Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspire Senior Living Excelsior Springs during CMS and state inspections, most recent first.
Food Storage and Emergency Supply Deficiencies: Facility staff failed to store and monitor food in accordance with professional standards. Observations showed an inadequate emergency food stock, dented and rusted cans kept in the storeroom and on the floor, bulk items without use-by dates, and defrosting ground beef without proper dating. The DM stated the emergency supply was not enough for 3 days and that dented cans had been kept for weeks before being turned in for credit.
Surveyors found that staff failed to provide proper perineal care and hygiene to two dependent residents requiring assistance with ADLs. For a cognitively impaired resident with multiple diagnoses, a CNA did not separate skin folds or clean all areas where urine or feces could have contacted the skin during peri-care. For another resident with a suprapubic catheter, recurrent UTIs, and irritant contact dermatitis, the ADON reused a single cleansing wipe by folding it and wiping the perineal area multiple times, despite other staff and leadership stating that wipes should only be used once. These practices did not follow the facility’s peri-care policy requiring separate wipes for each stroke and thorough cleansing of all affected areas.
Failure to obtain written consent before starting psychotropic medications for three residents. One resident had intact cognition and was receiving diazepam and quetiapine, while two others had impaired cognition and were receiving antianxiety, antipsychotic, and antidepressant medications. Records showed no signed consents before or after the meds were started, and interviews confirmed the DPOA had not been asked to sign paperwork and staff were unsure who was responsible for obtaining psychotropic consent.
A facility failed to refund or provide final accounting for several residents’ trust funds after discharge or death and failed to send a required letter to a resident whose account was within $200 of the SSI resource limit. Records showed one resident with moderate cognitive impairment and multiple diagnoses had a trust balance above the state limit, while several discharged or deceased residents still had remaining funds in their accounts. The BO said the missed refunds and notice were oversights.
Failure to Maintain Privacy During Personal Care: Staff failed to provide privacy for two residents during care. For one resident with dementia and total dependence on staff, CNAs performed peri-care with the curtain between the resident and roommate left open, exposing the resident in full view of the roommate. For another resident receiving wound care for a stage 3 pressure ulcer, the ADON and an LPN left the resident’s perineal area and buttock exposed while the window blinds were open to the parking lot.
Failure to complete Level I PASARR screening before admission for two residents. One resident had impaired cognition, dependence for ADLs, and diagnoses of anxiety, depression, and psychotic disorder; the care plan also noted dementia-related aggression risk and use of psychotropic and anti-anxiety meds. The medical record had no PASARR documentation, and the SSD, Administrator, and DON all acknowledged the screening should have been completed before admission.
Failure to Provide Ordered Nutritional Supplements: Multiple residents with cognitive impairment and nutritional concerns had physician orders for Mighty Shake three times daily, but MARs and nursing notes showed repeated missed doses because the supplement was out of stock, frozen, or otherwise unavailable. Staff interviews showed CMTs and CNAs knew the shakes were not being given, but the nurse, physician, and RD were not notified when the ordered supplements were missed.
Failure to document and store oxygen equipment properly affected several residents receiving O2 therapy. Staff did not date oxygen tubing or humidifier equipment as ordered, and two residents had oxygen accessories not properly stored or attached at the bedside. Residents involved had significant respiratory diagnoses including COPD, respiratory failure, HF, and Alzheimer’s disease, and one resident reported dry, bloody nasal passages and wanting humidified O2.
A facility failed to assess entrapment risk before installing bed rails and failed to verify that bed dimensions were appropriate for residents’ size and weight for three residents. One resident with MS and a history of falls had bilateral cane rails in use and had prior incidents in which an arm and shoulder were caught in the rail. Two other residents with severe cognitive impairment and fall histories also had bilateral cane rails, but their assessments lacked height, weight, and documentation that the rails fit their size and weight. Staff interviews showed the MDS Coordinator, DON, Maintenance Director, and Administrator were not aware of entrapment assessments, and the bed rail process did not include resident measurements or bed dimension checks.
Failure to Inspect Bed Frames and Bed Rails for Entrapment: Three residents who used bilateral cane rails or side rails had records showing bed rail use, falls, and significant medical issues such as MS, severe cognitive impairment, heart failure, and atrial fibrillation. One resident’s notes documented a fall in which the shoulder got caught in the bed rail. For all three residents, the record lacked documentation of pre-installation inspection of the bed frame and mattress and lacked evidence of an ongoing inspection process to identify possible entrapment areas. Staff interviews showed the CNA, LPN, MDS Coordinator, Maintenance Director, DON, and Administrator were not aware of an ongoing entrapment assessment process.
Medication refrigerator temperature was not being monitored in the CMT medication room, and surveyors found no temperature log sheet or logbook available. The refrigerator’s freezer compartment had ice buildup extending past the edges, and it contained two Mighty Shakes and Arformoterol for a resident. The CMT said he/she did not check the temperature and did not know where the log was kept, while the Administrator, RN, CMT, and DON gave differing accounts of who was responsible for checking and recording the refrigerator temperature.
The facility failed to maintain a qualified licensed administrator as required by state laws. Administrator A's license had expired, and she was unaware of this until it was brought to her attention. Despite receiving multiple renewal reminders from the BNHA, she claimed not to have received them. Administrator B was hired temporarily to fulfill the role until Administrator A's license could be renewed. The facility lacked a policy for checking administrator license status, which they plan to implement.
Expired medications, including Skintegrity Hydrogel, cranberry tablets, and Thera-M multi-vitamins, were found in two medication storage rooms. Staff interviews revealed confusion about who is responsible for checking and removing expired medications, despite the Administrator stating that monthly audits are conducted.
The facility failed to properly store nutritional supplements for 17 residents, as observed during an inspection. A box of thawed Mighty Shakes in the walk-in refrigerator was not labeled with a thaw or use-by date, and the Dietary Manager was unaware of the required time frames. This oversight had the potential to cause foodborne illnesses.
A facility failed to properly clean and disinfect blood pressure cuffs after use on a resident, as observed during a medication pass. A CMT used alcohol prep pads instead of disinfectant wipes, contrary to facility policy. Interviews with staff revealed inconsistencies in understanding and implementing cleaning protocols.
A facility failed to maintain an effective Antibiotic Stewardship Program, leading to the inappropriate prescription of antibiotics for a resident with chronic kidney disease and no UTI symptoms. Despite the absence of symptoms, a urinalysis was ordered, and antibiotics were prescribed before culture results were available. The resident was later found resistant to the prescribed antibiotic, necessitating a change in medication. Interviews revealed non-compliance with the facility's protocols, highlighting the need for better adherence to the McGeer Criteria.
Food Storage and Emergency Supply Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when facility staff failed to properly monitor food items for expiration dates, dispose of dented cans in a timely manner, and maintain a three-day emergency food supply. During observation of the dry storeroom, the emergency food stock contained only 12 cans of food and three bags of pasta for emergencies. The storeroom also contained two #10 cans of peas on the ground under the can storage rack, three rows of six dented #10 cans marked Do Not Use in the rack, and three additional dented #10 cans on the ground, including two being used as door stops and one lying under a storage rack; one can was rusted and bulging on the side. Large plastic bins of breadcrumbs, gram cracker crumbs, flour, and sugar were also observed with dates but no use-by dates. The Dietary Manager stated there was not enough food in the emergency supply to feed residents for three days and that the dented cans had been kept since the Thanksgiving and Christmas time frames, with disposal delayed until the credit was large enough to matter. In the walk-refrigerator, ground beef was defrosting with a received date but no date showing when defrosting started or a use-by date. The Dietary Manager stated the hamburger had been placed in the refrigerator sometime during the weekend, and later stated that food items should never be stored on the ground, bulk items should have a use-by date, and defrosting food should be dated. The Registered Dietician also stated opened items should be resealed and dated, food should not be stored on the ground, defrosted meat should have a date showing when it is to be used or when defrosting started, and dented cans should be turned in at the next available opportunity.
Failure to Provide Proper Perineal Care and Hygiene for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate perineal care and maintain personal hygiene for dependent residents requiring assistance with ADLs. For one resident with Alzheimer’s disease, respiratory failure, and heart failure, who was cognitively impaired and totally dependent on staff for ADLs, surveyors observed two CNAs performing peri-care. CNA B wiped the resident’s inner thighs with separate cleansing wipes but then used a single wipe twisted into the front of the genital opening without spreading the surrounding skin folds, and wiped down the leg and up to the anus without separating folds or verifying cleanliness. CNA B later stated they would normally wipe all areas exposed to urine or feces but did not do so in this instance. Other staff, including another CNA, the ADON, DON, and the Administrator, stated that proper peri-care requires cleaning all areas where urine or stool could touch and providing privacy, and an anonymous employee reported that CNA B did not provide good peri-care to two residents who required toileting and changing. For another resident who was cognitively intact but dependent on staff for personal hygiene and had diagnoses including irritant contact dermatitis due to friction or contact with body fluids, UTI, neuromuscular dysfunction of the bladder, and a suprapubic catheter, the ADON was observed providing peri-care after wound treatment. The ADON cleaned the perineal area by wiping once down the middle, then folded the same wipe and used it again down the middle of the perineal area, contrary to facility expectations. In an interview, the ADON stated that a cleansing wipe could be folded and reused up to three times during peri-care, while a CNA, the Administrator, and the DON each stated that a cleansing wipe should only be used once and should not be folded and reused. These observations and interviews showed that staff did not consistently follow the facility’s perineal care policy, which required thorough cleansing of all areas where urine or feces could contact the skin, use of separate wipes for each stroke, and proper technique to maintain hygiene and assess for skin breakdown.
Failure to Obtain Written Consent Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks and benefits of proposed care and treatments by not obtaining written consent before starting psychotropic medications for three sampled residents. Review of the facility policy showed residents have the right to be fully informed in advance about care and treatment changes that may affect their well-being. Record review showed Resident #44 had intact cognition, diagnoses of anxiety and depression, and was receiving diazepam and quetiapine, but there were no consents signed by the resident or representative before or after these medications were started. Resident #68 was not cognitively intact, had diagnoses of anxiety, depression, and psychotic disorder, and was receiving antianxiety, antipsychotic, and antidepressant medications, but the record also contained no signed consents before or after the medications began. Resident #9 had impaired cognition and diagnoses of depression, anxiety, and PTSD, and was receiving trazodone, venlafaxine, and bupropion, yet the electronic record showed no consents signed by the resident or representative before or after medication administration. During interviews, the resident's DPOA stated the facility did not have him/her sign paperwork regarding new medications, side effects, or medication changes. An RN stated written consent had not been obtained before starting psychotropic medications and was unsure who was responsible for obtaining it. The ADON, DON, and Administrator each stated residents and their representatives should know the potential side effects and reasons for taking psychotropic medications before taking them, and that signed psychotropic consents should be in place.
Resident trust funds not refunded or accounted for timely, and required balance notice not sent
Penalty
Summary
The facility failed to provide personal funds and a final accounting within 30 days after discharge or death for five residents and failed to notify one resident by letter when the resident’s trust account was within $200 of the SSI resources limit. Facility policy stated that resident trust accounts nearing the state maximum required notification by letter, and that refunds for discharged residents were to be completed within 5 business days, with resident funds reconciled no later than 30 days. The deficiency affected six of 18 residents sampled, with a facility census of 78. Resident #7 had moderate cognitive impairment on MDS and diagnoses including anemia, diabetes, hip fracture, seizure disorder, bipolar disorder, psychotic disorder, and anxiety disorder. Records showed the resident’s trust account balance was $8,072.15, and the BO stated she had discussed spending down the balance but did not know a letter was required when the account was within $200 of the state limit. Records also showed Resident #85 discharged with $3.51 in the trust account, Resident #86 expired with $268.27, Resident #87 discharged with $10.00, Resident #88 discharged with $57.31, and Resident #89 had $27.38 in the trust account; the BO stated these residents should have been refunded or their money sent back to Medicaid, and that these were oversights. The Administrator stated resident accounts should be reconciled and refunded as necessary within 5 days of discharge but no later than 30 days.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy for two residents during personal care. For one resident with Alzheimer’s disease, respiratory failure, heart failure, and total dependence on staff for care, CNA B and CNA C performed peri-care while the resident’s room door was closed but the curtain between the resident and the roommate remained open. The resident was exposed and the peri-care was performed in full view of the roommate. CNA B stated he/she would normally provide proper privacy between the resident and the roommate but did not. Staff interviews confirmed that privacy should be provided during peri-care by pulling the curtain. For another resident who was cognitively intact, dependent on staff for toileting, bathing, and dressing, and had a stage 3 pressure ulcer of the right buttock, colostomy, hospice status, and an above-the-knee amputation, the ADON and an LPN provided wound care while the resident’s perineal area and buttock were exposed. During the care, the window blinds next to the resident’s bed were open to the parking lot, and a car drove into the parking lot and parked while care was being provided. The resident said he/she just wanted staff to do what they needed to do regarding privacy during care. Multiple staff members stated that blinds should be closed and privacy provided when the resident would be exposed.
Failure to Complete PASARR Screening Before Admission
Penalty
Summary
The facility failed to ensure that a Level I PASARR assessment was completed before admission for two residents. The deficiency was identified during interview and record review and involved Resident #68 and Resident #80, two of 18 sampled residents in a facility census of 78. The facility’s PASARR policy, dated 1/30/24, stated that each resident must be screened for a mental disorder or intellectual disability prior to admission and that the initial Level I identification is completed before admission to the facility. For Resident #68, the quarterly MDS dated 11/6/25 showed cognition was not intact, the resident was dependent on staff for activities of daily living, and diagnoses included anxiety, depression, and psychotic disorder. The care plan revised 11/6/25 noted potential physical aggression related to dementia, psychotropic medication use related to psychosis, and anti-anxiety medication use related to an anxiety disorder. The medical record contained no documentation that a Level I PASARR had been completed. During interviews, the SSD said the facility did not have documentation of a Level I PASARR and was not sure if one had been completed, the Administrator said a Level I PASARR should be in the EMR and that the facility attempts to obtain it from the prior facility, and the DON said the Level I PASARR should have been completed before admission and was not sure of the policy when a resident is admitted from another facility.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide Mighty Shakes as ordered for multiple residents and did not notify the physician or RD when the supplements were not given. Resident #5 had diagnoses including dementia, low blood pressure, and anxiety, and was assessed as needing partial assistance with bed mobility and toileting and as having a potential nutritional problem related to dementia. The resident had a physician order for Mighty Shake three times a day, but the MAR showed multiple missed doses in December 2025 and January 2026. Nursing notes repeatedly documented that the supplement was unavailable, and there was no documentation that the physician or RD had been notified. Resident #4 had severe cognitive impairment, was dependent for toileting and bed mobility, and had diagnoses including heart failure, high blood pressure, and anemia. The resident also had a physician order for Mighty Shake three times a day, but the MAR showed multiple missed doses in December 2025 and January 2026. Nursing notes again documented that the shakes were out of supplement, and the record did not show that the physician or RD had been notified. The resident's care plan did not address the resident's use of health shakes. Resident #68 was dependent for activities of daily living, not cognitively intact, and had diagnoses of Parkinson's disease, muscle weakness, and Alzheimer's disease. The resident was on hospice care and had an order for Mighty Shake three times a day for weight loss with meals. The MAR showed missed doses because the shakes were frozen or not available on several occasions in December 2025 and January 2026. Staff interviews showed CNAs did not give the shakes, nurses and CMTs gave them, CMTs sometimes told dietary when supplies were low, and staff did not notify the nurse or physician when residents did not receive the ordered shakes. The DON and administrator stated that the physician should be notified when ordered shakes were not given.
Failure to Document and Store Oxygen Equipment Properly
Penalty
Summary
Proper respiratory care was not provided when staff failed to document the date oxygen tubing was cleaned or changed for four residents and failed to properly store oxygen accessories at the bedside for two residents. The facility’s Oxygen Administration policy, dated April 2006, did not provide specific guidance for changing disposable humidifiers, changing oxygen tubing, or regular intervals for checking and cleaning oxygen equipment, masks, tubing, nasal cannulas, or oxygen cylinder contents and humidifier fluid levels. Resident #9 had diagnoses including respiratory failure, diabetes, and PTSD, and was dependent on staff for showers and needed assistance with all other ADLs. Although the physician order summary directed staff to change oxygen tubing and humidifier every Sunday day shift, observations on 1/5/26, 1/7/26, and 1/8/26 showed a humidifier bottle dated 12/28 attached to the concentrator, an empty bag tied to the concentrator dated 7/27, nebulizer tubing sitting open on the nightstand dated 12/28, and oxygen tubing in use with no date written on it. Resident #29 had respiratory failure, diabetes, and heart failure, required substantial assistance with care, and was ordered oxygen at 2 liters per minute via nasal cannula with tubing and humidifier changed every Wednesday night shift. During observation and interview, the resident reported needing oxygen all the time, having dry nose and frequent bloody nose, and having oxygen tubing without a date; the oxygen storage bag was dated 1-1, no humidifier bottle was attached, and tubing on the portable tank was also not dated. Later observation showed the tubing had been replaced and dated, but no humidifier bottle was attached as ordered. Resident #39 had Alzheimer’s disease, respiratory failure, and heart failure, was dependent on staff for showers, transfers, and dressing, and had an order for oxygen tubing and humidifier changes every Sunday day shift. Observation showed an empty, undated humidifier bottle attached to the concentrator, undated oxygen tubing, and an undated supply storage bag; later the humidifier bottle was changed and dated, but the tubing attached to the portable oxygen cannister was still not dated. Resident #2 had COPD, trouble breathing at rest and with exertion, was on hospice, and was dependent on nursing staff for oxygen equipment needs. The resident had an order for oxygen as needed and for tubing and humidifier changes every Sunday night shift, but observation showed the nasal cannula tubing in use was not dated and no humidifier bottle was attached to the concentrator. The resident stated a humidifier was desired because the nose became dry while wearing oxygen.
Failure to assess bed rail entrapment risk and bed dimensions
Penalty
Summary
The facility failed to assess residents for entrapment risk from bed rails before installation and failed to ensure the bed dimensions were appropriate for the residents’ size and weight for three sampled residents. The facility policy dated 1/30/2024 required correct installation and maintenance of bed rails, assessment of entrapment risk prior to installation, confirmation that bed dimensions were appropriate, and routine inspection and preventive maintenance. Survey review found that staff did not complete entrapment assessments and did not measure resident beds before installing the rails. For one resident with multiple sclerosis, dependence for toileting and bed mobility, incontinence, and a history of falls, the care plan and physician order included bilateral cane rails for bed mobility and positioning. Nursing notes documented a fall in which the resident’s arm was caught behind the resident and another event in which the resident said a shoulder got caught in the bed rail after reaching off the side of the bed. During observation, the resident was seen in bed with both bilateral cane rails in the up position and stated the rails helped with getting out of bed. For two other residents, both with severe cognitive impairment and histories of falls, the records showed bilateral cane rails or side rails in use and physician orders for bilateral cane rails for bed mobility and positioning. However, the bed rail assessments did not include the residents’ height or weight and did not document that the installed rails were appropriate to the residents’ size and weight. Staff interviews confirmed that nurses, therapy, and maintenance handled the rail process, but the MDS Coordinator, DON, Maintenance Director, therapy supervisor, and Administrator were not aware of entrapment assessments or did not include resident measurements or bed dimensions in the assessment process.
Failure to Inspect Bed Frames, Mattresses, and Bed Rails for Entrapment
Penalty
Summary
The facility failed to complete regular inspections of bed frames, mattresses, and bed rails to identify possible entrapment areas for three sampled residents who used bilateral cane rails or side rails. For Resident #51, the quarterly MDS showed no cognitive impairment, dependence on staff for toileting and bed mobility, incontinence, and a history of falls with injury. The care plan and POS documented use of bilateral cane rails for bed mobility and positioning, and nursing notes described a fall in which the resident’s shoulder got caught in the bed rail after reaching off the side of the bed. The record contained no documentation that the bed frame and mattress had been inspected before the rails were installed or that ongoing inspections had been completed. For Resident #4, the quarterly MDS showed severe cognitive impairment, dependence on staff for toileting and bed mobility, one fall with injury, and diagnoses including heart failure, high blood pressure, and anemia. The bed rail assessment documented a history of falls and bilateral assist bars, but no height or weight was recorded and there was no documentation confirming the rails were appropriate to the resident’s size and weight. The care plan and POS documented use of bilateral cane rails for bed mobility and positioning, and the record again lacked documentation of pre-installation inspection of the bed frame and mattress or regular ongoing inspection for possible entrapment. A third resident record also showed severe cognitive impairment, delusions, use of side rails, set-up help with bed mobility, and a history of falls prior to admission, with diagnoses including atrial fibrillation, high blood pressure, and BPH. The care plan did not address side rail use, and the bed rail assessment again lacked height and weight information and did not confirm the rails were appropriate to the resident’s size and weight. Interviews with CNA, LPN, MDS Coordinator, Maintenance Director, DON, and Administrator showed the staff understood maintenance installed the rails, but they did not know of any entrapment assessments or ongoing process for measuring the bed frame, mattress, and bed rails.
Medication Refrigerator Temperature Not Monitored
Penalty
Summary
Drugs and biologicals were not stored under proper temperature controls in the CMT medication room because the facility could not provide a record showing that the refrigerator temperature had been monitored. During observation on 01/06/2026 at 3:20 P.M., surveyors found no refrigerator temperature log sheet on the refrigerator and no logbook in the medication room. The freezer compartment of the refrigerator had ice buildup extending past the edges of the compartment, and the refrigerator contained two Mighty Shakes and Arformoterol for Resident #9. The facility did not provide a medication storage policy. During interview, the CMT said he/she did not check the refrigerator temperature and was not sure where the temperature log was kept, and was not sure how long the ice had been built up in the freezer compartment. The Administrator said the medication refrigerator temperature log was usually kept on the counter above the refrigerator and that the night shift CMT was responsible for checking the temperature. RN A said the medication refrigerator temperature should be checked every shift, while CMT B said he/she did not check the temperature and was not aware of the ice buildup. The DON said the medication refrigerator temperature should be checked and recorded every night.
Failure to Maintain Licensed Administrator
Penalty
Summary
The facility failed to maintain a qualified licensed administrator on duty from the specified dates, as required by state laws. The facility's policy mandates that the governing board appoints an administrator who is duly licensed in accordance with federal and state requirements. However, a review of the Missouri Association of Nursing Home Administrators license registry revealed that Administrator A was not listed as a current Missouri Licensed Administrator. During an interview, Administrator A admitted she was unaware her license had expired and planned to contact the Missouri Board of Nursing Home Administrators (BNHA) to address the issue. Documentation from the BNHA indicated that Administrator A had been sent multiple reminders to renew her license, which she claimed not to have received. Upon realizing her license had expired, she informed the corporate office, and Administrator B was hired to temporarily fulfill the role of licensed administrator. Administrator B confirmed her temporary role and noted that the facility lacked a policy for checking the license status of administrators, which they plan to implement in the future.
Expired Medications Found in Storage Rooms
Penalty
Summary
The facility failed to remove expired medications from two medication storage rooms, which could potentially expose residents to unsafe or ineffective treatments. During an observation, three tubes of expired Skintegrity Hydrogel, used for treating pressure ulcers, were found in a medication room. Two of these tubes had expired in May 2024, and one had expired in October 2023. A Licensed Practical Nurse (LPN) confirmed the expiration and removed the tubes. Additionally, in another medication room, two bottles of expired cranberry tablets and three bottles of expired Thera-M multi-vitamins were discovered. A Certified Medication Aide (CMT) confirmed these medications were expired and removed them. Interviews with staff revealed a lack of clarity regarding the responsibility for checking and removing expired medications. The LPN mentioned that a supply person checks expiration dates daily, while the CMT believed someone else was responsible for checking and destroying expired medications. The Infection Preventionist nurse was unaware of who checks for expired medications, although they knew someone destroys them. The Administrator stated that nurses and CMTs conduct monthly audits and check expiration dates when restocking, but the presence of expired medications indicates a lapse in this process.
Improper Storage of Nutritional Supplements
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, specifically concerning the storage of nutritional supplements for 17 residents. During an inspection, it was observed that a box containing 59 four-ounce thawed Mighty Shakes, a nutritional supplement, was stored in the walk-in refrigerator without being labeled with a thaw or use-by date. The box was dated 08/22/24, but the significance of this date was unclear. Each carton of Mighty Shakes had a warning label indicating that the product should be stored frozen, thawed below 40 degrees, and used within 14 days. Additionally, seven Mighty Shakes in the reach-in refrigerator were also not labeled with a thaw or use-by date. The Dietary Manager (DM) admitted during an interview that she was unaware of the thawing and use-by time frames indicated on the Mighty Shake carton. Although there was a date on the box, the DM did not know who wrote it or what it signified. This lack of awareness and proper labeling had the potential to result in foodborne illnesses for the residents consuming these nutritional supplements.
Inadequate Cleaning of Patient Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of patient equipment, specifically blood pressure cuffs, after use on a resident. During a medication pass, a Certified Medication Aide (CMT) used a wrist cuff and a manual blood pressure cuff on a resident and placed them on the medication cart without adequately cleaning the cart or using a barrier. The CMT cleaned the cuffs with alcohol prep pads, which was not in accordance with the facility's policy that required the use of disinfectant wipes for such equipment. The CMT also cleaned her stethoscope with an alcohol prep pad and placed it back around her neck. Interviews with the CMT, Director of Nursing (DON), Infection Preventionist (ICP), and Administrator revealed inconsistencies in the understanding and implementation of the facility's cleaning protocols. The DON and Administrator both expected equipment to be cleaned after each use, with the Administrator specifying the use of disinfectant wipes for blood pressure cuffs. The ICP provided training on cleaning patient care equipment several times a year and stated the dry time for the facility's sanitizing wipes was four minutes. However, the CMT was unsure of the dry time for the cleaning products used.
Inadequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program, as evidenced by the inappropriate prescription of antibiotics for a resident. The resident, who was admitted with chronic kidney disease stage 3 and a urinary tract infection, was noted to have increased confusion but no urinary symptoms. Despite this, a urinalysis was ordered, and antibiotics were prescribed before the culture and sensitivity results were available. The resident's urinalysis showed positive results for gram-negative bacilli, but the culture results were not immediately available. The physician ordered Bactrim DS for a urinary tract infection, although the resident did not exhibit any signs or symptoms of a UTI. The culture and sensitivity report later indicated resistance to the prescribed antibiotic, leading to a change in medication to Gentamicin. Interviews with the Infection Preventionist and the Director of Nursing revealed that the facility did not adhere to its antibiotic stewardship protocol, which included using the McGeer Criteria for Infection Surveillance. The staff was aware that the resident did not meet the criteria for a urinalysis, and antibiotics were prescribed without appropriate justification. The Director of Nursing acknowledged the need for continuing education to ensure compliance with the facility's protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Excelsior Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Manor And Rehabilitation Center | 0.4 mi | ★★★★★ | 27 | 0 |
| Lawson Manor & Rehab | 5.6 mi | ★★★★★ | 4 | 0 |
| Norterre | 11.9 mi | ★★★★★ | 1 | 0 |
| Liberty Health And Wellness | 11.9 mi | — | 0 | 0 |
| Avalon View Health And Wellness | 13.8 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.