Elsberry Missouri Health Care Center
1827 Hwy B, Elsberry, MO 63343 · Lincoln County · 56 certified beds · avg 54 residents/day · certified since Jan 1, 2009
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 31, 2025 · F-0744
The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 14, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 16, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 10, 2025 (Past Non-Compliance)
All citations in the current public record (13)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 31, 2025 | ▲ G · Actual harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Jul 31, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 31, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 31, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 31, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 16, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 19, 2023 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Oct 19, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 19, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 19, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Oct 19, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Oct 19, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 19, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | F |
| 2025 | 6 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $28,704, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jul 31, 2025 | Fine | $28,704 |
| Jul 31, 2025 | Payment Denial | 4 days from Sep 10, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.79 | 3.66 | 3.95 | top 42% in Missouri; top 49% in the U.S. |
| Registered Nurse hours | 0.40 | 0.49 | 0.69 | bottom 47% in Missouri; bottom 21% in the U.S. |
| Weekend total nurse staffing | 3.18 | 3.22 | 3.50 | top 48% in Missouri; bottom 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.22 | 0.33 | 0.48 | bottom 35% in Missouri; bottom 16% in the U.S. |
| Total nursing staff turnover (%) | 38.6 | 56.0 | 45.8 | top 11% in Missouri; top 33% in the U.S. |
| RN turnover (%) | 42.9 | 47.8 | 42.9 | top 42% in Missouri; bottom 49% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.05, RN 0.32, weekend 2.56. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bonney, Robert | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/29/2021 |
| Elsberry Missouri Health Care Center INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/17/1974 |
| Haake, Linda | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/28/2008 |
| Haake, Linda | Individual | Corporate Director | NOT APPLICABLE | 11/01/2010 |
| Haake, Linda | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/31/1996 |
| Houston, Ben | Individual | Corporate Director | NOT APPLICABLE | 03/22/2010 |
| Lovelace, Wayne | Individual | Corporate Director | NOT APPLICABLE | 09/28/2008 |
| Mayes, Jim | Individual | Corporate Director | NOT APPLICABLE | 09/28/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Evercare of Calhoun | 11.3 mi | Hardin, IL | ★★★☆☆ | 3/5 | |
| Lincoln County Nursing & Rehab | 12.9 mi | Troy, MO | —/5 | abuseSFF | |
| Troy Manor | 13.3 mi | Troy, MO | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 265825.