Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Elsberry Missouri Health Care Center during CMS and state inspections, most recent first.
A resident with dementia and anxiety repeatedly wandered into other residents’ rooms, went through belongings, and was moved between rooms after conflicts with roommates. The care plan did not address the dementia diagnosis or the resident’s behaviors, and staff reported using only redirection and increased monitoring. The resident was later involved in a physical altercation with a roommate after being found in the roommate’s belongings, resulting in bruising and reopening of a skin tear.
Food items in the kitchen were observed open to air, not sealed, and not labeled or dated, including cheese, tomatoes, sandwiches, parmesan, and onion powder. The range hood had a buildup of grease and debris, a Dietary Aide with facial hair was observed working without a beard restraint, and the ice machine had visible crusty and yellow debris inside the unit.
The facility failed to implement its Legionella water management and surveillance policies. The water management team was not functioning as required, the water flow map was incomplete, cold water temperatures were not monitored, and water testing did not include Legionella. The DON and RN infection preventionists were not trained on ASHRAE standards and had not monitored residents with pneumonia for legionellosis or educated staff on what to watch for.
A facility failed to keep care plans current for two residents. One resident had worsening confusion, hallucinations, yelling out, pain, anxiety, and swallowing changes, but the care plan did not reflect the mechanically altered diet, pocketing/loss of food and liquids, or PRN pain and anxiety meds, and it lacked interventions for hallucinations and confusion. Another resident’s care plan still showed continuous O2 at 2 L NC even after the order changed to PRN use, and the MDS did not accurately assess oxygen therapy status.
A resident with diabetes, heart failure, kidney failure, restless leg syndrome, arthritis, and multiple diabetic foot wounds had repeated blood glucose readings above the physician’s call parameter, but staff did not document notifying the physician. The same resident also had pain monitoring ordered after a medication change, yet the order was entered and discontinued on the same day, with no documentation explaining why monitoring was not completed. During wound care, the resident reported significant pain, and staff did not respond at the time of the dressing changes.
A resident with severe cognitive impairment, dependent on staff for transfers, was injured when two CNAs used a mechanical lift sling with torn attachment loops for a transfer. The staff attached the lift to lower loops beneath the damaged ones, which tore during the transfer, causing the resident to fall and sustain a head laceration requiring ER treatment. Staff interviews indicated a lack of awareness regarding the need to remove damaged slings from use, despite facility policy and manufacturer instructions.
Failure to Address Dementia-Related Wandering and Room Intrusion
Penalty
Summary
The facility failed to ensure a resident with dementia received appropriate care to meet individualized dementia-related needs. Resident #49 had diagnoses of dementia and anxiety disorder and was documented as wandering into other residents’ rooms, going through their belongings, and becoming upset when redirected or confronted. The resident’s care plan, revised after the altercation, only noted that the resident could get confused about where to go and needed redirection, but it did not address the dementia diagnosis, the behavior of entering other residents’ rooms and belongings, or specific interventions tailored to the resident’s needs. Record review showed repeated room changes for Resident #49 after conflicts with roommates. On one occasion, the resident was found upset and shaking after being unable to access personal items and after a roommate yelled at the resident. Staff moved the resident to another room, and later moved the resident again to a different room. The resident’s significant change MDS showed severely impaired cognition and no behavioral symptoms directed toward others, despite staff documentation and interviews describing repeated wandering into other residents’ rooms and belongings. On 07/28/25, staff found Resident #49 in a roommate’s room with the roommate’s belongings. The resident and roommate became verbally and physically aggressive, and the roommate punched Resident #49 multiple times in the arm. The resident sustained a large bruise to the arm and reopening of an existing skin tear on the hand. Interviews with staff and residents described that Resident #49 frequently entered other residents’ rooms, got into closets and drawers, and had previously tried to get into another resident’s bed. Staff stated that monitoring and redirection were the only interventions used, and the DON stated the facility did not have a policy for dementia care and had not directed staff on specific interventions for the resident’s wandering and room-entry behaviors.
Food Storage, Kitchen Sanitation, and Staff Hygiene Deficiencies
Penalty
Summary
Food items in the kitchen were observed not to be labeled, dated, covered, or sealed in accordance with the facility’s food storage policy. In the reach-in refrigerator, an opened five-pound bag of shredded cheddar cheese was open to air and not sealed, a metal pan labeled tomatoes was partially covered with foil but not dated and open to air, a plastic container holding individually wrapped sandwiches was not labeled or dated, and a partial plastic bag of grated parmesan cheese stored inside a zippered bag was not dated. Later, a 20-ounce container of onion powder on a shelf over the preparation counter had its lid open to air and not closed. The Dietary Manager stated food items should be labeled, dated, and closed or sealed, and that checks for proper labeling and dating were done every other day when he was not working. The kitchen range hood had a moderate buildup of dark debris and clear grease on the baffle filters, with yellow grease drips and runs visible on the interior of the hood. The Maintenance Supervisor stated the filters had been cleaned previously and that kitchen staff wiped down the interior, while the Dietary Manager stated the filters were run through the dish machine every other week and the inside of the hood was wiped weekly. Dietary Aide A, who had a beard and sideburns, was observed rolling silverware in napkins and filling beverage glasses without wearing a beard restraint, despite the facility policy requiring facial hair to be covered. The ice machine also had crusty debris and yellow-colored debris visible inside the unit over the accumulated ice on both sides, and staff described routine emptying, wiping, and monthly cleaning of the machine.
Failure to Implement Legionella Water Management and Resident Monitoring
Penalty
Summary
The facility failed to implement its infection prevention and control program for Legionella by not following its own Legionella and Water Management Policy and Legionella Surveillance and Detection policy. The policy called for a water management team that included the Administrator, Maintenance Supervisor, DON, and Medical Director, but the Administrator stated the facility did not have a water management team and had not had a water management meeting. The Maintenance Director said there had been only one water management team meeting since the last survey, and the Administrator also stated the facility’s water flow map included only entry and exit points and water heaters, with no other areas in the building. The facility also did not have documentation showing monitoring of cold water temperatures, and the Maintenance Director said he did not monitor cold water temperatures and did not know the cold and hot water ranges to prevent Legionella growth. He stated he sent monthly water samples for E. coli, lead, and copper testing to the department of natural resources, but those tests did not include Legionella. He also said he did not check for sediment, scaling, or biofilm. The facility policy review showed no direction for assessing hot and cold temperatures within the facility and did not address how often the water management team was to meet. Clinical staff were also not trained or monitoring residents as directed by policy. The DON said she did not know what ASHRAE standards were, had not attended a water management meeting, had not monitored residents with pneumonia for legionellosis, and had not educated staff on what to monitor for. RN M said he/she and the Administrator were the infection preventionists, but he/she had not monitored any residents for legionellosis and had not educated staff. The Administrator stated staff should be monitoring residents for legionellosis per policy, but the facility had not implemented that monitoring plan.
Care plans not updated for changing behaviors, swallowing needs, pain/anxiety meds, and oxygen orders
Penalty
Summary
The facility failed to keep the comprehensive care plan current and consistent with residents’ changing conditions, needs, and risks for two residents. The report states that the care plan was to be completed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals, but the facility did not make appropriate updates for Resident #34 and Resident #17. The facility policy also stated that the care plan should be revised quarterly, with a significant change, and as needed. For Resident #34, the record showed diagnoses including cerebrovascular disease, dementia, dysphagia, and hallucinations. The resident’s condition changed over time, with progress notes documenting poor appetite, refusal to get out of bed for meals, being fed by staff, yelling out, talking in sleep, and being extremely confused. The resident also had physician orders for PRN Tylenol, later PRN morphine for pain, and later PRN lorazepam for anxiety. A significant change MDS showed severe cognitive impairment, dependence for eating, loss of liquid/solids from the mouth when eating or drinking, holding food in the mouth/cheeks or residual food after meals, a mechanically altered diet, and pain that frequently interfered with sleep and day-to-day activities. Despite these changes, the updated care plan dated 07/29/25 did not address the resident’s mechanically altered diet, loss of liquid/solids from the mouth, or pocketing food. It also did not include interventions for the resident’s auditory and visual hallucinations or periods of confusion, and it did not address the PRN pain and anxiety medications available for pain and/or anxiety. Observation and staff interview showed the resident yelling out, asking for help, asking where he/she was, and stating pain in the legs, while an LPN stated the resident had developed new anxiety and yelling out behaviors and that interventions used in practice were not listed on the care plan. For Resident #17, the care plan dated 04/24/25 still showed continuous oxygen at 2 liters per nasal cannula, even though the physician order dated 05/30/25 changed oxygen to 2 liters per nasal cannula as needed for shortness of breath. The care plan was not updated to reflect that the resident no longer required continuous oxygen therapy. The quarterly MDS dated 07/17/25 showed oxygen therapy was required, but continuous and as-needed oxygen therapy were not assessed. Observation showed the resident with portable oxygen at 2 liters per nasal cannula, and the resident stated oxygen was used as needed and not continuously.
Failure to Report Critical Blood Glucose Values and Monitor Pain
Penalty
Summary
The facility failed to follow physician orders and its own policy when staff did not notify the physician of blood glucose results that were outside the ordered reporting parameters for one resident. The resident had diagnoses including diabetes mellitus, heart failure, kidney failure, and restless leg syndrome, and was receiving accu checks four times daily. The physician order dated 07/14/25 directed staff to call the physician with a blood glucose greater than 400, and the facility policy required reporting values less than 50 or greater than 400 unless otherwise instructed by the physician. Review of the resident’s MAR showed multiple elevated blood glucose readings without documentation that the physician was notified. On 07/16/25, the resident’s blood glucose was documented as 497 at midday and 409 at dinner time. On 07/17/25, the readings were 465 at midday and 482 at dinner time. On 07/18/25, the readings were 461 at midday and 487 at dinner time. The EMR and nursing notes contained no documentation that staff reported any of these values to the physician as required. The facility also failed to adequately monitor pain for the same resident, who had multiple diabetic wounds to the feet, pressure ulcers, and arthritis-related pain. The resident’s orders included PRN pain medications and an order to monitor pain every shift for one week related to a medication change, but the MAR showed the pain monitoring order was entered and discontinued on the same day and did not remain available to prompt staff. There was no documentation of an order to discontinue the monitoring or an explanation for why it was not completed. The care plan addressed pain generally, but did not specify how often pain should be monitored or whether staff should offer an intervention before therapy or wound treatments. During the survey, the resident reported significant pain, including pain rated 9/10 and later 7/10 during wound care, and staff did not respond to the resident’s pain report at the time of the dressing changes.
Resident Injury Due to Use of Damaged Mechanical Lift Sling
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident using a mechanical lift. Two CNAs transferred a resident from a wheelchair to bed using a full body sling that had two torn attachment loops. Instead of replacing the sling, the staff attached the lift to the lower loops beneath the torn ones. During the transfer, these lower loops tore, causing the resident to fall from the lift and sustain a laceration to the back of the head, which required emergency room treatment. The resident involved had severely impaired cognition, was nonverbal most of the time, and was dependent on staff for transfers, requiring extensive assistance and use of a mechanical lift. The facility's mechanical lift policy and the manufacturer's instructions both required inspection of slings for wear prior to each use and immediate removal from service if any tearing, fraying, or wear was found. Despite these requirements, the damaged sling was used for the transfer. Interviews with staff revealed that the CNAs believed the sling was safe to use because the green loops appeared intact, even though the purple loops were broken. Laundry staff were responsible for inspecting slings for damage during washing but reported not having found any damaged slings. The restorative aide, who was assigned to conduct weekly audits of slings, was unaware of the damaged sling prior to the incident.
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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 Elsberry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evercare Of Calhoun | 11.2 mi | ★★★★★ | 3 | 0 |
| Silex Community Care | 12.1 mi | — | 0 | 0 |
| Lincoln County Nursing & Rehab | 12.9 mi | — | 3 | 0 |
| Troy Manor | 13.3 mi | ★★★★★ | 0 | 0 |
| Abbey Senior Health | 24 mi | ★★★★★ | 1 | 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.