Grand Manor Health Care Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

showed his/her diagnoses of morbid obesity and schizophrenia. Review of the resident's care plan, dated 9/24/25, showed the following:-Problem: The resident was involved in a resident-to-resident altercation with his/her roommate where he/she was the aggressor;-Intervention: The resident and his/her roommate will be separated. The resident will be monitored when in common area. The resident will be placed on one-on-one protective oversight until seen by psychiatrist. Review of the resident's nurse's notes, dated 9/24/25, showed the following:-11:03 P.M., the resident walked past the nurse's station then ran to his/her roommate (who was) sitting in a chair in the hallway. The resident started hitting him/her on his/her arms. The resident's roommate kicked him/her in the arm. Both residents were separated. The resident continually looked for the other resident. The resident was removed from the view of his/her roommate. The resident went into his/her room scratching and biting on his/her arm. The resident showed staff scrape to left scalp and temporal area. There was no active bleeding. The resident was threatening to hit his/her head on the wall and cut his/her throat The resident was encouraged out of his/her room to be monitored. The police and ambulance called for transport to the hospital. The resident refused treatment for area;-11:18 P.M., spoke with the resident's sibling, guardian, and left message with the resident's family member. The resident's doctor was called and reported behaviors and self-inflected injuries. The resident was sent out to hospital. The resident sat calmly with police awaiting ambulance. The DON and Administrator were called;-11:48 P.M., the ambulance here for the resident. The resident ambulated and got on stretcher without assist. The police escorted with resident. During an interview on 9/30/25 at 7:43 A.M., the resident said he/she was doing fine. The resident said he/she hit his/her roommate because he/she felt the roommate was watching him/her as he/she slept and he/she was frightened. The resident said he/she does not want to harm anyone or him/herself again. Observation at that time showed the resident was monitored by staff. During an interview on 9/30/25 at 11:10 A.M., Certified Medication Technician (CMT) D said there were no concerns with either resident since the altercation. CMT D said he/she was inserviced on the abuse and neglect policy. The residents should be separated immediately and reported to the charge nurse immediately. During an interview on 9/30/25 at 11:20 A.M., Licensed Practical Nurse (LPN) E said neither resident has had any further behaviors. LPN E said he/she was inserviced on the abuse and neglect policy.

He/She should separate residents and report immediately. During an interview on 10/3/25 at 10:46 A.M, the Administrator said Resident #2 has been pleasant with no other issues with any residents. The resident is encouraged to engage in activities which he/she is enjoying. There are no concerns with Resident #1.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Manor Health Care Center

3645 Cook Ave Saint Louis, MO 63113

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 0688 Level of Harm - Minimal harm or potential for actual harm

interview on 10/1/25 at 10:12 A.M., the Director of Nursing (DON) said she expected all restorative orders obtained from the Therapy Director to be completed and ordered or recommended. The DON did not know why this order was overlooked. During an interview on 10/3/25 at 10:47 A.M., the Administrator said she expected the restorative orders to be followed as written. The Administrator said there has been turnover with the restorative aide position. 2623652

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Manor Health Care Center

3645 Cook Ave Saint Louis, MO 63113

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 - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

not locate him/her. CMT F said he/she was inserviced on the facility's elopement policy and when they are smoking in an unsecured area, residents need to be monitored. During an interview on 10/1/25 at 4:26 P.M., Licensed Practical Nurse (LPN) G said about 7:00 P.M., CMT F said he/she could not locate the resident to administer the resident's medication. LPN G said the resident usually sat in the first-floor common area waiting for a smoke break. LPN G said the resident never wandered off like this before. LPN G said they started a search for the resident and followed the proper elopement protocol. LPN G said he/she was recently inserviced on the facility's elopement protocol to ensure to monitor residents when smoking in unsecured areas. During an interview on 10/2/25 at 8:36 A.M., Receptionist H said the resident was at the reception desk wanting a cigarette, so he/she gave the resident a cigarette. The resident went to go smoke with Certified Nurse Aide (CNA) G and some other residents outside. After about 30 minutes, CNA G and some other residents came in, but Resident #1 stayed outside. Receptionist H said he/she did not see the resident come in later. Receptionist H said he/she was recently inserviced on the elopement policy and to ensure residents are monitored while smoking in an unsecured area. During an interview on 10/2/25 at 1:26 P.M., CNA G said he/she took the resident outside with other residents around 9:00 P.M. to smoke. The resident seemed fine. CNA G did not see the resident come in later. CNA G was inserviced on

the elopement policy and monitoring residents while outside in an unsecured area. During an interview on 10/3/25 at 10:43 A.M., the Administrator said the last employee was inserviced on 9/25/25 regarding the facility's elopement policy with an emphasis on monitoring residents in unsecured areas. There have been no concerns with the resident since the incident. 2627186

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Manor Health Care Center

3645 Cook Ave Saint Louis, MO 63113

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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Based on observation, interview and record review, the facility failed to ensure recipes were followed while preparing pureed meals. The facility had eight residents on pureed meals. The sample was six. The census was 112. Review of the facility's Dietary Food Preparation Policy, dated 7/5/23, showed the following:-Standardized Recipes: Standardized recipes will be used for all product prepared;-Procedure: -Use standardized recipes provided with menu cycle; -The Dietary Manager will monitor and check routinely the cooks' use of recipes. If favorite recipes are added to the recipe file, they must be written, standardized and approved by the Registered Dietitian; -Pureed recipes are found in the recipe binder.

Observation on 9/30/25 at 12:20 P.M., showed [NAME] A took four, four-ounce scoops of diced chicken, placed it in a blender and blended for approximately 10 seconds, then added one slice of white bread and continued to blend. While blending, [NAME] A added water. [NAME] A said he/she did not know how much water he/she was adding and blended for approximately one minute. Observation after blending, showed

the chicken breast to have small lumps of meat and was not smooth. [NAME] A poured the mixture into a tin pan. [NAME] A did not have a recipe present during the preparation. Review of the facility's Pureed Herb Roasted Chicken recipe, dated 2024, showed the following:-10 Servings: two tablespoons of chicken base, two cups of water and one pound and 14 oz of herb roasted chicken;-Dissolve chicken base in water to make chicken broth. Place prepared chicken in a washed and sanitized food processor. Gradually add broth and blend until smooth. Observation on 9/30/25 at 12:25 P.M., showed [NAME] A took six, four-ounce scoops of diced potatoes and placed them into a blender and blended. While blending, he/she added water. [NAME] A said he/she did not know how much water he/she was adding and blended for approximately 40 seconds. Observation after blending showed the potatoes were smooth. During an interview on 9/30/25 at 12:26 P.M., [NAME] A said he/she has been at the facility for 14 years and he/she did not feel he/she needed to look at a recipe. Observation on 10/1/25 at 1:10 P.M, showed [NAME] B took ten, eight-ounce scoops of diced carrots, five slices of white bread and one quarter cup of melted margarine and placed it into a blender and blended for about one minute. Observation after blending showed a smooth consistency. [NAME] B had the recipe present during meal preparation. During an interview on 10/1/25 at 1:12 P.M, [NAME] B said he/she always added bread to make the mixture smooth. Review of the facility's Pureed Candied Carrots recipe, dated 2024, showed the following:-10 servings: One quart and one cup of candied carrots and a quarter cup of margarine. Description: No Bread;-Place prepared vegetables and margarine

in a sanitized food processor and blend until smooth. During an interview on 10/1/25 at 2:03 P.M., the Dietary Manager (DM) said he/she could not find a recipe for mashed potatoes. DM said cooks should look at recipes during meal preparation. DM said he/she did not know why the cooks did not follow the recipe or have them present during meal preparation. During an interview on 10/1/25 at 2:06 P.M., the Regional Dietary Manager (RDM) said he/she expected all recipes to be followed as written. RDM said this will ensure the proper nutrition for the residents. RDM said the recipes are kept in a binder in the kitchen for reference. During an interview on 10/3/25 at 10:50 A.M., the Administrator said the recipes should be present and followed during meal preparation. 2623652

Event ID:

Facility ID:

If continuation sheet