Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elderberry Health Care during CMS and state inspections, most recent first.
Surveyors found that food items in the walk-in refrigerator and kitchen were not properly dated, labeled, or sealed, including undated deli meats, cheese, and cake, as well as a box of apples with visible spoilage and fruit flies. Staff interviews confirmed that dietary staff were responsible for these tasks, but the required procedures were not consistently followed.
A resident's advance directive information was not consistently updated across the medical record, resulting in conflicting documentation of code status. Although the resident was cognitively intact and had clearly requested to be full code, the electronic medical record and MAR continued to indicate DNR status due to breakdowns in communication and unclear staff responsibilities for updating records.
A resident with chronic urinary retention was found to have an indwelling urinary catheter in use without a corresponding physician order and without a securement device to prevent tension or trauma. Staff interviews revealed unawareness of the missing securement device, and leadership confirmed these were staff oversights.
The facility failed to ensure dishware was clean and dry before storage and neglected to label and date leftover perishable foods in the walk-in cooler. Observations revealed wet and debris-covered dishware, and undated opened cheese packages in the cooler. Staff interviews confirmed these practices were not in line with expected standards.
The facility failed to manage waste disposal properly, with two dumpsters found open and trash accumulated around them. Staff interviews confirmed that it was the responsibility of all shifts to ensure the dumpsters were closed and the area was clean. A sign was present to remind staff to close the dumpsters due to bears in the area.
The facility failed to display oxygen use signage outside the rooms of two residents using supplemental oxygen. One resident with COPD and Emphysema was observed using oxygen without signage, and another with COPD and Acute Respiratory Failure also lacked signage. Staff interviews revealed confusion over responsibility for placing signs, with a clerk in training not fully informed of the task.
A facility failed to include necessary statements in their arbitration agreement, affecting a resident with moderate cognitive impairment. The agreement lacked verbiage about the right to rescind within 30 days and that signing was not a condition for admission or continued care. Staff interviews revealed awareness of these rights, but the current agreement did not reflect them.
A resident with dementia struck another resident on the head with a statue, causing a laceration. The incident was witnessed by a NA who intervened. The facility's care plan lacked interventions for potential behavioral issues, leading to a deficiency in protecting residents from abuse.
The facility failed to post required contact information for State agencies and advocacy groups, including the State Survey Agency and the Ombudsman program, on its bulletin boards. Despite claims from the Activities Director and Administrator that the information was posted, observations during a recertification survey revealed the absence of such postings in the facility's common areas.
The facility did not consistently post daily nurse staffing sheets for 18 days over a two-month period. The Medical Record staff was responsible for posting on weekdays, while charge nurses were to post on weekends and days off. However, this was not consistently done, and the Administrator was unaware of the lapses.
The facility failed to maintain accurate medical records for two residents, leading to documentation deficiencies. One resident's tracheostomy suctioning was mis-documented, with staff admitting to inaccuracies and misunderstanding prompts. Another resident's leg laceration treatment was poorly documented, lacking details in the Treatment Administration Record. The DON and Administrator were unaware of these issues, indicating insufficient monitoring processes.
Failure to Properly Date, Label, and Dispose of Food Items
Penalty
Summary
Surveyors observed multiple instances of improper food storage and handling in the facility's kitchen and walk-in refrigerator. Specifically, food items such as a slice of cake, a disposable container labeled as containing tomato slices, opened bags of deli meat, a tomato slice wrapped in plastic, blocks of sliced cheese, and a bag of shredded cheese were all found without proper dating or labeling. Additionally, some of these items were not properly sealed. These observations were made during a walkthrough of the walk-in refrigerator. Further inspection in the kitchen revealed a box of apples stored on a cart, with approximately seven apples showing signs of bruising and brown areas, and the presence of several fruit flies around the apples. Staff interviews confirmed that food not labeled, dated, or expired was disposed of, and that dietary staff were responsible for ensuring proper food storage practices. However, the observed deficiencies indicated that these procedures were not consistently followed.
Failure to Consistently Update Advance Directive Information in Medical Records
Penalty
Summary
The facility failed to maintain consistent and updated advance directive information throughout the medical record for one resident. The resident's medical record contained conflicting documentation regarding code status, with an advance directive form indicating Do Not Resuscitate (DNR) status, while a more recent form indicated full code status. Despite the resident being cognitively intact and clearly expressing a desire to be full code during an interview, the electronic medical record and medication administration record continued to display DNR status. Staff interviews revealed that the process for updating advance directive information involved multiple steps and personnel, including the social worker, medical records clerk, and MDS assistant, but communication breakdowns led to delays and inconsistencies in updating the resident's code status across all records. The social worker described the process for handling advance directives, which included assessing cognitive status, obtaining necessary signatures, and forwarding the completed form for scanning and record updates. However, the medical records clerk and MDS assistant each believed it was the other's responsibility to update the electronic medical record banner, and the physician was uncertain about whether she had documented the change in a progress note or written a new order. The medical records clerk initially stated he was not notified of the change, but later recalled being informed and notifying the MDS assistant, though the update was still not made in the system. As a result, the resident's current wishes regarding resuscitation were not accurately reflected in all parts of the medical record, leading to confusion among staff who relied on the electronic banner and medication administration record for code status information. The lack of a clear, coordinated process for updating and communicating changes to advance directives contributed directly to the deficiency identified during the survey.
Failure to Obtain Physician Order and Use Catheter Securement Device
Penalty
Summary
A resident with chronic urinary retention was admitted to the facility with an indwelling urinary catheter. The resident's baseline care plan indicated the presence of the catheter, and the Minimum Data Set confirmed its use. However, a review of the resident's physician orders revealed there was no documented order for the indwelling urinary catheter, although there was an order for catheter care and output documentation. During an observation of catheter care, it was noted that the resident did not have a catheter securement device in place, although there was no visible tension on the tubing and the drainage bag was appropriately positioned. Multiple nursing assistants and a nurse interviewed were unaware of the absence of the securement device until it was pointed out, and all acknowledged that a securement device should have been used. The DON and Administrator confirmed that both the lack of a physician order and the missing securement device were oversights by staff.
Deficiency in Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to ensure that dishware was clean and properly dried before being stored for use, and also failed to label and date leftover perishable foods in the walk-in cooler. During an initial tour of the kitchen, it was observed that several pieces of dishware, including divided plates, domed lids, and trays, were stacked while still wet and had visible debris on them. Specifically, 7 out of 10 divided plates, 11 out of 20 domed lids and bottoms, and 6 out of 20 trays were stacked wet. Additionally, some dishware had white, yellow, black, and clear sticky debris. Furthermore, three large plastic bags containing opened and partially used packages of yellow sliced cheese were found in the walk-in cooler without any date labels. Interviews with staff, including the Dietary Manager and the Administrator, confirmed that the dishware should have been left to dry in the rack and that opened food items should have been labeled and dated.
Improper Waste Disposal Management
Penalty
Summary
The facility failed to properly manage waste disposal as observed during a survey. Two dumpsters were found with their doors open, one three-quarters open and the other completely open, with visible trash bags inside. Additionally, there was accumulated trash and debris around both dumpsters, including used plastic gloves, tissues, a plastic cup, and a plastic food container with food debris. A sign was present on the second dumpster, reminding staff to close the doors due to the presence of bears in the area. Interviews with staff revealed that Cook #1 confirmed the dumpsters were left open and there was trash around them. He mentioned that it was the responsibility of all shifts to ensure the doors were closed and the area was clean. The Dietary Manager acknowledged the issue, stating that the sign was placed due to previous bear problems and reiterated that all staff were responsible for maintaining the dumpsters. The Administrator also expressed the expectation that dumpster doors should be closed and the area kept free of trash.
Failure to Display Oxygen Use Signage
Penalty
Summary
The facility failed to apply signage indicating the use of oxygen outside the rooms of two residents who were using supplemental oxygen. Resident #69, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and Emphysema, had a physician's order to use and titrate oxygen to maintain levels between 88-92%. Despite being observed wearing oxygen via nasal cannula at 3.5 liters per minute, there was no signage for oxygen use near the entrance of Resident #69's room during multiple observations. Similarly, Resident #273, admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure, had a physician's order for baseline oxygen at 4 liters, with instructions to titrate as needed. Observations revealed that Resident #273 was using oxygen at 2.5 liters per minute, yet there was no signage indicating oxygen use near the room entrance during several checks. Interviews with staff, including nursing assistants, a nurse, the Director of Nursing (DON), and the Administrator, revealed a lack of clarity and communication regarding the responsibility for placing oxygen use signage. The nurse on the hall was initially responsible, but the task was also expected to be checked by a clerk during weekly rounds. However, the clerk was still in training and had not been fully informed of this responsibility, leading to the oversight.
Arbitration Agreement Deficiency
Penalty
Summary
The facility failed to ensure that their arbitration agreement explicitly stated that residents or their legal representatives have the right to rescind the agreement within a 30-day timeframe and that signing the agreement was not a condition of admission or a requirement to continue receiving care. This deficiency was identified during a review of the facility's admission packet and arbitration agreement dated 06/21/23, which did not include these necessary statements. The issue affected one resident, who was moderately cognitively impaired, and whose representative signed the arbitration agreement without the required information being present. Interviews with facility staff, including a Social Worker and the Administrator, revealed that while the Social Worker explained the choice to accept, decline, or rescind the arbitration agreement to residents and families, the specific verbiage regarding the 30-day rescind period and the non-requirement of signing for admission or continued care was missing from the current agreement. The Administrator was unaware that the arbitration agreement in use lacked this critical information, despite stating that residents or their representatives could rescind or decline the agreement and that signing was not a condition for admission.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a resident-to-resident altercation occurred. Resident #74, who was admitted with unspecified dementia and other mental health issues, struck Resident #73 on the head with a statue after believing that Resident #73 was going to enter her room. This incident resulted in a laceration on Resident #73's head, which required treatment with steri strips. Despite Resident #74's intact cognition and lack of documented behavioral issues, the care plan did not include any goals or interventions for potential behavioral problems. The incident was witnessed by Nurse Aide (NA) #3, who intervened by moving Resident #73 away and seeking assistance from a nurse. The facility's administrator explained the process for handling abuse situations, which includes assessing the involved residents, investigating the incident, and separating the residents to prevent future altercations. However, the report does not mention any specific actions taken prior to the incident to prevent such occurrences, highlighting a deficiency in protecting residents from abuse.
Failure to Post Required Agency Contact Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the State Survey Agency, adult protective services, the Office of the State Long-Term Care Ombudsman program, and the protection and advocacy network. This deficiency was observed during a recertification survey conducted over four days. On three separate occasions, surveyors noted the absence of required signage on the facility's front hallway bulletin board and other common areas. Despite the Activities Director's claim that Ombudsman posters were displayed throughout the facility, the necessary contact information for other agencies was not visible. During an interview, the Administrator acknowledged that the information should be posted and suggested that the signage might have been removed by someone, although she was unsure when or by whom. The Administrator stated that she updated the board as needed and believed the required information was in place. However, observations confirmed the lack of postings, indicating a failure to maintain compliance with regulations requiring the display of contact information for state and advocacy agencies.
Failure to Post Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that daily nurse staffing sheets were completed and posted for 18 out of 59 days during the period from July 1, 2024, to August 28, 2024. Observations on August 25, 2024, revealed that the daily nurse staffing sheet posted at the nurses' station was outdated, showing the date of August 23, 2024, with no sheet available for August 24, 2024. A review of the records confirmed the absence of staffing sheets on specific dates, primarily on weekends or days when the Medical Record staff was off duty. Interviews with the Medical Record staff and the Administrator revealed a lack of clarity and oversight regarding the responsibility for posting the staffing sheets in the absence of the Medical Record staff. The Medical Record staff indicated that the charge nurse was responsible for posting the sheets on weekends and his days off, but this was not consistently done. The Administrator was unaware that the charge nurses were not fulfilling this responsibility, and there was no system in place to verify that the postings were completed as required.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, leading to deficiencies in documentation. For one resident, there was a physician's order for tracheostomy suctioning every 12 hours, but staff documented that suctioning was performed 50 out of 51 times in August 2024, despite interviews revealing that the resident was only suctioned in emergencies and disliked the procedure. Multiple nurses admitted to mis-documenting the suctioning frequency, with one nurse misunderstanding the computer prompt and another unaware that they could document when suctioning was not provided. The Director of Nursing (DON) and Administrator were unaware of the mis-documentation, and the order was not updated to reflect the actual need for suctioning. For another resident, the facility failed to document treatment provided after the resident sustained a laceration to the left lower leg. The initial investigation report indicated that the laceration was treated with steri strips, which later came off, requiring a different dressing. However, there was no documentation of the change in orders or the condition of the laceration on specific dates. The Treatment Administration Record (TAR) lacked documentation of the steri strips application. Interviews with the nurse involved and the resident's physician highlighted poor documentation practices, with the physician expecting detailed wound documentation that was not present. The DON and Administrator were also unaware of the lack of documentation for the laceration. These deficiencies indicate a failure in maintaining accurate medical records and ensuring proper documentation of treatments and procedures. The facility's monitoring processes for accuracy in medical records were insufficient, as evidenced by the lack of awareness from the DON and Administrator regarding the documentation issues. The discrepancies in documentation practices among the nursing staff contributed to the incomplete and inaccurate medical records for the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marshall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Health And Rehabilitation | 7.2 mi | ★★★★★ | 2 | 0 |
| The Greens At Weaverville | 7.9 mi | ★★★★★ | 0 | 0 |
| Emerald Ridge Health And Rehabilitation | 11.1 mi | ★★★★★ | 11 | 1 |
| Bear Mountain Health And Rehabilitation | 12.6 mi | ★★★★★ | 2 | 0 |
| River Bend Health And Rehabilitation | 13.2 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.