Aspire Senior Living Excelsior Springs

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to properly store and monitor food items for expiration dates, dispose of dented cans in a timely manner, and failed to maintain a three-day emergency food supply. This affected all residents in the facility. The facility census was 78. Request for facility Food Department Policies on food storage not provided;Observation in the Dry Storeroom on 1/5/25 at 9:00 A.M., showed:- Emergency Food Stock had only 12 cans of food and three bags of pasta for emergencies. - Two #10 sized cans of peans on the ground underneath the can storage rack. - Three rows of six #10 sized cans (18 total) in the can storage rack are dented and marked Do Not Use. - Three dented #10 sized cans on the ground labeled Do Not Use. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance, of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for three Residents (Resident #9, Resident #44, and Resident #68) of the 18 sampled residents. The facility census was 78. Review of the facility's Protecting, Promoting and Ensuring Resident Rights- Facility Responsibility policy, dated 1/30/25, showed every Resident has the right to be fully informed, in advance, about the care and treatment and of any changes in the care or treatment that may affect the resident's well-being. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for five residents (Resident #85, #86, #87, #88 and #89) and failed to notify by letter one resident (Resident #7) when they were within $200.00 of the Supplemental Security Income (SSI) resources limit. This affected six of 18 residents sampled. Facility census was 78. Review of facility policy Facility Resident Trust Fund, undated, showed:- The individuals trust account should be kept below the balance of $5700.00 as a best practice rule, however, the current limit for Medicaid recipients is $5909.25. Any individual Resident Trust Account that is nearing (within $200 dollars) the state specified maximum balance will require the following action: [...]

Inspectors wroteBased on observation and interview, the facility failed to provide privacy for two Residents (Resident #2 and #39) of 18 sampled residents during cares when staff failed to close the privacy curtain during peri-care for Resident #39 and failed to close the window blinds when performing a dressing change to Resident #2's buttock wound. The census was 78. Review of the facilities Perineal Care policy, dated April 2025, showed:- Staff were to provide privacy by pulling curtain or closing room door if a private room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment of the Level I preadmission screening resident review (PASARR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities completed before admission to the nursing facility) was completed before admission for two Residents (Resident #68 and Resident #80). The affected two of 18 sampled residents. The facility census was 78. Review of the facility's Preadmission Screening for Individuals with a Mental Disorder/Intellectual Disability PASARR policy, dated 1/30/24, showed:- Ensure each resident in a nursing facility is screened for a mental disorder or intellectual disability prior to admission; [...]

Inspectors wroteBased interview and record review the facility failed to provided care and treatment in of accordance with professional standards of practice when facility staff failed to follow physician's orders for three of 18 sampled residents (Resident #5, #24 and #68), when staff did not provide Mighty Shakes (a nutritional supplement used in individuals needing supplemental nutrition) and failed to notify the physician the shakes had not been given to Residents #5, #51 and #68 as ordered. The facility census was 78. The facility did not provide the requested policy regarding professional standards. 1. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff dated 11/20/25 showed:-No cognitive impairment;-Partial assistance from staff with bed mobility and toileting; -Incontinent of bowel and bladder; [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when facility staff did not provide proper incontinence care for two of 18 sampled residents (Resident #2 and #39). The facility census was 78. Review of the facilities Perineal Care policy, dated April 2025, showed:- It is the practice of this a facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown;- Staff were to provide privacy by pulling curtain or closing room door if a private room;- Cleanse buttocks and anus, front to back; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned for four residents (Residents #2, #9, #29, and #39) and additionally failed to properly store oxygen accessories at the bedside for two residents (Resident #2 and #29). This affected four of 18 sampled residents. The facility census was 78. Review of the facility's Oxygen Administration policy, dated April 2006, showed:- There was no specific guidance on changing out prefilled disposable humidifiers by month or week;- Label humidifier with date and time opened. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation and when staff failed to ensure the bed's dimensions were appropriate for the resident's size and weight for three of 18 residents sampled (Residents #51, #4 and #24). The facility census was 78. Review of the facility's Bed Rails policy dated 1/30/2024 showed:-Ensure correct installation and maintenance of bed rails;-The facility will ensure correct installation and use maintenance of bed rails; -The facility will assess the resident's risk for entrapment from bed rails prior to installation and ensure the beds dimensions are appropriate for the residents size and weight;-The facility will follow the manufacturers recommendations and specifications for installing and maintaining bed rails; [...]

Inspectors wroteBased on observation interview and record review the facility staff failed to complete inspection of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three of 18 sampled residents (Resident #51, #4 and #24). The facility census was set 78.1. Review of Resident #51's quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff dated 08/05/25 showed:-No cognitive impairment;-Dependent on staff for toileting and bed mobility;-Incontinent of bowel and bladder;-Two or more falls with injury since admission;-Diagnoses included Multiple Sclerosis (MS) a chronic autoimmune disease that can cause high cholesterol and depression. [...]

Inspectors wroteBased on observation, interview, and record review the home failed to store all drugs and biologicals under proper temperature controls, when the facility was unable to provide a record that the refrigerator temperature in the Certified Medication Technician (CMT) medication room had been monitored to ensure medication was being stored at the proper temperature. The facility census was 78. The facility did not provide a medication storage policy. Observation of the medication room labeled as the CMT medication room (Certified Medication Technicians) on 01/06/2026 at 3:20 P.M. showed:-No refrigerator temperature log sheet on refrigerator and no logbook available in medication room;-The freezer compartment of the refrigerator had ice buildup on it and extending past the edges of the compartment;-Contents of the refrigerator included: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a qualified licensed administrator on duty from [DATE] to [DATE]. The facility census was 78. Review of an undated facility policy regarding the Administrator showed: -The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. A licensed administrator is responsible for the day-to-day functions of the facility. Review of the job description for the Administrator position showed: - Minimum Requirements, Abilities and Expectations include Current Administrator license or certification as required by state regulations. Review of the current Missouri Association of Nursing Home Administrators license registry web site showed Administrator A not listed as a current Missouri Licensed Administrator. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to remove expired medications from two of two medication storage rooms observed for medication storage. This failure had the potential to subject residents to unsafe or ineffective treatments. The facility census was 77. Review of the facility's undated policy titled, Storage of Medications revealed, . No discontinued, outdated, or deteriorated medications are to be used . All such medications are destroyed according to a facility policy . During an observation on 07/24/24 at 10:46 AM, Licensed Practical Nurse (LPN) 1 and the surveyor observed the medication room by nurse's station. Three tubes of expired Skintegrity Hydrogel, used in the treatment of some pressure ulcers, were noted on a shelf within a cabinet. Two of the tubes had an expiration date of May 2024. One had an expiration date of October 2023. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to store food in accordance with professional standards of food service safety for 17 of 17 residents who received nutritional supplements. This had the potential to result in food born illnesses for residents who consumed nutritional supplements. The facility census was 77. Review of the facility's undated policy titled, Aspire Supplements, revealed the policy did not address thaw and use-by dates for any dietary supplement. During the initial tour of the kitchen on 07/22/24 at 8:40 AM, a box containing 59 four-ounce thawed Mighty Shakes (a nutritional supplement) was noted in the walk-in refrigerator in the main kitchen. The box was dated 08/22/24. Each four-ounce carton contained a warning label that recorded, . store frozen, thaw at below 40 degrees. Use thawed product within 14 days . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff appropriately cleaned and disinfected patient equipment after using a wrist cuff and manual blood pressure cuff for one of three residents (Resident (R) 21) observed during the medication pass out of a total census of 77. This failure could promote the spread of multi drug resistant organisms (MDROs) throughout the facility. The facility census was 77. Review of the facility's undated policy titled, Medication Cart Clean/Disinfecting, revealed, . Clean all equipment (BP cuffs, pulse ox, etc.) that comes in contact with resident per packaging between each use . Review of R21's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses that included cerebral ischemia. [...]

Inspectors wroteBased on interview, record review, and review of Centers for Disease Control and Prevention (CDC) guidance and facility policy, the facility failed to maintain a functional Antibiotic Stewardship Program that ensured criteria was met for the use of antibiotics for one of two residents (Resident (R) 47) reviewed for antibiotics out of a total sample of 22. This had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary. The facility census was 77. Review of an undated, untitled CDC document located at https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html revealed, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated . Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority . [...]

Inspectors wroteBased on record review and interview, the facility failed to review and update their facility-wide assessment to determine what resources are necessary to care for their residents competently during day to day operations and emergencies. The facility census was 54. The facility did not provide a policy regarding maintaining a facility assessment. Review of the facility assessment, provided by the facility, showed: -The assessment was last updated on 12/3/2021. - The information provided did not include any updates or evidence of review for the first six months of 2022. During an interview on 6/23/2022 at 3:00 P.M., the Administrator said: - The facility assessment has not been updated to reflect recent changes at the facility, including change of ownership. - It is the Administrator's responsibity to ensure the facility assessment is reviewed regularly and updated as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the residents' medical record accessible to staff for 14 residents (Resident #51,#7, #36, #12, #26, #153, #11, #34, #9, #49, #30, #4, #45 and #3) out of 14 sampled resident's. The facility census was 54. 1. Record review of the resident's sampled on survey, Resident #51,#7, #36, #12, #26, #153, #11, #34, #9, #49, #30, #4, #45 and #3), showed the following records were not accessible: - Nurses Notes prior to 12/1/17; - Care Plans; - Physicians orders prior to 1/1/17; - admission and Quarterly risk assessments prior to 12/1/17; - Physician notes prior to 12/1/17; - Pharmacy Recommendations. - Immunization Records Observation on 6/20/22 at 11:00 A.M., showed the care plans were not readily available to staff and staff did not have access to the previous electronic health record. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop quality assessemnt and assurance (QAA) activities and a quality assurance/performance improvement (QAPI) plan which drives the facility's ability to address any areas of concern and to correct any quality deficiencies identified by the QAPI process. The facility census was 54. The facility did not provide a policy for their QAA/QAPI committee and process. The facility was unable to provide record of their QAA/QAPI committee and process. During an interview on 6/23/22 at 10:40 A.M, the Administrator said: -The QAA committee met on 2/8/22, with the Administrator, Director of Nursing and Medical Director in attendance. - There is no record or minutes from this meeting as the records were kept on the Administrator's computer, which was erased when the facility changed ownership on 6/1/22.

Inspectors wroteBased on record review and interview, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. The facility census was 54. The facility did not provide a policy in regards to their QAA process or committee. The facility was unable to provide record of the QAA and QAPI program. During an interview on 6/23/22 at 10:40 A.M., the Administrator said: - The facility has had one QAA Committee meeting on 2/8/22. The Administrator, Director of Nursing and Medical Director were present. - There are no minutes or record of this meeting as the records were kept on the Administrator's computer, and previous ownership erased the computer when the facility changed ownership on 6/1/22.

Inspectors wroteBased on record review and interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 54. The facility did not provide a policy regarding their QAA committee. The facility was unable to provide any record or minutes of the QAA program. During an interview on 6/23/22 at 10:40 A.M., the Administrator said: -The QAA committee has met once, on 6/23/2022, with the Administrator, Director of Nursing and Medical Director present. -There are no minutes or records of this meeting because previous ownership erased the computer where these records were kept when the facility changed ownership on 6/1/2022. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 54. The facility did not provide a policy regarding RN staffing. Review of the staffing sheets for March 2022 showed: - No RN scheduled for eight consecutive hours on 3/13/22 and 3/27/22. Review of the staffing sheets for April 2022 showed: - No RN scheduled for eight consecutive hours 4/9/22, 4/16/22, 4/17/22, 4/23/22, and 4/24/22. Review of the staffing sheets for May 2022 showed: - No RN scheduled for eight consecutive hours on 5/7/22 and 5/22/22. Review of the staffing sheets for June 2022 showed: - No RN scheduled for eight consecutive hours on 6/4/22, 6/5/22, 6/18/22, and 6/19/22. During an interview on 6/23/22 at 3:00 P.M., the Administrator said: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide record that Certified Nurse Assistants (CNAs) received the required 12 hours in-service education; failed to provide record that competencies were completed and to provide dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) education. The facility census was 54. The facility did not provide a policy regarding CNA education. The facility was unable to provide requested records documenting CNAs have received the required 12 hours per year of in-service education. During an interview on 6/23/22 at 3:00 P.M., the Administrator said due to the recent change of ownership, the facility and administrator do not have access to personnel records, including those verifying CNAs receiving the required 12 hours in-service education per year.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure pharmacy services thoroughly reviewed the resident medication regimens to identify irregularities related to the use of psychotropic medications for two of 14 sampled residents (Resident #4 and #30) reviewed for unnecessary psychotropic medication use. The facility census was 54. Review of the facility policy for Psychopharmcologic Drugs Gradual Dose Reduction (GDR) Schedule, dated 2009, showed: - Antipsychotics (Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders. They are also the mainstay together with mood stabilizers in the treatment of bipolar disorder.): [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to assure staff served food to the residents that was palatable, attractive, and served at a safe and acceptable temperature to the residents. The facility census was 54. Review of the facility policy for food temperatures, dated April 2006, showed: -The Dietary Services Manager (DSM) or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled. -Keep the temperature of hot foods no less than 140 Degrees Fahrenheit during tray assembly. -Hot food should be at least 120 Degrees Fahrenheit when served to the resident. -Take and record all temperatures for all items at all meals. Observation of the regular meal test hall tray on 6/21/22 at 1:00 P.M., showed: -Roast Pork was 133.3 degrees Fahrenheit; -Baked Sweet Potato was 125.4 degrees Fahrenheit; [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff stored and prepared food in a safe and sanitary manner, and dispose of food in a timely manner. The facility census was 54. Review of the facility policy on Receiving and Storage of Food, dated April 2011, showed: -The Dining Services Managers (DSM) is responsible for receiving and storing food and nonfood items. -All perishable items are stored in either refrigerators (at a temperature of 40 degrees Fahrenheit or below) or freezers (at a temperature of 0 degrees Fahrenheit or below.) -Follow the rule of First In First Out (FIFO) Observation of the kitchen on 6/20/22 at 10:02 A.M., showed: - Large fan over the ice machine dirty with dust and debris; - The hood and air filters over the stove are dirty; - The top of the oven idirty with dust and food debris. Observation of the three door refrigerator on 6/20/22 at 10: [...]

Inspectors wroteBased on record review and interviews, the facility failed to assure all residents were offered the flu and pneumonia vaccinations in a timely manner. This affected six out of 14 sampled residents (Residents #7, #9, #12, #153, #34, and #36). The facility census was 54. The facility did not provide a policy for pneumonia or influenza vaccinations for the residents. Review of the Centers for Disease Control (CDC) website for Pneumococcal Vaccine Timing for Adults showed: - For those who have never received a pneumococcal vaccine or those with unknown vaccination history, administer one dose of PCV 15 (a 15-valent pneumococcal conjugate vaccine (Vaxeuvance) or a PCV29 (20 valent pneumococcal conjugate vaccine (Prevnar20) - If PCV 15 is used, the recommended interval for an additional vaccine is one year; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the exhaust/mechanical ventitation system. The facility census was 54. 1. Observation on 6/22/22 beginning at 1:47 P.M. showed the following bathroom vents were not operating when tested: - room [ROOM NUMBER], #410, #408, #306, and #206. These bathrooms did not have outside ventiliation/windows. 2. Observation of the bathroom vent in the conference room showed the vent was caked with dust. This bathroom did not have any outside ventiliation/windows. 3. During an interview on 6/22/22 at 5:00 P.M. the Administrator said: - The facility had not had a Maintenance Director since 6/3/22; - She was not sure how often the ventilation was checked but the system should work.

Inspectors wroteBased on interview and record review, the facility failed to provide individual residents with quarterly statements for two (Resident #45 and Resident #4) of two sampled residents. The facility census was 54. The facility did not provide a policy regarding providing quarterly statements. The facility was unable to provide any quarterly statements for Resident #45 or Resident #4. During an interview on 6/23/22 at 10:50AM, the Administrator said: - The facility currently does not have a Business Office Manager (BOM). - The Administrator believes that the previous BOM did send out quarterly statements to residents or their responsible parties. - The facility does not have access to these records to verify this has been done. During a recent change of ownership, the facility lost access to the Business Office records.

Inspectors wroteBased on record review and interview, the facility failed to ensure they utilized the correct Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form, a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility, for two residents sampled for beneficiary notifications (Resident #45 and Resident #33). The facility census was 54. The facility did not provide a policy for the SNFABN notices. 1. Review of Resident #45's medical record on 6/23/22 at 10:34 A.M. showed: - The resident received Medicare services beginning on 3/24/22 with the last covered day on 5/9/22; - Therapy discharged the resident from Medicare covered services on 5/9/22; - The facility issued the SNFABN notice on 5/6/22, but used an outdated form. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to screen four of five newly hired staff members when they did not check the Nurse Aide (NA) Registry upon hire. The facility census was 54. Review of the facility policy titled Abuse Prevention Program dated as revised December 2016 included the following: - The policy statement showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. - As part of their abuse prevention, the administration will conduct employee background checks and will not knowingly employ any individual who have had a finding entered into the state Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. 1. Review of Housekeeping Supervisor's (HS) personnel file showed his/her date of hire was 3/23/22. [...]

Inspectors wroteBased on interview and closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs, including caregiver support and referrals to local contact agencies, as appropriate and involved the resident and if applicable the resident representative and interdisciplinary team in developing a discharge plan for one resident (Resident #53) in a review of two closed records. The facility census was 54. The facility did not provide a policy for discharge planning. 1. Review of the progress note dated 4/7/22 at 11:09 A.M. showed: - The resident was discharged home with Hospice. - The resident took all medications with him/her. Review of the closed medical record for Resident #53 showed no discharge care plan with instructions for the family for the care of the resident at home. [...]

Inspectors wroteBased on interview and closed record review, the facility staff failed to complete a comprehensive discharge summary for one discharged residents (Resident #53). The facility census was 54. Record review of the closed record for Resident #53 showed the resident was discharged to home on 4/7/22 and the staff did not complete a discharge summary. During an interview on 6/23/22 at 3:17 P.M. the Social Services Director (SSD) said: - He/she is responsible for writing the discharge summaries when a resident is discharged from the facility; - The resident was discharged to home, there was no discharge summary completed. During an interview on 6/23/22 at 3:17 P.M. the Administrator said: -She would expect a discharge summary to be written when a resident is discharged from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to fully develop and implement their staff vaccination policy for COVID-19 when they did not ensure all required components were included in the policy. Facility census was 54. Review of the facility policy for Employee COVID-19 Vaccinations dated 2/22/22 showed: - It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines - Policy Explanation: COVID-19 remains a threat to the population's health, and those that reside in long-term care or congregate setting have been greatly affected by this pandemic. Vaccination against COVID-19 ensures that employees will provide a safe workplace and decrease the risk of transmission to this vulnerable population. [...]