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🔎 Creve Coeur Manor

Inspection Results


Inspection Overview

Creve Coeur Manor has been cited for a total of 132 deficiencies since we began saving each survey.

In Missouri, the average facility has **43.77 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

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

Survey Date: 2024-11-20
Correction Date: 2024-12-16
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Dispose of garbage and refuse properly.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Keep all essential equipment working safely.

Survey Date: 2024-11-20
Correction Date: 2024-12-12
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-11-20
Correction Date: 2024-12-20
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-03-13
Correction Date: 2024-03-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-02-07
Correction Date: 2024-03-08
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-02-07
Correction Date: 2024-03-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-08-11
Correction Date: 2023-09-08
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: C

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Survey Date: 2023-08-11
Correction Date: 2023-09-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-08-11
Correction Date: 2023-09-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-08-11
Correction Date: 2023-09-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure the activities program is directed by a qualified professional.

Survey Date: 2023-08-11
Correction Date: 2023-09-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-08-11
Correction Date: 2023-09-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2023-08-11
Correction Date: 2023-09-08
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-08-11
Correction Date: 2023-11-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-08-11
Correction Date: 2023-09-08
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless 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.

Survey Date: 2023-08-11
Correction Date: 2023-09-08
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2023-08-11
Correction Date: 2023-09-13
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2023-04-25
Correction Date: 2023-05-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-10
Correction Date: 2023-05-31
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-10
Correction Date: 2023-05-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-11-28
Correction Date: 2022-12-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-11-28
Correction Date: 2022-12-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Survey Date: 2022-08-17
Correction Date: 2022-09-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-17
Correction Date: 2022-09-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-17
Correction Date: 2022-09-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2022-04-22
Correction Date: 2022-05-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2022-04-22
Correction Date: 2022-05-12
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2022-02-08
Correction Date: 2022-02-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-02-08
Correction Date: 2022-02-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-12-07
Correction Date: 2022-01-06
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Survey Date: 2021-12-07
Correction Date: 2021-12-16
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2021-12-07
Correction Date: 2022-02-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-12-07
Correction Date: 2022-02-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2021-12-07
Correction Date: 2022-02-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-12-07
Correction Date: 2022-01-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-12-07
Correction Date: 2022-01-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2021-12-07
Correction Date: 2022-01-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2021-12-07
Correction Date: 2022-01-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2021-12-07
Correction Date: 2022-01-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2021-12-07
Correction Date: 2022-02-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-12-07
Correction Date: 2021-12-16
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2021-12-07
Correction Date: 2022-03-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2021-12-07
Correction Date: 2022-02-10
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2021-12-07
Correction Date: 2021-12-16
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2021-12-07
Correction Date: 2022-01-13
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2021-12-07
Correction Date: 2022-01-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: F

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2021-12-07
Correction Date: 2022-01-20
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure staff are vaccinated for COVID-19

Survey Date: 2021-12-07
Correction Date: 2022-04-22
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-08-11
Correction Date: 2021-09-11
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-02-05
Correction Date: 2021-02-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-17
Correction Date: 2021-01-15
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless 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.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that residents are free from significant medication errors.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2020-03-06
Correction Date: 2020-04-06
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Assess the resident when there is a significant change in condition

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: B

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

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-04-12
Correction Date: 2019-05-12
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless 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.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-04-26
Correction Date: 2018-05-26
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**