Review of the resident’s medical record showed it did not contain an entrapment assessment
or an informed consent for the use of side rails.
Review of the resident’s nurses notes, dated (MONTH) (YEAR) through (MONTH) (YEAR), showed
staff did not document information related to the resident’s use of side rails or wish for
side rails.
Observation on 4/23/18 at 2:27 P.M., showed the resident in bed with two quarter side
rails raised, one on each side of the head of bed.
Observation on 4/25/18 at 2:51 P.M., showed the resident in bed with two quarter side
rails raised, one on each side of the head of bed.
Observation on 4/26/18 at 9:24 A.M., showed the resident in bed with two quarter side
rails raised, one on each side of the head of bed.
4. Review of Resident #68’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severe cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility;
-Required total assistance of two or more staff for transfers.
Review of the resident’s side rail screen, dated 3/16/18, showed staff documented the
resident will have one side rail to assist the resident in reposition and transfer and
resident expressed a desire to have side rails raised while in bed.
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order to have left side side
rail for an enabler with an order date of 4/24/18. Further review showed the order for
side rails did not contain a [DIAGNOSES REDACTED].
Review of the resident’s medical record showed it did not contain an entrapment assessment
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 51)
or an informed consent for the use of side rails.
Review of the resident’s nurses notes, dated (MONTH) (YEAR) through (MONTH) (YEAR), showed
staff did not document information related to the resident’s use of side rails or wish for
side rails.
Observation on 4/25/18 at 9:46 A.M., showed the resident in bed with one half side rail up
on the resident’s left side of the bed.
Observation on 4/25/18 at 2:48 P.M., showed the resident in bed with one half side rail up
on the resident’s left side of the bed.
5. During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) L said if
the resident’s bed has siderails attached to them they should have the side rails raised
while in bed.
During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said
residents with physician orders [REDACTED]. LPN M said staff complete side rail
assessments but he/she is not sure if they complete entrapment assessments or obtain
informed consents. LPN M said residents with side rails should have a physician’s orders
[REDACTED].
During an interview on 4/26/18 at 11:30 A.M., LPN F said residents who need side rails
should have a physician order [REDACTED]. LPN F said he/she is not sure if a informed
consent should be obtained. He/She said entrapment assessments are done by the Director of
Nursing (DON).
During an interview on 4/26/18 at 1:48 P.M., the Quality Assurance Nurse said facility
staff is in the process of developing a policy for entrapment assessments, and does not
currently have any entrapment assessments documented.
During an interview on 4/26/18 at 12:55 P.M., the Assistant Director of Nursing (ADON)
said they do not have side rail consents for the use of side rails.
During an interview on 4/26/18 at 6:56 P.M., the DON said if the resident used siderails,
staff should obtain an informed consent, a physician’s orders [REDACTED]. The DON said
staff should have removed Resident #63’s side rails because he/she doesn’t use side rails.

F 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the
director of nurses on a full time basis.

Based on interview and record review, facility staff failed to provide the services of a
Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week.
The facility census was 99.
Review of the facility’s Staffing Pattern, reviewed (MONTH) (YEAR), showed for a census of
96 residents, provisions will be made for:
-Director of Nursing (DON): 40 hours per week;
-Assistant DON: 40 hours per week;
-Program Manager (PM): 40 hours per week;
-Two Licensed Practical Nurse/RN: total of 16 hours each shift (day, evening, and night).
Review of the facility’s Licensed Nurses staffing schedule, dated (MONTH) (YEAR), showed
staff did not document an RN was scheduled to work for the month of April.
Review of the facility’s RN staff time sheets, dated 4/1/18 through 4/25/18, showed the
total hours worked between the only two staffed RNs (the DON and the PM), on the following

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 52)
dates:
-Saturday 4/7/18, 0 hours;
-Sunday 4/8/18, 0 hours;
-Tuesday 4/10/18, 7.50 hours;
-Thursday 4/12/18, 7.25 hours;
-Saturday 4/14/18, 0 hours;
-Sunday 4/15/18, 0 hours;
-Saturday 4/21/18, 0 hours;
-Sunday 4/22/18, 0 hours.
During an interview 4/26/18 8:28 A.M., the Administrator said the PM is the full time RN
who works Monday through Friday. The DON serves as the RN on weekends, but sometimes
he/she is only in the building for a couple hours at a time. The PM said he/she does not
work on the weekends.
During an interview on 4/26/18 at 9:05 A.M., Certified Medication Technician (CMT) A said
he/she does staffing and other than the DON, the only RN on staff is the PM, who works
Monday through Friday. The DON is not scheduled/staffed to work on the weekends. The CMT
said the facility does not have an RN scheduled/staffed to work Saturdays and Sundays.
During an interview on 4/26/18 at 11:10 A.M., the DON said he/she sometimes enter the
facility on the weekends for about two to three hours, but not eight hours. He/She said
the facility did not have an RN scheduled to work the weekends at this time.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to develop and implement
policies and procedures to address the appropriate timeframes for the different steps in
the Medication Regimen Review (MRR) process to identify irregularities and minimize or
prevent adverse consequences for two residents (Resident #48 and #68), of five sampled
residents selected for medication management. The facility census was 99.
1. Review of the facility’s records showed it did not contain a policy to address
appropriate timeframes for the different steps in the MRR process.
2. Review of Resident #48’s medical records, showed staff documented the resident was
admitted to the facility on [DATE], with [DIAGNOSES REDACTED].
Review of the resident’s Care Plan for [MEDICAL CONDITION], last updated 8/8/16, showed
staff documented the resident had [DIAGNOSES REDACTED].
-Administer [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] and [MEDICAL
CONDITION] disorder), [MEDICATION NAME] (medication to treat depression), and Quetiapine
(medication to treat [MEDICAL CONDITIONS] disorder and depression);
-Document behaviors as they occur;
-Abnormal Involuntary Movement Scale (AIMS) assessment on admission, quarterly and with
significant changes;
-Pharmacist and Physician will evaluate and document continued use of medications, and
taper medications monthly as indicated.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 11/14/17, showed staff assessed the resident as follows:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 53)
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
-Received Antipsychotics and Antidepressant medications daily during the seven-day review
period;
-Received Antipsychotics on a routine basis, with last attempted gradual dose reduction
(GDR) 10/16/17.
Review of the MRR dated 12/7/17, showed the Consultant Pharmacist documented:
-[MEDICATION NAME] 15 milligrams (mg) by mouth (PO) at bedtime (QHS) for unintentional
weight loss (since 4/7/17);
-Even though this medication is being used for unintentional weight loss, CMS regulations
require that all antidepressants be reviewed for a gradual dose reduction twice during the
1st year, then yearly thereafter in an attempt to find the lowest effective dose. With
this in mind:
-Please consider a dose reduction to [MEDICATION NAME] 7.5mg PO QHS (or consider
discontinuation using a titration).
Review of the MRR dated 1/9/18 showed the Consultant Pharmacist documented no
irregularities found.
Review of the resident’s physician’s orders [REDACTED].
Review of the MRR dated 2/5/18, showed the Consultant Pharmacist again documented:
-[MEDICATION NAME] 15mg PO QHS for unintentional weight loss (since 4/7/17);
-Even though this medication is being used for unintentional weight loss, CMS regulations
require that all antidepressants be reviewed for a gradual dose reduction twice during the
1st year, then yearly thereafter in an attempt to find the lowest effective dose. With
this in mind:
-Please consider a dose reduction to [MEDICATION NAME] 7.5mg PO QHS (or consider
discontinuation using a titration).
Review of the resident’s POS, dated 2/1/18 through 2/28/18, showed on 2/6/18, the
physician ordered a dose reduction for [MEDICATION NAME] to 7.5mg PO QHS. Staff did not
document a physician’s response until two months after the Consultant Pharmacist’s
recommendation.
Review of the MRR, dated 3/13/18, showed the Consultant Pharmacist documented please
consider checking the following labs (laboratory blood tests) :
-CMP (Complete Metabolic Panel- blood test to assess the status of a person’s metabolism),
CBC (Complete Blood Count- blood test to assess the cells that make up your blood), every
6 months;
-FLP (Fasting Lipid Panel-measures the level of specific cholesterol in the blood),
Vitamin D, TSH (a blood test that measures the [MEDICAL CONDITION] hormone levels), and
HbA1C (measures how well diabetes is controlled) yearly.
Review of the MRR, dated 4/5/18, showed the Consultant Pharmacist documented:
-Quetiapine 50mg PO every morning (QAM) and 150mg PO at bedtime (QHS) since 10/16/17;
-CMS regulations require that antipsychotics be reviewed for a gradual dose reduction in
an attempt to find the lowest effective dose;
-With this in mind: Please consider a dose reduction to Quetiapine 50mg QAM and 100mg PO
QHS.
Review of the resident’s POS, dated 4/1/18 through 4/26/18, showed the following orders:
-Quetiapine 100mg (take with 50mg=150mg) at bedtime for [MEDICAL CONDITION];
-Quetiapine 50mg tab every morning and at bedtime for [MEDICAL CONDITION];
-CMP, CBC, FLP, Vitamin D, TSH, and HbA1C ordered 4/18/18.
Staff did not document a physician’s response to the recommended laboratory tests until 30
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 54)
days later, and did not document a response to the dose reduction of [MEDICATION NAME] as
recommended by the Pharmacist on 4/5/18 (three weeks prior).
During an interview on 4/26/18 at 1:29 P.M., the Assistant Director of Nursing (ADON) said
the Psychiatrist is scheduled to be at the facility the following week, but he/she was
unsure exactly which day. The ADON said the MRR form was faxed to the Psychiatrist’s
office for review.
3. Review of Resident #68’s medical record showed staff documented the resident was
admitted on [DATE], and has [DIAGNOSES REDACTED].
Review of the resident’s MDS, dated [DATE], showed facility staff assessed the resident as
follows:
-Severe cognitive impairment;
-diagnosed with [REDACTED].
-No behaviors;
-Did not receive antianxiety medications during the assessment period.
Review of the MRR, dated 2/1/18, showed the Consultant Pharmacist documented:
-[MEDICATION NAME] (anxiety medication) 2 mg/ml (0.25mL) by mouth every four as needed for
anxiety;
-The patient has not received this medication thus far. The resident has an as needed
(PRN) order for [MEDICATION NAME] dated 9/1/17. CMS regulation states as needed [MEDICAL
CONDITION] orders must be limited to 14 days unless the prescribing practitioner believes
it is appropriate for the as needed order to extend beyond the 14 days and documents the
rationale in a progress note and indicates the duration for the order.
-Please discontinue this medication at this time:
-A progress note was created and new prescription written that includes quantity and
duration.
Further review of the MRR dated 2/1/18, showed the physician marked disagree and signed
the paper. The Physician did not document a rationale for declining the recommendation.
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
During an interview on 4/26/18 at 12:55 P.M., the ADON said he/she is not sure why there
was not a rationale for the declination of the pharmacy recommendation.
4. During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said
he/she is not sure what the pharmacy review process is.
During an interview on 4/26/18 at 11:30 A.M., LPN F said he/she is not sure about the
pharmacy review process. He/She said the pharmacist completes them and then sends the ADON
notes, who forwards them to the physician.
During an interview on 4/26/18 at 12:55 P.M., the ADON said the pharmacist comes once a
month and reviews the resident’s medications. Then the consultant pharmacist prints the
MRR and the ADON faxes them to the physician. The ADON said if he/she gets an order from
the physician regarding the MRR then he/she or the nurse whom he/she delegates will note
it in the resident’s chart. The ADON said if he/she does not hear back from the physician,
staff will call and try to get telephone orders and have the physician sign the form when
he/she comes back in the facility. The ADON said he/she tries to get the physician to sign
the sheet or write a rational if they disagree. He/She said he/she knew that the physician
was supposed to sign and write a rationale, but he/she tries to encourage them to sign and
write an rationale. The ADON said he/she is responsible to ensure this is done.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 55)
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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to obtain an appropriate
[DIAGNOSES REDACTED].#44). Additionally facility staff failed to obtain stop dates of 14
days or less on as needed (PRN) [MEDICAL CONDITION] medications (chemical substance that
changes brain function and results in alterations in perception, mood, consciousness or
behavior), for two residents (Resident #22 and #44). The facility census was 99.
1. Review of the facility’s Rights of Medication Administration policy, undated, showed
staff are directed to:
-Identify the resident;
-Check the medication;
-Check the dose;
-Check the route of administration;
-Check the time the medication is supposed to be given;
-Document administration immediately;
-Confirm the reason for use;
-Ensure a proper response to the medication.
2. Review of the facility’s Physical and Chemical Restraint policy, (YEAR), showed staff
are directed to ensure residents remain free from chemical restraints by:
-Ensuring restraints are used to treat a medical symptom;
-Reviewing the resident’s condition, circumstances, and environment along with their
medical symptom;
-Documenting any trial reductions in the resident’s care plan and charting the resident’s
response to the reduction daily.
3. Review of Resident #22’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument, dated 01/03/18, showed staff assessed the resident as follows:
-Unable to complete cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-No assistive devices;
-Hospice.
Review of the resident’s physician’s orders [REDACTED]. Further review showed staff did
not document information in the resident’s medical record to support extending the
medication beyond 14 days.
During an interview on 04/26/28 at 5:57 P.M., Licensed Practical Nurse (LPN) J said all
medication, especially [MEDICAL CONDITION] medications, should include a corresponding
[DIAGNOSES REDACTED]. He/She said PRN [MEDICAL CONDITION] medication orders should include
a stop date within 14 days.
During an interview on 04/26/18 at 6:59 P.M., the Director of Nursing (DON) said nursing
staff should make sure all [MEDICAL CONDITION] medications include a [DIAGNOSES REDACTED].
4. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted
on [DATE].
Review of the resident’s care plan, dated 11/21/17, showed staff did not provide direction
or interventions to address the resident taking [MEDICAL CONDITION] medication.
Review of the residents’ MDS, dated [DATE], showed staff assessed the resident as follows:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 56)
-Severe cognitive impairment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, dressing, eating,
toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s nurses notes, dated 01/16/18, showed staff called the physician
after the resident became upset about his/her pets and his/her trial date and threw a
medical chart at the nurse. The staff were ordered to administered a one time dose of 20mg
of [MEDICATION NAME] intravenously (by injection).
Review of the resident’s nurse’s notes, dated 02/07/18, showed the resident was upset
about his/her new roommate and he/she yelled and banged his/her hands on the nurse’s
station.
Review of the resident’s POS, dated 02/07/18, showed staff are directed to administer by
injection 20mg of [MEDICATION NAME] (antipsychotic) to the resident daily PRN for
aggressive behavior for 90 days.
Review of the National Institute of Health’s U.S. National Library of Medicine showed,
[MEDICATION NAME] (Ziprasidone), is used to treat the symptoms of [MEDICAL CONDITION] (a
mental illness that causes disturbed or unusual thinking, loss of interest in life, and
strong or inappropriate emotions). It is also used to treat episodes [MEDICAL
CONDITION](frenzied, abnormally excited or irritated mood) or mixed episodes (symptoms
[MEDICAL CONDITION] depression that happen together) in patients with [MEDICAL CONDITION]
disorder (manic [MEDICAL CONDITION]; a disease that causes episodes of depression,
episodes of mania, and other abnormal moods). Ziprasidone is in a class of medications
called atypical antipsychotics. It works by changing the activity of certain natural
substances in the brain.
Further review of the resident’s medical record showed staff did not document a [DIAGNOSES
REDACTED].
Review of the resident’s Quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Cognitively intact;
-Mood feeling tired/moving slow several days a week;
-No behaviors;
-Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene;
-Antidepressant medication seven days a week.
Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer a
2.5mg tablet of [MEDICATION NAME] (antipsychotic) to the resident at bedtime. Further
review showed staff did not document a corresponding medical diagnosis.
Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer a
1mg tablet of [MEDICATION NAME] to the resident every morning. Further observation showed
staff did not document a corresponding medical diagnosis.
Review of the National Institute of Health’s U.S. National Library of Medicine showed
[MEDICATION NAME] is used to treat the symptoms of [MEDICAL CONDITION] (a mental illness
that causes disturbed or unusual thinking, loss of interest in life, and strong or
inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also
used to treat episodes [MEDICAL CONDITION](frenzied, abnormally excited, or irritated
mood) or mixed episodes (symptoms [MEDICAL CONDITION] depression that happen together) in
adults and in teenagers and children [AGE] years of age and older with [MEDICAL CONDITION]
disorder (manic [MEDICAL CONDITION]; a disease that causes episodes of depression,
episodes of mania, and other abnormal moods). [MEDICATION NAME] is also used to treat
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 57)
behavior problems such as aggression, self-injury, and sudden mood changes in teenagers
and children 5 to [AGE] years of age who have autism (a condition that causes repetitive
behavior, difficulty interacting with others, and problems with communication).
[MEDICATION NAME] is in a class of medications called atypical antipsychotics. It works by
changing the activity of certain natural substances in the brain.
Review of the resident’s nurse’s notes, dated 04/12/18, showed the resident was not
himself/herself. His/Her speech is slow and he/she has an unsteady gait.
Further review of the resident’s medical record showed staff did not document a [DIAGNOSES
REDACTED].
During an interview on 04/25/18 at 4:25 P.M., the Social Services Director said he/she is
unsure if the resident has a mental illness but he/she said the resident does not have any
signs or symptoms of mental illness. He/She said the state is referring the resident for
Guardianship due to the resident not being able to make responsible life decisions on
his/her own.
During an interview on 04/26/18 at 10:19 A.M., Physician P said [MEDICATION NAME] should
only be administered to [MEDICAL CONDITION] residents with psychotic episodes but it gets
misused for behaviors. He/She said his/her practice does not like to use antipsychotics at
all. He/She said they should only be used for residents who are psychotic or out of
control. He/She said a resident should not receive a [MEDICATION NAME] injection without a
proper diagnosis. He/She said [MEDICATION NAME] should not be used for behaviors related
to a response to a stressful situation. He/She said [MEDICATION NAME] causes the most
metabolic disruption in comparison to other antipsychotics.
During an interview on 04/26/18 at 1:52 P.M., the resident said he/she does not need some
of the medication the facility gives to him/her. He/She said he/she thinks the medication
is what made his/her legs have muscle spasms. He/She said the Assistant Director of
Nursing (ADON) told him/her he/she could not see a different physician.
During an interview on 04/26/28 at 5:57 P.M., LPN J said all medication, especially
[MEDICAL CONDITION] medications, should include a corresponding [DIAGNOSES REDACTED].
He/She said PRN [MEDICAL CONDITION] medication orders should include a stop date within 14
days.
During an interview on 04/26/18 at 6:59 P.M., the DON said Resident #44 displays signs
symptoms of mental illness and has a [DIAGNOSES REDACTED]. He/She expects staff would have
documented the state of the resident’s improvement. He/She does not think the resident is
lucid. He/She said the resident was on a PRN antipsychotic for aggressive behaviors.
He/She is not sure if any lesser drugs were used prior to the [MEDICATION NAME]. He/She
said the [MEDICATION NAME] is usually used for [MEDICAL CONDITION] but he/she does not
think the resident has that diagnosis. He/She said he/she expects staff to use other
interventions prior to using medication. He/She said the resident was upset about calling
the pound to check on his/her dogs and became more upset after finding out he/she had lost
his/her dogs, as he/she should in that situation. The DON said he/she thinks the resident
was upset about the situation. He/She said nursing staff should make sure all [MEDICAL
CONDITION] medications list a [DIAGNOSES REDACTED].

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 58)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to dispose of
outdated and discontinued medications for five residents (Residents #68, #201, #202, #203,
and #204). Facility staff also failed to dispose of four outdated stock medications. The
facility census was 99.
1. Review of the facility’s policy on Storage of Medications, dated 6/12/2003, showed
staff are directed:
-Outdated, contaminated or deteriorated medications and those in containers which are
cracked, soiled, or without secure closures are immediately removed from stock and
disposed of according to procedures for medication destruction in Policy F-23 (Disposition
and Return of Medication), and reordered from the pharmacy if a current order exists;
-Medication storage areas are kept clean, well lit, and free of clutter.
2. Review of the facility’s policy on Disposition and Return of Medication, dated
6/12/2003, showed staff are directed:
-Carded non-controlled substances and sealed unit of use containers may be returned to the
pharmacy within 30 days of discontinuation/discharge;
-All medications not in use or discontinued should be destroyed or returned within 30
days.
3. Review of the facility’s records showed:
-Resident #68 was re-admitted to the facility on [DATE] without a physicians order for
[MEDICATION NAME] 150 mg (heartburn medication) or [MEDICATION NAME] (blood pressure
medication) 100 mg;
-Resident #201 was a current resident of the facility;
-Resident #202 had been discharged from, the facility on 7/27/17;
-Resident #203 had expired in the facility on 2/6/18; and
-Resident #204 was re-admitted to the facility on [DATE] without a physicians order for
[MEDICATION NAME] 10mg (muscle relaxer).
4. Observation on 4/23/18 at 10:44 A.M., showed a bin full of medications that had been
discontinued by the physician or from residents who had been discharged /expired from the
facility. Further observation showed the bin included:
-For Resident #68: a bubble card of [MEDICATION NAME] 150 mg with a date of 7/19/17, and
[MEDICATION NAME] with a date of 3/08/18;
-For Resident #203: a bubble card of [MEDICATION NAME] 125 mcg ([MEDICAL CONDITION]
medication) with a date of 1/31/18; and
-For Resident #204: a bubble card of [MEDICATION NAME] 10 mg 1/2 tabs with a date of
8/08/17.
5. Observation of the medication cart on 4/23/18 at 1:27 P.M., showed the following:
-For Resident #201: a box of Sodium Chloride 0.9% (normal saline) with a date of 4/24/16;
-For Resident #202: a box of [MEDICATION NAME] 2.5mg/3ml (breathing treatment) with a date
of 12/20/16;
-A bottle of Chlorexidine [MEDICATION NAME] 4% Liquid (medicated mouthwash) stock
medication with a date of 4/19/17;
-Cranberry 450 mg tablets with a date of 1/18/18; and
-Gericare wax removal ear drops with a date of 9/17/17.
6. During an interview on 4/23/18 at 1120, Licensed Practical Nurse (LPN) K said the
nurses are responsible to give any expired or discontinued medications to the Director of
Nursing (DON) or Assistant Director of Nursing (ADON) as soon as possible so they can be
destroyed. He/She said the nurses and Certified Medication Technicians (CMT) are to check
the carts and medication rooms monthly, and the pharmacy is also responsible for checking
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 59)
them monthly.
During an interview on 4/23/18 at 3:31 P.M., CMT P said all CMT’s are expected to check
the medication carts daily during their shift and if any expired medications are found
they should report it to their nurse who is then responsible to take care of them.
During an interview on 4/26/18 at 8:04 P.M., the DON said the CMT’s and the nurses are
expected to check the med carts for expired meds, and the ADON also checks the carts once
a month. The DON said he/she destroys meds from the med room once a month.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on observation, interview, and record review facility staff failed to store food and
maintain kitchen surfaces in a sanitary manner to prevent potential cross-contamination.
The facility census was 99.
Review of the facility’s policy on Food Storage, (YEAR), showed staff are directed to:
-Store food on clean dry shelves, clean from contaminants;
-Store food at appropriate temperatures and using appropriate methods;
-Label all food items with the name and the date by which it should be sold, consumed, or
discarded;
-Rotate products so the oldest are used first;
-Discard food past the expiration date;
-Store deliveries as soon as they have been inspected;
-Store leftovers in covered, labeled and dated containers;
-Store poisonous materials and chemicals separate from food;
-Never leave any food item uncovered and not labeled.
1. Observation on 04/23/18 at 10:57 A.M., showed the following:
-Coffee stains on the two lower shelves of the coffee station;
-Soiled plastic drip mats on the shelves of two beverage service carts;
-Four large Tupperware like containers of cereal unsealed, unlabeled, and not dated;
-Four small Tupperware like containers of cereal unlabeled and not dated;
-One opened sliced cheese in the refrigerator unsealed, unlabeled, and not dated;
-One loaf of bread unsealed, unlabeled, and not dated;
-Debris on refrigerator shelves;
-One large bag of instant mashed potatoes unsealed;
-Three bags of crab Rangoon open, unsealed, unlabeled, and not dated;
-One bag of large brats open, unsealed, unlabeled, and not dated;
-One bag of chicken patties open, unsealed, unlabeled, and not dated;
-One bag of French fries open, unsealed, unlabeled, and not dated;
-One bag of hamburger patties open, unsealed, unlabeled, and not dated;
-20 large bottles of seasoning open and unsealed,;
-One large bowl of seasoning open, unsealed, unlabeled, and not dated stored on the bottom
shelve next to kitchen sink;
-Four pitchers of drinks in colored pitchers on the beverage cart, undated;
-Two five-gallon buckets of dish cleaning chemicals stored in dry storage.
During an interview on 05/02/18 at 2:07 P.M., dietary staff Q said staff should wipe off
any noticeable debris as soon as possible. He/She said open food should be sealed and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 60)
dated with the open date and expiration date. He/She said chemicals should never be stored
with food.
During an interview on 05/02/18 at 2:12 P.M., dietary staff R said staff should clean up
any messes as soon as they see it. He/She said open food should be wrapped and dated with
a sharpie. He/She said staff should put the open and use by date. He/She said chemicals
should never be stored with food. He/She said all dietary staff are in-serviced
During an interview on 05/02/18 at 2:15 P.M., the Dietary Manager said staff should clean
up any spilled food or drink in the kitchen immediately. He/She said open food should be
labeled and dated and stored appropriately. He/She said all dietary staff are trained to
seal, label, and date all food items and he/she is not sure why some food was open and
undated. He/She said chemicals should never be stored with food. He/She said the chemicals
were delivered on Friday, 04/20/18, and they should have been put away over the weekend.
He/She said chemicals are stored with rags and mops in the utility room near the kitchen.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

Based on observation, interview, and record review, facility staff failed to appropriately
sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after
use for five residents (Resident #12, #32, #188, #205, and #237), to prevent the spread of
infection causing contaminants. Facility staff also failed to wear gloves or wash/sanitize
hands during meal assistance for six residents (Resident #26, #29, #44, #48, #79, #188) to
prevent the spread of infection causing contaminants. The facility census was 99.
1. Review of the facility’s policy on Blood Sugar Monitoring, undated, showed staff are
directed:
-Observe (standard) universal precautions;
-Wash hands before and after all procedures;
-Clean and dry skin well before procedure;
-Dispose of disposable equipment appropriately;
-Thoroughly clean all equipment used with super Sani Cloth and return to appropriate
storage area;
-Follow the manufacturer’s directions for the type of equipment used in the facility.
2. Observation on 4/23/18 at 12:26 P.M., showed Certified Medication Technician (CMT) A
removed a glucometer from the top drawer of the medication cart, applied gloves, checked
Resident #12’s blood glucose level, laid the unsanitized multi-use glucometer on top of
the Medication Administration Record [REDACTED]. The CMT did not sanitize the multi-use
glucometer before or after use.
3. Observation on 4/23/18 at 12:40 P.M., showed CMT A sanitized hands, applied gloves,
removed the unsanitized multi-use glucometer from the top drawer of the cart, checked
Resident #32’s blood glucose level, placed the unsanitized multi-use glucometer on top of
the MAR, and sanitized hands. The CMT did not sanitize the multi-use glucometer before or
after use.
4. Observation on 4/23/18 at 12:42 P.M., showed CMT A applied gloves, picked up the
unsanitized glucometer from on top of the MAR, checked Resident #188’s blood glucose
level, and placed the unsanitized multi-use glucometer on top of the cart. The CMT did not
sanitize the multi-use glucometer before or after use.
5. Observation on 4/23/18 at 3:51 P.M., showed CMT U removed a glucometer from the top

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 61)
drawer of the medication cart, did not don gloves, checked Resident #205’s blood glucose
level, and laid the unsanitized multi-use glucometer on top of the medication cart. The
CMT did not sanitize the multi-use glucometer before or after use.
6. Observation on 4/23/18 at 3:55 P.M., showed CMT U removed the unsanitized glucometer
from the top of the medication cart, did not don gloves, and checked Resident #237’s blood
glucose level. He/She placed the unsanitized multi-use glucometer on top of the medication
cart. The CMT did not sanitize the multi-use glucometer before or after use.
7. During an interview on 4/26/18 at 9:03 A.M., CMT A said staff are expected to clean the
multi-use glucometers with bleach wipes or alcohol pad after use with each resident, but
staff did not have any bleach wipes available for use at the moment.
During an interview on 4/26/18 at 5:51 P.M., Licensed Practical Nurse (LPN) B said staff
are expected to clean the glucometers between residents and daily, for infection control.
During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said staff are
expected to use bleach wipes to clean the multi-use glucometers after each use on a
resident, and leave wet for about a minute. Glucometers should also be cleaned weekly. The
DON said it is absolutely not okay to use alcohol pads to clean the glucometers.
8. Observation on 04/23/18 at 12:46 P.M., showed Licensed Practical Nurse (LPN) F used
his/her bare hands to pick up glasses of water and Kool-Aid by the rims and served
multiple residents. The LPN did not wear gloves to directly touch the rim of the glass to
prevent the spread of infection.
9. Observation on 04/23/18 at 12:56 P.M., showed the Assistant Director of Nursing (ADON)
used his/her bare hands to pick up glasses of water and Kool-Aid by the rim and served
Resident #26. The CNA did not wear gloves to directly touch the rim of the glass to
prevent the spread of infection.
10. Observation on 4/23/18 at 1:15 P.M., showed Certified Nursing Assistant (CNA) G served
Resident #48 his/her meal in the dining room. The CNA held the glass of kool aid by the
rim, pulled the spout with his/her bare hands to open a carton of strawberry shake, and
poured the shake into a cup. The CNA did not wear gloves to directly touch the rim of the
glass and the carton spout to prevent the spread of infection.
11. Observation on 04/24/18 at 12:52 P.M., showed CNA N used his/her bare hands to pick up
a glass of water by the rim and served Resident #29. The CNA did not wear gloves to
directly touch the rim of the glass to prevent the spread of infection.
12. Observation on 04/24/18 at 1:00 P.M., showed CNA N used his/her bare hands to pick up
glasses of water and juice by the rim and served Resident #44. The CNA did not wear gloves
to directly touch the rim of the glass to prevent the spread of infection.
13. Observation on 4/24/18 at 1:19 P.M., showed CNA N used his/her bare hands to pick up a
glass of water by the rim and served Resident #188. The CNA did not wear gloves to
directly touch the rim of the glass to prevent the spread of infection.
14. Observation on 4/24/18 at 1:21 P.M., showed CNA G used his/her bare hands to pick up
two glasses of liquids by the rim and served Resident #79. The CNA did not wear gloves to
directly touch the rim of the glass to prevent the spread of infection.
15. During an interview on 04/26/18 at 5:50 P.M., CNA I said staff should wash their hands
and sanitize before serving food to residents. He/She said staff should hold the base of
the glass and not the top so they do not make anyone sick.
During an interview on 4/26/18 at 5:51 P.M., Licensed Practical Nurse (LPN) B said when
staff serve resident’s meals, they are expected to hold the glass towards the bottom and
not by the rim, particularly if staff did not wear gloves.
During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said he/she
expects staff to hold glasses towards the bottom and hold plates on the side, without
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 62)
touching the food, when they serve meals to residents.

F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and
all bed rails and mattresses must attach safely to the bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to complete an
inspection of bed frames, mattresses, and bed rails as part of a regular maintenance
program to identify areas of possible entrapment for three residents (Residents #13, #63,
and #68) with side rails to reduce the risks of accidents. The facility census was 99.
1. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System
Dimensional and Assessment Guidance to Reduce Entrapment, dated (MONTH) 10, 2006 showed
413 people died as a result of entrapment events in the United States. Further review
revealed those among the most vulnerable for these entrapment type events are elderly
patients and residents especially those who are frail, confused, restless or who have
uncontrolled body movement.
2. Review of the FDA document entitled, Practice Hospital Bed Safety, dated (MONTH) 2013,
showed seven different potential, zones of entrapment. The guidance characterizes the
head, neck, and chest as key body parts that are at risk for entrapment.
3. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing
Homes and Home Health Care: The Facts, showed the potential risks of bed rails may
include:
-Strangling, suffocating, bodily injury or death when patients or part of their body are
caught between rails or between the ed rails and mattress;
-More seriously injuries from falls when patients climb over rails;
-Skin bruising, cuts, and scrapes;
-Inducing agitated behavior when bed rails are used as a restraint;
-Feeling isolated or unnecessarily restricted;
-Preventing patients, who are able to get out of bed, from performing routine activities
such as going to the bathroom or retrieving something from a closet.
4. Review of Resident #13’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Required extensive assistance of two or more staff for bed mobility;
-Required total assistance of one staff for locomotion and dressing;
-Required total assistance of two or more staff for transfer, toilet use, and personal
hygiene.
Review of the resident’s side rail screen, dated [DATE], showed staff documented the
resident will have two side rails to be used as an enabler to promote independence and the
resident has expressed a desire to have the side rails raised while in bed.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s medical record showed it did not contain a maintenance inspection
to include an entrapment assessment for the use of siderails.
Observation on [DATE] at 8:57 A.M., showed the resident in bed with two full side rails
raised.
Observation on [DATE] at 9:22 A.M., showed the resident in bed with two full side rails
raised.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 63)
Observation on [DATE] at 9:18 A.M., showed the resident in bed with two full side rails
raised.
5. Review of the Resident #63’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Moderate cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility, transfers,
locomotion, dressing, and personal hygiene.
Review of the resident’s side rail screen, dated [DATE], showed staff documented the
resident will have one side rail to assist the resident to reposition and transfer.
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
Review of the resident’s medical record showed it did not contain a maintenance inspection
to include an entrapment assessment for the use of siderails.
Observation on [DATE] at 2:27 P.M., showed the resident in bed with two quarter side rails
raised, one on each side of the head of bed.
Observation on [DATE] at 2:51 P.M., showed the resident in bed with two quarter side rails
raised, one on each side of the head of bed.
Observation on [DATE] at 9:24 A.M., showed the resident in bed with two quarter side rails
raised, one on each side of the head of bed.
6. Review of Resident #68’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severe cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility;
-Required total assistance of two or more staff for transfers.
Review of the resident’s side rail screen, dated [DATE], showed staff documented the
resident will have one side rail to assist the resident to reposition and transfer and the
resident expressed a desire to have side rails raised while in bed.
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order to have the left side
rail for an enabler with an order date of [DATE]. Further review showed the order for side
rails did not contain a [DIAGNOSES REDACTED].
Review of the resident’s medical record showed it did not contain a maintenance inspection
to include an entrapment assessment for the use of siderails.
Observation on [DATE] at 9:46 A.M., showed the resident in bed with one half side rail up
on the resident’s left side of the bed.
Observation on [DATE] at 2:48 P.M., showed the resident in bed with one half side rail up
on the resident’s left side of the bed.
7. During an interview on [DATE] at 10:10 A.M., the Maintenance supervisor said he/she is
expected to complete the measurements for entrapment assessments for residents with side
rails, but he/she does not document them.
During an interview on [DATE] at 11:10 A.M., Certified Nurse Assistant (CNA) L said if the
resident’s bed has siderails attached to them, staff should raise the side rails while the
resident is in bed.
During an interview on [DATE] at 11:16 A.M., Licensed Practical Nurse (LPN) M said he/she
is not sure if anyone measures the residents’ mattress/bed frames, and side rails for the
zones of entrapment.
During an interview on [DATE] at 11:30 A.M., LPN F said entrapment assessments with
measurements are done by the Director of Nursing (DON).
During an interview on [DATE] at 12:55 P.M., the Assistant Director of Nursing (ADON) said
staff do not have side rail consents for the use of side rails.
During an interview on [DATE] at 6:56 P.M., the DON said if the resident used siderails,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265720

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

04/26/2018

NAME OF PROVIDER OF SUPPLIER

CREVE COEUR MANOR

STREET ADDRESS, CITY, STATE, ZIP

1127 TIMBER RUN DRIVE
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 64)
staff should be completing entrapment assessments. The DON said facility staff did not
measure the zones for entrapment.