Creve Coeur Manor

In the surveyor’s words

From the most serious findings on record at Creve Coeur Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 22, 2022

  Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety of one confused resident (Resident #602), who eloped from the second floor (designated secured unit) early in the morning and did not return to the facility until approximately 19 hours later. The facility had assessed the resident to be at risk for elopement, and the resident had wandered away from his/her home prior to a hospitalization and subsequent admission to the facility. When the resident had increased agitation during the evening and night shift, prior to the elopement, staff did not put interventions into place to adequately monitor and address the resident's behaviors. […]

• Immediate jeopardy, isolatedF689Dec 7, 2021

  Based on observation, interview and record review, the facility failed to follow their policy by failing to provide adequate supervision to ensure the safety of one resident (Resident #21) who had been admitted on the second floor (the designated secured unit) from a hospital on 4/21/21, after a suicide attempt and failed to put interventions in place when the resident continued to be elopement seeking. The facility failed to implement interventions to monitor the elevators, provide education or inservices to staff and residents, independently using the elevator, regarding elopement. The facility failed to educate all staff on residents at risk for elopement. […]

• Actual harm, isolatedF686May 21, 2026

  Based on interview and record review, the facility failed to ensure staff assessed and monitored one resident (Resident #3) identified as at risk for developing pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). When staff from an outside hospice agency identified a new skin issue and notified the facility nurse, the nurse failed to document the notification and failed to notify the physician timely, resulting in a delay in treatment. Two residents were sampled for pressure ulcers and problems were found with one. The sample was 6. […]

• Actual harm, isolatedF689Apr 25, 2023

  Based on observation, interview and record review, the facility failed to provide adequate supervision on a secured unit for one resident who was on 1 on 1 supervision (Resident #2). The facility also failed to lock the second floor medication room and the staff break room, leaving medications accessible to residents. These deficiencies had the potential to affect all residents who could access these areas. Additionally, the facility failed to update a resident's care plan after he/she allegedly drank hand sanitizer and was sent to the hospital after being found unconscious in his/her room (Resident #1). The sample size was 7. […]

• Actual harm, isolatedF692Dec 7, 2021

  Based on observation, interview and record review, the facility failed to ensure a timely nutritional assessment or interventions by the Registered Dietician (RD) for residents who had a significant weight loss (Residents #40 and #41). The facility also failed to monitor and implement resident specific interventions including health shakes and fortified foods (cheesy eggs, super cereal, power potatoes and power pudding) along with larger portions sizes when ordered. The facility identified 64 residents with one or more fortified foods and/or larger portion sizes. Of those 64 residents, five were sampled and problems were found with all five (Residents #41, #7, #51, #27 and #8). […]