Elsberry Missouri Health Care Center

Based on observation, interview, and record review, the facility failed to ensure food items were labeled, dated, and covered; failed to maintain the range hood to be free of an accumulation of grease and debris; failed to ensure staff wore beard restraints to prevent potential contamination; and failed to ensure the ice machine was free of a buildup of debris. The census was 54.Review of the undated facility policy, Food Storage-Refrigeration, showed foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with expiration dates. The manager and/or his/her designee shall check the refrigerators daily to ensure leftovers are discarded and all food is properly stored. 1. Observation on 7/28/25 at 10:51 A.M. of the reach-in refrigerator in the kitchen showed the following:-An opened five-pound bag of shredded cheddar cheese was open to air and was not sealed;-A small metal pan, labeled tomatoes, was partially covered with foil and was not dated. The pan was open to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the facility policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The administrator said the facility did not have a water management team, did not have a water flow map with the details of the water flow though the building and that include all of the elements the facility policy directed, and the facility had not been monitoring cold water temperatures. The Director of Nursing had not been trained to monitor residents with pneumonia for possible Legionnaire's Disease as directed by the facility policy. The facility census was 54. Review of the facility's Legionella and Water Management…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to make appropriate updates and revisions to develop a plan of care consistent with residents' specific conditions, needs and risks for two residents (Resident #34 and #17) in a review of 17 sampled residents. The facility failed to revise Resident #34's care plan to provide staff direction for interventions related to the resident's auditory and visual hallucinations and confusion, did not update to address the resident's mechanically altered diet/loss of liquid/solids from his/her mouth when eating or drinking, holding food in his/her mouth/cheeks or residual food in mouth after meals, and did not address pain medications for pain and/or anxiety, and failed to revise Resident #17's care plan to include the resident's current oxygen therapy order. The facility census was 54. Review of the undated facility policy, Care Plan, showed the following:-A care plan is initiated upon admission (known as the baseline care plan) and is revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow physician's orders and facility policy when they did not notify the physician of blood glucose results (the amount of sugar in the blood outside of the parameter outlined in the physician's orders and facility policy for one resident, (Resident #2) in a sample of 17 residents. The facility also failed to adequately monitor pain for one resident (Resident #2) who had multiple diabetic wounds to his/her feet and arthritis. The facility census was 54. Review of the undated facility policy, Blood Glucose Test Procedure, showed the following:-Record test results in electronic medical record (EMR);-Report any values less than 50 or greater than 400 to the physician. Unless otherwise instructed by physician. Review of the undated facility policy, Notification of Changes, showed the facility will notify the resident, consult with the resident's physician and the resident's legal representative or an interested family member when a significant change in the resident's physical, mental or psychosocial status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and facility document review, the facility failed to ensure the designated Dietary Manager (DM) had the required education, certification, or experience to qualify her for the position. This had the potential to affect 52 of 52 residents who received meals from the dietary department. Findings included: During an interview on 10/18/2023 at 2:09 PM, the Administrator stated the facility had no policy or procedure addressing the requirements to serve in the dietary management position. A review of the DM's employee file revealed the facility initially hired the DM in August 2022 as a housekeeper and laundry aide. No documentation of training was found within the DM's employee file regarding her move from housekeeping and laundry to the position of DM, nor was there any information regarding any food service certifications. An Employee 60 Day Review, dated 01/16/2023, indicated the DM was learning new role, including ordering, cooking, and supervising, and an Employee 90 Day Review, dated 03/27/2023, indicated the DM continues to learn. The DM's employee file also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, facility document and policy review, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure staff maintained meal temperature monitoring records for each meal service; failed to ensure staff maintained monitoring records of the sanitizer concentrations for the three-compartment sink to ensure items were properly sanitized; and failed to ensure staff thawed a roll of ground beef in accordance with professional standards. These failures had the potential to affect 52 of 52 residents who received meals from the dietary department. Findings included: 1. A review of an undated facility policy titled Department Meal Service: Meal Service Temperatures revealed, Purpose To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service. The policy also indicated, Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis. The procedural section of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, document review, and facility policy review, the facility failed to properly store and secure medications for 2 (Hall 100 medication cart and facility medication/treatment cart) of 3 medication carts observed and failed to ensure proper labeling of eye drops for 1 (Resident #43) of 3 residents observed for eye drop administration during medication pass. Specifically, the facility failed to ensure medications remained in direct line of sight of staff or were in a locked compartment, failed to properly store tramadol under a double lock, and failed to date an eye drop container when opened. Findings included: A review of an undated document titled Medication storage in the facility revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review revealed Schedule III and IV controlled medications are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and document review, the facility failed to ensure three (Certified Nursing Assistant (CNA) #7, #8, and #11) of five CNAs had at least 12 hours of in-service training per year. Findings included: During an interview on 10/19/2023 at 4:56 PM, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Health Information Manager (HIM) stated the facility had no policy related to required training for CNAs. A review of a Centers for Medicare and Medicaid Services (CMS) memorandum dated 04/07/2022 regarding the Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers revealed In response to the COVID-19 PHE [Public Health Emergency] and under the Secretary's authority set out at section 1135 of the Social Security Act, CMS enacted several temporary emergency declaration blanket waivers which were intended to provide health care providers with extra flexibilities required to respond to the COVID-19 pandemic. The memorandum indicated, CMS is ending the specific emergency declaration blanket waivers for SNFs/NFs [Skilled Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) form included all current mental illness diagnoses for one (Resident #26) of one sampled resident reviewed for PASARR requirements. Findings included: A review of a document provided by the facility titled What to submit to COMRU [Central Office Medical Review Unit] for client entering a Skilled Nursing Facility, dated January 2020, revealed that when completing a Level One Nursing Facility Pre-admission Screening for MI/ID [mental illness/intellectual disability], staff should Be sure to complete all blanks and Be sure Section B#2 (Mental Illness Diagnosis) is answered - Refer to client's diagnosis list. A review of Resident #26's admission Record revealed the facility admitted the resident on 04/04/2022. The Diagnosis Information section of the admission Record indicated, No Data Found. A review of Resident #26's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/2022, revealed Resident #26 had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to follow physician orders related to wound care for one (Resident #43) of three residents reviewed for wound care. Findings included: Review of an undated facility policy titled Physician Services revealed, All physician or other health care professional verbal orders, including telephone orders, will be immediately recorded, dated, and signed by the person receiving the order. The policy also noted, All physician orders will be followed as prescribed and if not followed the reason shall be recorded on the resident's medical record during that shift. Review of an undated facility policy titled Clean Dressing Change revealed, It is the policy of the facility to ensure change dressings [sic] in accordance with State and Federal Regulations, and national guidelines. The facility policy indicated Procedure: 1. Verify and review physician's order for procedure. The policy also indicated 19. Apply clean dressing as ordered and ensure the dressing is dated. Review of Resident #43's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff maintained infection control practices to prevent the spread of infection during treatments of wounds and administration of medications for one (Resident #43) of two residents observed for wound care and two (Resident #21 and Resident #152) of eight residents observed during medication pass. Findings included: A review of an undated facility policy titled Hand Hygiene Guidelines, revealed, Key times to wash hands included before and after treating a cut or wound. The policy revealed Sanitizers can quickly reduce the number of germs on hands in many situations. A review of an undated facility policy titled Clean Dressing Change, revealed, It is the policy of the facility to ensure change [sic] dressings in accordance with State and Federal Regulations, and national guidelines. The policy revealed Procedure: 1. Verify and review physician ' s order for procedure. 2. Perform hand hygiene and assemble equipment and supplies needed for dressing change. 3. Identify the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.