Inspection Reports for
The Grande At Creve Coeur
450 N Lindbergh Blvd, Creve Coeur, MO 63141, United States, MO, 63141
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
4.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
66% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 4
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to individual service plans, admission criteria, physician orders, and resident record admission information at an assisted living facility.
Findings
The facility failed to develop individualized service plans addressing resident falls, skin tears, and hospice care; admitted a resident with behaviors posing harm risk; failed to follow physician's orders for wound care; and did not maintain complete resident records including preferred funeral home and dentist information.
Deficiencies (4)
19 CSR 30-86.047(28)(G) Individual Service Plan - The facility failed to develop individualized service plans for residents, including addressing falls, skin tears, and hospice care.
19 CSR 30-86.047(29)(A) Not Admit/Care For-Harm Self or Others - The facility admitted a resident with behaviors presenting a reasonable likelihood of harm to self or others.
19 CSR 30-86.047(47)(A) Physicians Orders Followed - The facility failed to follow physician's orders for wound care for a resident, including dressing a wound as ordered.
19 CSR 30-86.047(58)(A) Resident Record Admission Info - The facility failed to maintain complete resident records, missing preferred funeral home and dentist information for sampled residents.
Report Facts
Resident census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident falls, pre-screening, and ISP documentation |
| Administrator | Administrator | Interviewed regarding ISP documentation, pre-screening, and admission policies |
| Care Giver H | Care Giver | Observed providing care to resident with pressure ulcer |
| CMA F | Certified Medication Aide | Interviewed regarding wound care and communication with Director of Wellness |
| Director of Wellness | Director of Wellness | Interviewed regarding ISP reviews and resident face sheets |
| Nurse | Nurse | Interviewed regarding pressure ulcer orders and resident care |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to an incident involving staff threatening and potentially abusing a resident.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews showing staff threatening and inappropriate handling of a resident. The facility did not train staff adequately on abuse prevention and intervention.
Findings
The facility failed to develop and implement adequate policies to prohibit mistreatment, neglect, and abuse of residents. Staff did not intervene appropriately during an incident where a Certified Nurse's Aide threatened a resident and shoved a towel in the resident's mouth, and the facility lacked training on handling such situations.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to develop a policy instructing staff to immediately intervene and remove a suspected abuser when a staff member threatened to assault a resident and shoved a towel in the resident's mouth. The policy also lacked steps to address abusive behavior by other employees.
Report Facts
Resident census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician B | Named in statements related to the incident involving resident abuse | |
| Certified Nurse's Aide A | Named as the staff member who threatened the resident and shoved a towel in the resident's mouth | |
| Certified Nurse's Aide C | Witnessed and reported the incident, involved in resident care during the event | |
| Administrator | Reported the incident to the Director of Wellness and commented on facility policies |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 12
Date: Jun 26, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for The Grande at Creve Coeur, Missouri, following a state survey conducted on 06/26/2023. It addresses regulatory compliance issues identified during the inspection.
Findings
The facility failed to ensure individualized evacuation plans were included in residents' individual service plans, maintain an Employee Disqualification List and criminal background checks for contract workers, develop individualized service plans for sampled residents, provide a safe and effective medication system, and maintain accurate medical records and documentation for residents. Several deficiencies were noted related to resident care, safety, and documentation.
Deficiencies (12)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - The facility failed to ensure residents needing more than minimal assistance had individualized evacuation plans in their individual service plans for four sampled residents. The census was 43.
19 CSR 30-86.047(12) EDL Requirements - The facility failed to maintain documents showing all contract workers had an Employee Disqualification List review prior to contact with residents. The census was 43.
19 CSR 30-86.047(13)(A) Criminal Background Check Requirements - The facility failed to maintain documents showing all contract workers had a criminal background check completed prior to contact with residents. The census was 43.
19 CSR 30-86.047(28)(G) Individual Service Plan - The facility failed to develop individualized service plans for two of four sampled residents. The census was 43.
19 CSR 30-86.047(29)(A) Not Admit/Care For-Harm Self or Others - The facility failed to ensure residents with behaviors presenting a likelihood of harm to self or others were admitted appropriately. The census was 43.
19 CSR 30-86.047(46) Safe & Effective Medication System - The facility failed to provide a safe medication system when a medication aide walked away after administering medication without ensuring consumption. The census was 43.
19 CSR 30-86.047(47)(A) Physicians Orders Followed - The facility failed to follow physician orders for wound treatments for two sampled residents. The census was 43.
19 CSR 30-88.010(10) Advance Directive Requirements - The facility failed to review advanced directives annually for three of four sampled residents. The census was 43.
19 CSR 30-88.010(36) Personal Clothing/Possessions - The facility failed to ensure personal inventory lists were completed for seven of seven reviewed residents. The census was 43.
19 CSR 30-88.010(61)(A) Staffing Ration, Resident Care & Fire Safety - The facility failed to ensure CPR trained staff were available on each shift for full code residents. The census was 43.
19 CSR 30-91.010 (9)(A)-(E) Installation-placement of EMD - The facility failed to ensure electronic monitoring devices were mounted in a fixed, stationary position for two of five sampled residents. The census was 43.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review - The facility failed to maintain full and accurate medical records for hospice and home health services for one sampled resident and one reviewed resident. The census was 43.
Report Facts
Census: 43
Hospice staff count: 35
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 1
Date: Oct 10, 2022
Visit Reason
The inspection was conducted due to an alleged incident of abuse and neglect involving Resident #5, requiring review of policies and investigation of the incident.
Findings
The facility failed to follow its abuse and neglect policy by not reporting an alleged incident to the Department of Health and Senior Services. Video evidence and staff interviews showed inappropriate staff behavior and failure to intervene when the resident fell.
Deficiencies (1)
19 CSR 30-88.010(23) The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents and failed to report an alleged abuse incident to the Department of Health and Senior Services. The census was 43.
Report Facts
Resident census: 43
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 1
Date: Oct 18, 2021
Visit Reason
The visit was conducted to investigate a complaint regarding alleged abuse involving a certified nurse's aide and a resident. The report includes a statement of deficiencies and a plan of correction.
Complaint Details
The complaint investigation was triggered by a report received on 09/30/21 alleging that a certified nurse's aide hit a resident in the mouth at the beginning of September. The investigation found that the incident occurred but was not properly reported or investigated by the facility.
Findings
The facility failed to follow its abuse policy and conduct a thorough investigation of an incident where a staff member restrained a resident's arm and covered the resident's mouth. The investigation and reporting procedures were not properly followed, and corrective actions were not taken.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to follow their abuse policy and conduct a thorough investigation to rule out physical abuse when a staff member restrained a resident's arm and covered the resident's mouth. This had the potential to affect all residents.
Report Facts
Census: 44
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 1
Date: Feb 3, 2021
Visit Reason
The visit was conducted to assess compliance with regulations regarding locked resident room doors and to address deficiencies identified during the inspection.
Findings
The facility failed to ensure that resident room door locks did not require special knowledge, tools, or effort to unlock from inside the room. Observations and interviews confirmed that some residents could not unlock their doors without staff assistance.
Deficiencies (1)
19 CSR 30-86.022(7)(F) Locked Resident Room Doors: The facility failed to ensure resident room door locks allowed residents to unlock doors from inside without special knowledge or tools, as demonstrated by two residents unable to unlock their doors independently.
Report Facts
Resident census: 39
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 1
Date: Oct 27, 2020
Visit Reason
The inspection was conducted to assess compliance with infection control procedures related to COVID-19 and to document deficiencies and corrective actions.
Findings
The facility failed to follow acceptable infection control practices for COVID-19, including ensuring staff remained quarantined after exposure. The administrator allowed a business manager to return to work without a signed physician's release, contrary to CDC guidelines.
Deficiencies (1)
19 CSR 30-86.047(34)(A) Disease/Infection Control, Report Category I. The facility failed to protect all residents by not following acceptable infection control practices for COVID-19 and allowing exposed staff to return to work without proper quarantine and physician release.
Report Facts
Census: 37
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 6
Date: Sep 13, 2019
Visit Reason
The inspection was conducted to assess compliance with individual evacuation plans and other regulatory requirements for residents needing assistance during emergencies at The Sheridan at Creve Coeur.
Findings
The facility failed to ensure residents who required more than minimal assistance had individualized evacuation plans in their service plans. The facility also failed to include designated staff in evacuation plans for several residents and did not ensure proper documentation and staff training related to evacuation procedures.
Deficiencies (6)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - In Resident ISP. The facility failed to ensure residents needing more than minimal assistance had individualized evacuation plans in their service plans for three of ten sampled residents.
19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan - Staff Requirements. The facility failed to include designated staff in resident individual evacuation plans for five of ten sampled residents.
19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate. The facility failed to include proximity to areas of refuge or exits in individual evacuation plans for five of ten sampled residents.
19 CSR 30-86.047(20)(I) Personnel Record - Physician Statement, Employee. The facility failed to ensure new employees had a documented physician statement indicating ability to work in a long-term care facility for three sampled employees.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to ensure residents received proper care based on their individualized service plans for three of ten sampled residents.
19 CSR 30-88.010(29) Dignity/Privacy. The facility failed to ensure residents were treated with dignity and respect, including privacy during treatment and care, for two sampled residents.
Report Facts
Resident census: 41
Deficiencies cited: 6
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 1
Date: Nov 29, 2018
Visit Reason
The inspection was conducted to assess compliance with water temperature regulations in resident-accessible plumbing fixtures.
Findings
The facility failed to maintain water temperatures within the required range of 105 to 120 degrees Fahrenheit in seven resident room bathrooms. The issue was classified as a Class II deficiency with potential to affect all residents.
Deficiencies (1)
19 CSR 30-86.032(34) Hot Water 105-120 Degrees F: The facility failed to maintain water temperatures between 105°F and 120°F in seven resident room bathrooms, posing a risk to residents.
Report Facts
Resident census: 31
Residents with Alzheimer's or dementia: 23
Residents on secured unit: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding water temperature checks and maintenance procedures | |
| Maintenance Director | Interviewed about daily temperature checks and mixing valve adjustments | |
| Maintenance Supervisor | Mentioned in relation to draining the hot water tank and temperature measurements | |
| Plant Operations Director | Responsible for inservice maintenance and water temperature monitoring in plan of correction |
Inspection Report
Plan of Correction
Census: 22
Deficiencies: 4
Date: Jul 31, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to protective oversight, proper care per individual service plan, resident condition and medication review, and development and implementation of abuse/neglect policies.
Findings
The facility failed to provide protective oversight for residents involved in physical altercations, failed to provide proper care and interventions per individualized service plans, failed to maintain accurate resident incident documentation, and failed to develop and implement adequate policies to report abuse and neglect. The census at the time was 22 residents.
Deficiencies (4)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight when one resident with a history of verbal and physical aggression injured another resident. This deficient practice affected three of three sampled residents.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to provide direction and interventions in Resident #1's individualized service plan to ensure proper care for redirecting behaviors, reducing elopement risk, and managing wandering and aggressive behaviors.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to maintain a record including monthly reviews of resident condition and medication consumption for one of three sampled residents.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: The facility failed to develop and implement written policies and procedures to report incidents of resident to resident abuse to the Department of Health and Senior Services when one resident was found choking another resident.
Report Facts
Census: 22
Deficiencies cited: 4
Inspection Report
Plan of Correction
Census: 21
Deficiencies: 2
Date: Mar 1, 2018
Visit Reason
The document is a plan of correction submitted in response to deficiencies identified during a survey completed on 03/01/2018 at The Sheridan at Creve Coeur facility.
Findings
The facility failed to provide proper care per individualized service plans for residents with fall risks and wounds, and failed to ensure medication was administered as ordered by physicians. Deficiencies included inadequate fall risk assessments, lack of timely physician notification, and medication administration errors.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to ensure residents at risk of falls and with wounds received proper care as defined in their individualized service plans. Safety interventions and documentation were inadequate for two sampled residents.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to ensure a resident received medication as ordered by the physician, with late administration documented for one of three sampled residents.
Report Facts
Census: 21
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