Elsberry Missouri Health Care Center

Inspectors wroteBased 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. Resident #49 became verbally agitated with Resident #46 and in response Resident #46 punched Resident #49 in the arm multiple times resulting in a large bruise to the resident's arm and reinjury to an existing skin tear on the resident's hand. [...]

Inspectors wroteBased 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. Observation on 7/28/25 at 10:51 A.M. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make appropriate updates and revisions to develop a plan of care consistent with residents' specific conditions, needs and risks for two residents (Resident #34 and #17) in a review of 17 sampled residents. The facility failed to revise Resident #34's care plan to provide staff direction for interventions related to the resident's auditory and visual hallucinations and confusion, did not update to address the resident's mechanically altered diet/loss of liquid/solids from his/her mouth when eating or drinking, holding food in his/her mouth/cheeks or residual food in mouth after meals, and did not address pain medications for pain and/or anxiety, and failed to revise Resident #17's care plan to include the resident's current oxygen therapy order. The facility census was 54. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders and facility policy when they did not notify the physician of blood glucose results (the amount of sugar in the blood outside of the parameter outlined in the physician's orders and facility policy for one resident, (Resident #2) in a sample of 17 residents. The facility also failed to adequately monitor pain for one resident (Resident #2) who had multiple diabetic wounds to his/her feet and arthritis. The facility census was 54. Review of the undated facility policy, Blood Glucose Test Procedure, showed the following:-Record test results in electronic medical record (EMR);-Report any values less than 50 or greater than 400 to the physician. Unless otherwise instructed by physician. [...]

Inspectors wroteBased 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. On 4/8/25, the administrator became aware of the resident's fall from a mechanical lift during a transfer. Upon discovery, the facility investigated and notified the appropriate parties. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, facility document and policy review, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure staff maintained meal temperature monitoring records for each meal service; failed to ensure staff maintained monitoring records of the sanitizer concentrations for the three-compartment sink to ensure items were properly sanitized; and failed to ensure staff thawed a roll of ground beef in accordance with professional standards. These failures had the potential to affect 52 of 52 residents who received meals from the dietary department.

Inspectors wroteBased on observations, interviews, document review, and facility policy review, the facility failed to properly store and secure medications for 2 (Hall 100 medication cart and facility medication/treatment cart) of 3 medication carts observed and failed to ensure proper labeling of eye drops for 1 (Resident #43) of 3 residents observed for eye drop administration during medication pass. Specifically, the facility failed to ensure medications remained in direct line of sight of staff or were in a locked compartment, failed to properly store tramadol under a double lock, and failed to date an eye drop container when opened.

Inspectors wroteBased on interviews and document review, the facility failed to ensure three (Certified Nursing Assistant (CNA) #7, #8, and #11) of five CNAs had at least 12 hours of in-service training per year.

Inspectors wroteBased on interviews, record review, and facility document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) form included all current mental illness diagnoses for one (Resident #26) of one sampled resident reviewed for PASARR requirements.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to follow physician orders related to wound care for one (Resident #43) of three residents reviewed for wound care.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure staff maintained infection control practices to prevent the spread of infection during treatments of wounds and administration of medications for one (Resident #43) of two residents observed for wound care and two (Resident #21 and Resident #152) of eight residents observed during medication pass.