Aspire Senior Living Excelsior Springs

Based 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: two Mighty Shakes (a nutritional supplement used in individuals needing supplemental nutrition) and Arformoterol (a medication used for long-term maintenance treatment of chronic obstructive pulmonary disease) for Resident #9. During an Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. During an interview on [DATE] at 11:45 A.M., Administrator A said she was not aware her license had expired and she would reach out to the Missouri Board of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. LPN1 confirmed the hydrogel had expired and removed the tubes from the medication room. During an interview on 07/24/24 at 10:48 AM, LPN1 stated, The supply person goes through the med rooms daily.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 . It was recorded that Mighty Shake ingredients included skim milk. The nutritional supplements were not labeled with a thaw or use-by date. At 8:45 AM, seven Mighty Shakes were noted in the reach-in refrigerator in the main…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. During an observation on 07/24/24 at 8:55 AM, Certified Medication Aide (CMT) 1 took R21's blood pressure using a wrist cuff. CMT1 then placed the dirty wrist cuff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 . Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.

Based 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. During an interview on 6/20/22 at 11:13 A.M., the Minimum Data Set (MDS) coordinator said the care plans were not in one place, some were in the old electronic health record, some were in the new health record. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.

Based 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.

Based 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. -The facility committee should be comprised of the Medical Director, Administrator, Director of Nursing, social services, pharmacist, Dietary Manager, and possibly a charge nurse and Certified Nursing Assistant.

Based 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: - The facility has an RN that primarily works the night shift, 6:00 P.M. to 6:00 A.M. - The administrator thought this constituted 8 consecutive hours of RN coverage within a 24 hour period.

Based 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.): - During the first year of use of these drugs, there must be a gradual dose reduction attempt in two separate quarters, unless clinically contraindicated. The attempts should be at least a month apart; - After the first year, the gradual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Green Beans were 106.1 degrees Fahrenheit; -Apple Cobbler was 101.2 degrees Fahrenheit. Observation of the pureed meal test tray on 6/21/22 at 1:14 P.M., showed: -Roast Pork was 137.1 degrees Fahrenheit; -Green…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 10:15 A.M., showed: - Three packages of tortillas, wrapped in plastic, no label or date; - One ziploc back of breakfast sausage, no label or date; - One open bag of mozzarella cheese, no label or date;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; - For those who previously received a vaccine the minimal interval for additional vaccination is one year 1. Review of Resident #9's medical record showed: - No documentation of the pneumonia vaccine and no documentation of influenza vaccine. 2. Review of Resident #153's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.

Based 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.

Based 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. Review of Resident #154's medical record on 6/23/22 at 10:35 A.M. showed: - The resident received Medicare services beginning on 12/29/21 with the last covered day on 1/18/22; - Therapy discharged the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. There was no documentation to show they checked the NA registry. 2. Review of NA A's personnel file showed his/her date of hire was 5/2/22. There was no documentation to show they checked the NA registry. 3. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. No care plan to address the Hospice needs or goals for the discharge of the resident to home. During an interview on 6/23/22 at 3:17 P.M. the Social Services Director (SSD) said: - The resident went home with Hospice services. - There is no discharge plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.