Citizens Memorial Healthcare Facility

In the surveyor’s words

From the most serious findings on record at Citizens Memorial Healthcare Facility, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as possible when staff failed to check the temperature of soup prior to serving and failed to ensure the resident was in an appropriate upright position prior to meal service for one resident (Resident #44) resulting in a burn from the hot liquid. The facility census was 95. Review of the facility policy titled, Event Reporting, approved 10/2025, showed the following:-The incident reporting system will be used to report possible errors, untoward events, and near misses to management, risk manager/administration;-To promptly document information relative to possible errors, untoward events, and near misses;-Definition of event is an occurrence that ideally should… […]

• No harm, potential for more than minimal, widespreadF812Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to date stored food in the refrigerator and freezer; failed to discard prepared food after the use by date; and failed to follow proper hygiene practices when two staff failed to wear beard nets. The facility's census was 95.Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to date stored food in the refrigerator and freezer; failed to discard prepared food after the use by date; and… […]

• No harm, potential for more than minimal, patternF804Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to have a process in place to ensure food was served at a palatable temperature to all residents when food was below the optimal holding temperature before leaving the kitchen and was not routinely temped by all kitchen staff. This resulted in complaints regarding cold food from seven residents (Resident #55, #39, #72, #11, #83, #61, and #52.) The facility census was 95. Review of the facility's policy titled, Safe Food Handling and Preparation, approved 12/2025, showed the following:-The Director of Nutritional Services/Food Service Supervisor (DNS) is responsible for maintaining and establishing safe food procedures which meet the conditions set up by the Missouri Department of Health and Senior Services;-Purpose was… […]

• No harm, potential for more than minimal, patternF880Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during personal cares for one resident (Residents #5) who had a catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) and when the staff failed to complete proper hand hygiene during personal cares for two residents (Resident #5 and #57)… […]

• No harm, potential for more than minimal, patternF658Dec 8, 2023

  Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to accurately and consistently monitor and document weights for three residents (Resident #37, #73, and #56). The facility census was 103. Record review of the facility's policy titled, Patient Weights. dated April 2022, showed the following: -In long-term care setting, weights will be done on admission, monthly, and as needed or ordered; -Upon admission to long-term care facility, an initial weight will be obtained; -Wheelchair weights: balance scales, patient may be rolled upon platform by placing scale side flaps down, receive weight, weight empty wheelchair, and subtract weight of chair from total weight of resident; -Document the weight in the electronic medical… […]