Manor at Elfindale, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards when staff failed to use effective hair restraints; failed to consistently date opened foods and properly close frozen foods to prevent freezer burn; stored a measuring cup in the thickener container, and did not close the container; failed to clean the fans inside of the refrigerator; and failed to clean the deflector shield in the ice machine located in the kitchen. The facility census was 94.1. Review of the 2013 Food Code, issued by the Food and Drug Administration (FDA), showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when the outside of the ice machine had drips of lime down the side, the ice machine vent had fuzzy lint present, and one knob was missing from the cook stove. The facility census was 94.1. Review showed the facility did not provide a policy regarding cleaning the ice machine. Review of the cleaning schedule for September 2025 showed the following:-The September cleaning schedules showed the night shift was to wipe down the ice machine and ice reflector guard on Fridays;-The week of 09/01/25, no staff initialed completing this task;-The week of 09/08/25, no staff initialed completing this task. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete the baseline care plans for all residents within 48 hours of admission and failed to document resident and/or representative was provided a copy of the baseline care plan when staff did not complete a full baseline care plans within 48 hours of admission for two residents (Residents #37 and #95) and failed to document representative or resident notification of the care plan for the residents. A sample of 19 residents was selected for review in a facility with a census of 94. Review showed the facility did not provide a policy related to Baseline Care Plans.1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a complete comprehensive person-centered care plan for all residents when staff did not care plan relating to a wound for one resident (Resident # 5), did not care plan oxygen usage for one resident (Resident #101), and did not care plan regarding a fracture for one resident (Resident #38). The facility census was 94. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to obtain orders for the use of oxygen and care plan the use of oxygen for one resident (Resident #3). The facility census was 94. Review showed the facility did not provide a policy regarding oxygen therapy.1. Review of Resident #3's face sheet (a general information sheet) showed the following:-admission date of 03/06/25;-Diagnoses included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), respiratory failure with hypoxia (low levels of oxygen) and hypercapnia (high levels of carbon dioxide in blood), congestive heart failure (CHF - a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply), and chronic kidney disease. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made three errors out of 31 opportunities resulting in an 9.67% error rate when facility staff failed to administer one medication and administered a medication that did not indicate a dosage to one resident (Resident #47) and failed to prime an insulin pen to ensure an accurate dose to one resident (Resident #52) during medication pass observations. The facility had a census of 94.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed ensure all residents were free of significant medication errors when staff failed to prime one resident's (Resident #52) insulin pen prior to insulin administration to ensure accurate dosing. The facility census was 94. Review of the facility procedure titled Insulin Pen Use, dated 05/19/25, showed staff should prime the insulin pen by pointing it up in the air, dialing one or two units on the insulin pen, and then fully press the plunger. A drop of insulin should appear at the needle tip. Repeat the priming procedure until a drop appears. Review of the Humalog (fast acting insulin) Kwikpen packet insert, dated March 2023, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the ice machine in a clean manner when the ice reflector shield in the ice machine located in the kitchen had a build-up of a black substance that appeared to be mold on the ice reflector shield, failed to ensure the air cooling vent in the walk in freezer was free of lint which could blow on to food stored in the walk-in freezer, and failed to ensure two fluorescent light fixtures in the dry storage pantry had covers and one cover for a fluorescent light fixture was broken. If the light bulbs were to shatter or break, food stored in the dry pantry could be contaminated by broken glass. The facility census was 90. The facility did not have a policy for the kitchen cleanliness. Record review of the Missouri 2013 Food code, showed the following information: [...]

Inspectors wrote2. Record review of Resident #5's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia, muscle weakness, and stroke. Record review of the resident's significant change (major decline or improvement in the resident's status) MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive staff assistance of two staff for bed mobility, transfer, dressing, and toilet use; -Bed rails not used. Record review of the resident's care plan, dated 4/17/2017 and last revised on 11/11/2021, showed the following information: -The resident had self-care deficits with activities of daily living (ADLs) to include bed mobility, transfers, dressing, mobility, hygiene, and toileting, related to disease process; -One turn rail on bed to assist with repositioning; [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse involving two residents (Resident #8 and Resident #58) to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours of receiving the allegation. A sample of 18 residents was selected for review. The facility census was 90. Record review of the facility's policy titled, Abuse and Neglect Prevention Standard, showed the following information: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms; [...]