Inspection Reports for
Elsberry Missouri Health Care Center
1827 HIGHWAY B, ELSBERRY, MO, 63343-3126
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
54 residents
Based on a July 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 54
Deficiencies: 5
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care planning, medication administration, dementia care, food safety, infection control, and other facility operations at Elsberry Missouri Health Care Center.
Findings
The facility failed to update care plans to reflect residents' current conditions and needs, failed to notify physicians of critical blood glucose results, inadequately monitored pain, did not provide appropriate dementia care interventions, failed to maintain food safety standards, and did not implement a comprehensive Legionella water management program.
Deficiencies (5)
Failed to update care plans for residents with specific conditions including hallucinations, diet changes, oxygen therapy, and pain management.
Failed to notify physician of blood glucose results outside ordered parameters and failed to adequately monitor pain for a resident with diabetic wounds.
Failed to provide appropriate dementia care and interventions for a resident who wandered into other residents' rooms and caused altercations.
Failed to ensure food items were labeled, dated, and covered; failed to maintain kitchen equipment and ensure staff wore beard restraints; ice machine had debris buildup.
Failed to implement facility policy for Legionella control including lack of water management team, incomplete water flow mapping, no cold water temperature monitoring, and lack of staff training on Legionella monitoring.
Report Facts
Facility census: 54
Residents sampled: 17
Blood glucose readings: 497
Blood glucose readings: 409
Blood glucose readings: 465
Blood glucose readings: 482
Blood glucose readings: 461
Blood glucose readings: 487
Pain rating: 9
Pain rating: 7
Diabetic ulcer size: 1
Pressure ulcer size: 0.5
Diabetic ulcer size: 1.5
Diabetic ulcer size: 0.5
Diabetic ulcer size: 1
Pressure ulcer size: 1
Pressure ulcer size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nurse Aide | Mentioned in observation of Resident #34's care and response to pain |
| LPN K | Licensed Practical Nurse | Provided interview about Resident #34's condition and care plan |
| CNA H | Certified Nurse Aide | Interviewed about care plan usage and updates |
| Assistant Director of Nursing | ADON | Interviewed about care plan responsibilities and updates |
| Director of Nursing | DON | Interviewed about care plan expectations and dementia care |
| Administrator | Administrator | Interviewed about care plan accuracy and facility policies |
| Director of Nurse | Director of Nurse | Interviewed about blood glucose and pain monitoring policies |
| RN N | Registered Nurse | Observed during wound dressing and pain management for Resident #2 |
| CNA B | Certified Nurse Aide | Reported altercation between residents #46 and #49 |
| LPN C | Licensed Practical Nurse | Interviewed about resident altercation and wound care |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about kitchen equipment cleaning and water management |
| Dietary Manager | Dietary Manager | Interviewed about food safety and kitchen hygiene |
| RN M | Registered Nurse | Infection preventionist interviewed about Legionella monitoring |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
The inspection was conducted following a complaint regarding a resident's fall from a mechanical lift during transfer, which resulted in injury.
Complaint Details
The complaint investigation found that the resident fell due to use of a lift sling with torn loops. The complaint was substantiated with evidence including staff interviews, resident records, and photos of the damaged sling.
Findings
The facility failed to ensure safe transfer of a resident using a mechanical lift with a sling that had torn attachment loops, causing the resident to fall and sustain a head laceration requiring emergency treatment. The facility investigated, educated staff, and implemented weekly audits of lift slings to prevent recurrence.
Deficiencies (1)
Failure to ensure safe transfer of a resident using a mechanical lift with a sling that had torn attachment loops, resulting in a fall and injury.
Report Facts
Residents affected: 1
Facility census: 55
Laceration size: 5
Staples received: 3
Date of resident's MDS assessment: Jan 30, 2025
Date of resident's care plan: Feb 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Involved in transferring the resident when the sling failed |
| CNA B | Certified Nurse Aide | Involved in transferring the resident when the sling failed |
| RA E | Restorative Aide | Assigned to weekly audits of lift slings and involved in corrective actions |
| Director of Nursing | Provided statements on sling safety and corrective measures | |
| Administrator | Notified of incident and described expectations for staff and corrective plan |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to PASARR screening, wound care, medication storage and administration, dietary management, food safety, infection control, and staff training at Elsberry Missouri Health Care Center.
Findings
The facility was found deficient in multiple areas including incomplete PASARR mental illness diagnosis documentation, failure to follow wound care physician orders, improper medication storage and labeling, inadequate dietary manager qualifications and food safety practices, poor infection control during wound care and medication administration, and insufficient CNA in-service training hours.
Deficiencies (7)
Failed to ensure PASARR form included all current mental illness diagnoses for one resident.
Failed to follow physician orders related to wound care for one resident.
Failed to properly store and secure medications for two medication carts and failed to ensure proper labeling of eye drops for one resident.
Failed to ensure the designated Dietary Manager had required education, certification, or experience.
Failed to maintain meal temperature monitoring records, sanitizer concentration logs, and failed to ensure proper thawing of ground beef.
Failed to maintain infection control practices during wound treatments and medication administration for multiple residents.
Failed to ensure three CNAs had at least 12 hours of in-service training per year.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 52
Residents affected: 1
Residents affected: 2
Residents affected: 3
In-service training hours: 11.5
In-service training hours: 5
In-service training hours: 8.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #14 | Primary Physician | Named in PASARR screening and wound care order findings |
| RN #1 | Registered Nurse | Observed and interviewed regarding wound care and medication pass deficiencies |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding medication storage of tramadol |
| Director of Nursing | DON | Interviewed regarding wound care, medication storage, infection control, and CNA training |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies including medication storage, wound care, dietary management, infection control, and CNA training |
| Dietary Manager | DM | Named in dietary management and food safety deficiencies |
| Certified Dietary Manager | CCDM | Named in dietary management training and oversight |
| Dietary [NAME] #13 | Dietary Staff | Interviewed regarding meal temperature and sanitizer monitoring |
| CNA #7 | Certified Nursing Assistant | Named in CNA training deficiency |
| CNA #8 | Certified Nursing Assistant | Named in CNA training deficiency |
| CNA #11 | Certified Nursing Assistant | Named in CNA training deficiency |
Inspection Report
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Elsberry Missouri Health Care Center, summarizing the findings from the survey completed on 10/28/2020.
Findings
No health deficiencies were found during the inspection.
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