Inspection Reports for
Elsberry Missouri Health Care Center
1827 HIGHWAY B, ELSBERRY, MO, 63343-3126
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
79% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 55
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
The document is a plan of correction submitted in response to a deficiency cited during a survey completed on 2025-04-16 regarding accident hazards related to mechanical lift devices.
Findings
The facility failed to ensure one resident was safely transferred using a mechanical lift sling that had torn attachment loops, causing the resident to fall and sustain a head laceration. The facility implemented weekly audits of lift slings and updated policies to prevent recurrence.
Deficiencies (1)
F 689: The facility did not ensure the resident environment was free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. A lift sling with torn attachment loops broke during transfer causing a resident to fall and sustain a head laceration.
Report Facts
Facility census: 55
Maximum weight capacity: 600
Date of deficiency correction: Apr 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cami Butts | Administrator | Signed plan of correction and involved in corrective actions |
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
Annual Inspection
Deficiencies: 7
Date: Oct 19, 2023
Visit Reason
The inspection was the annual survey of Elsberry Missouri Health Care Center to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including PASARR screening for mental disorders and intellectual disabilities, quality of care related to wound care, medication labeling and storage, dietary staffing and training, food safety, infection control, and nurse aide in-service training requirements.
Deficiencies (7)
F645 PASARR screening was deficient as the facility failed to ensure a Pre-Admission Screening and Resident Review form included all current mental illness diagnoses for one sampled resident.
F684 Quality of care was deficient as the facility failed to follow physician orders related to wound care for one resident, including undated policies and incomplete wound care documentation.
F761 Labeling and storage of drugs and biologicals was deficient as the facility failed to properly store and secure medications for three medication carts and ensure eye drops were dated when opened.
F801 Staffing was deficient as the facility failed to ensure the designated Dietary Manager had the required education, certification, or experience, potentially affecting 52 residents.
F812 Food safety requirements were deficient as the facility failed to maintain meal temperature logs and ensure proper thawing and storage of food items.
F880 Infection prevention and control was deficient as the facility failed to maintain infection control practices during wound treatments and medication administration for multiple residents.
F947 Required in-service training for nurse aides was deficient as three CNAs did not complete the required 12 hours of annual training.
Report Facts
Residents affected: 52
Certified Nursing Assistants: 5
CNAs deficient in training: 3
Medication carts observed: 3
Residents reviewed for wound care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #14 | Primary Physician | Confirmed review and signing of PASARR forms and wound care orders |
| RN #1 | Registered Nurse | Observed wound care and medication pass, confirmed medication orders and hand hygiene practices |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding wound care orders, medication cart security, and hand hygiene policies |
| Administrator | Facility Administrator | Interviewed regarding PASARR screening, wound care, medication administration, dietary manager staffing, and training |
| Licensed Practical Nurse (LPN) #6 | Licensed Practical Nurse | Observed medication cart and storage of controlled substances |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding qualifications, training, and food safety practices |
| Dietary Cook #13 | Dietary Cook | Interviewed regarding food safety and training |
| Certified Nursing Assistant (CNA) #7 | Certified Nursing Assistant | Interviewed regarding in-service training and work history |
| Certified Nursing Assistant (CNA) #8 | Certified Nursing Assistant | Interviewed regarding in-service training and work history |
| Certified Nursing Assistant (CNA) #11 | Certified Nursing Assistant | Interviewed regarding in-service training |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 18, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's compliance with fire safety and smoke barrier requirements under Medicare/Medicaid regulations and the National Fire Protection Association Life Safety Code.
Findings
The facility was found not in substantial compliance due to failure to maintain smoke separation in accordance with NFPA 101. Specifically, a 6 inch by 6 inch opening around a sprinkler pipe in the smoke barrier wall was not properly sealed.
Deficiencies (1)
K372: The facility failed to maintain smoke separation as required by NFPA 101. A 6 inch by 6 inch opening around a sprinkler pipe in the smoke barrier wall was not sealed with fire rated material.
Report Facts
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding the smoke barrier opening and did not know how or when it occurred |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Report Facts
Regulatory compliance references: 42
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.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
This document reports the results of the annual recertification survey and state licensure inspection of Elsberry Missouri Health Care Center.
Findings
No health deficiencies were cited as a result of the annual recertification survey. No state licensure deficiencies were cited as a result of the state inspection.
Inspection Report
Life Safety
Census: 49
Capacity: 56
Deficiencies: 3
Date: Oct 28, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain the sprinkler system free of dust and debris, and did not ensure electrical receptacle retention testing was conducted as required. Additionally, lint buildup was found in the gas clothes dryers' top compartment, posing a fire hazard.
Deficiencies (3)
K353 Sprinkler System - The facility failed to maintain sprinklers clean and free of dust, which could interfere with proper operation in an emergency. This deficiency affected four of five smoke compartments.
K914 Electrical Systems - The facility did not ensure electrical receptacle retention testing was conducted according to NFPA 99 standards. This deficiency had the potential to affect all occupants in five smoke compartments.
K932 Features of Fire Protection - The facility failed to ensure the laundry dryers' top compartments were free of lint buildup, which could pose a fire hazard in one of five smoke compartments.
Report Facts
Facility capacity: 56
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Responsible for sprinkler and electrical outlet maintenance; interviewed regarding deficiencies | |
| Administrator | Interviewed regarding expectations for sprinkler cleanliness and dryer lint removal |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 2
Date: Mar 7, 2019
Visit Reason
The inspection was conducted to evaluate compliance with nutritional needs and menu preparation standards at Elsberry Missouri Health Care Center, focusing on adherence to dietary guidelines for residents on pureed and mechanical soft diets.
Findings
The facility failed to follow the spreadsheet menu for lunch on 3/4/19 for residents on pureed and mechanical soft diets, including not adding bread to pureed items and not serving gravy as required. Staff lacked proper serving utensils and did not comply with dietitian-approved meal preparation policies.
Deficiencies (2)
F803: Menus and nutritional adequacy were not met as the facility failed to follow the spreadsheet menu for pureed and mechanical soft diets on 3/4/19, including omission of bread and gravy and improper serving portions.
A5001: Nutritional needs were not met as residents did not receive adequate diets in accordance with physician orders and national guidelines, referencing deficiency F803.
Report Facts
Census: 55
Inspection Report
Life Safety
Census: 55
Capacity: 56
Deficiencies: 9
Date: Mar 7, 2019
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code investigation to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to develop and maintain an adequate emergency preparedness plan and did not meet the applicable provisions of the 2012 Life Safety Code. Deficiencies included failure to track location of staff and residents during emergencies, unsealed openings in ceilings compromising fire barriers, improperly maintained smoke barrier doors, and unsafe smoking area practices.
Deficiencies (9)
E018 Emergency preparedness policies and procedures were not adequately developed or maintained, including failure to track location of on-duty staff and sheltered residents during emergencies.
K161 The facility failed to maintain fire resistance barriers between the first floor and attic by not repairing openings in the ceiling, risking exposure to fire and smoke.
K374 The facility failed to maintain smoke barrier doors with a 20-minute fire resistance rating, allowing passage of smoke and fire through holes in the doors.
K741 The facility failed to ensure combustibles were not intermixed with burned cigarettes in the designated smoking area, posing a fire hazard.
K932 The facility failed to maintain the laundry area free of excessive lint buildup on gas dryers, creating a fire hazard.
A2007 All openings between floors were not fire-stopped with suitable noncombustible material, violating fire safety regulations.
A2054 Smoke section walls and doors were not properly separated by one-hour fire-rated walls and self-closing doors as required.
A2057 Designated smoking areas lacked proper ashtrays of noncombustible material and safe design.
A2067 Clothes dryers were not properly vented to the outside and lint traps were not cleaned regularly.
Report Facts
Facility census: 55
Facility capacity: 56
Date of survey: Mar 7, 2019
Inspection Report
Life Safety
Census: 52
Capacity: 56
Deficiencies: 4
Date: Apr 6, 2018
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code survey to assess compliance with fire safety and smoke barrier requirements.
Findings
The facility failed to ensure smoke barriers were complete and properly sealed, allowing passage of smoke and fire between compartments. Electrical equipment such as power strips and extension cords were improperly used, creating potential fire hazards affecting multiple residents.
Deficiencies (4)
K372: The facility failed to ensure smoke barriers were complete and sealed, allowing passage of smoke and fire to another compartment. Observations showed unsealed holes and conduits penetrating smoke barriers in multiple locations.
K920: Electrical equipment such as power strips and extension cords were improperly used in resident areas, creating fire hazards. Observations included multiple power strips and extension cords plugged into outlets and adapters in resident rooms.
A2054: Each smoke section must be separated by one-hour fire-rated walls that close automatically upon fire alarm activation. This regulation was not met as evidenced by K372.
A3030: Electrical wiring and equipment must be installed and maintained per NFPA 70 standards. This regulation was not met as evidenced by K920.
Report Facts
Facility capacity: 56
Census: 52
Residents potentially affected: 24
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 6, 2018
Visit Reason
The inspection was conducted as an annual recertification survey and licensure inspection of Elsberry Missouri Health Care Center.
Findings
No health deficiencies or state licensure deficiencies were cited as a result of this annual recertification survey and licensure inspection.
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