Elsberry Missouri Health Care Center

In the surveyor’s words

From the most serious findings on record at Elsberry Missouri Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF744Jul 31, 2025

  Based on observation, interview and record review, the facility failed to ensure one resident, (Resident #49), with diagnosis of dementia, in a review of 17 sampled residents, received appropriate care to ensure his/her individualized dementia care needs were met. Resident #49 wandered in and out of other residents' rooms uninvited and went through other residents' belongings upsetting other residents. In response, the facility frequently moved the resident to different rooms. On 7/28/24, Resident #49 was looking through his/her roommate's (Resident #46) belongings. […]

• Actual harm, isolatedF689Apr 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #3), out of eight sampled residents, was safely transferred from a wheelchair to bed with a mechanical lift. Staff used a lift sling with two torn attachment loops for the transfer, hooking the sling to the lift with the two attachment loops below the torn loops. During the transfer, the lower loops tore, causing the resident to fall from the lift. The resident sustained a laceration to the back of his/her head which required treatment in the emergency room . The facility census was 55. On 4/16/25 at 12:55 P.M., the administrator was notified of the past noncompliance which occurred on 4/8/25. […]

• No harm, potential for more than minimal, widespreadF812Jul 31, 2025

  Based on observation, interview, and record review, the facility failed to ensure food items were labeled, dated, and covered; failed to maintain the range hood to be free of an accumulation of grease and debris; failed to ensure staff wore beard restraints to prevent potential contamination; and failed to ensure the ice machine was free of a buildup of debris. The census was 54.Review of the undated facility policy, Food Storage-Refrigeration, showed foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with expiration dates. The manager and/or his/her designee shall check the refrigerators daily to ensure leftovers are discarded and all food is properly stored. 1. […]

• No harm, potential for more than minimal, widespreadF880Jul 31, 2025

  Based on interview and record review, the facility failed to implement the facility policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The administrator said the facility did not have a water management team, did not have a water flow map with the details of the water flow though the building and that include all of the elements the facility policy directed, and the facility had not been monitoring cold water temperatures. […]

• No harm, potential for more than minimal, widespreadF801Oct 19, 2023

  Based on interviews and facility document review, the facility failed to ensure the designated Dietary Manager (DM) had the required education, certification, or experience to qualify her for the position. This had the potential to affect 52 of 52 residents who received meals from the dietary department. Findings included: During an interview on 10/18/2023 at 2:09 PM, the Administrator stated the facility had no policy or procedure addressing the requirements to serve in the dietary management position. A review of the DM's employee file revealed the facility initially hired the DM in August 2022 as a housekeeper and laundry aide. […]