Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Moberly during CMS and state inspections, most recent first.
Medication administration and catheter care failures were identified for multiple residents. A CMT gave potassium chloride without diluting it as ordered and did not instruct a resident to rinse and spit after an inhaler. An LPN removed insulin pens immediately instead of holding them in place per manufacturer directions. Staff also hung a catheter drainage bag above a resident’s bladder during a lift transfer, allowing urine to flow back toward the bladder.
Failure to Provide Consistent ADL Hygiene, Showering, and Shaving Assistance: Multiple residents who were dependent on staff for bathing, personal hygiene, and shaving had long gaps between showers, repeated missed shaving care, and observations of greasy hair, facial stubble, body odor, and poor hygiene. Staff interviews confirmed showers were often missed because of staffing shortages, the shower aide was pulled to the floor, and residents were only shaved on shower days.
Insufficient staffing caused missed restorative nursing and delayed hygiene care. A restorative aide was repeatedly pulled to work as a CNA, so residents with restorative orders received therapy inconsistently, and several residents went long periods without showers or shaving. Staff said they were rushed, the shower aide was often reassigned, and there was not enough CNA coverage to complete resident care needs.
After being notified by a structural engineer that the middle common area, including the nurses station and resident sitting area, was not structurally sound, the facility failed to restrict access, allowing residents, staff, and visitors to continue using the area. Staff and residents were observed in the unsafe area for several days, and communication lapses among the Administrator, maintenance, and the regional project manager contributed to the delay in implementing safety measures.
The facility did not provide an RN on duty for eight consecutive hours each day as required, with staffing records showing 15 days without RN coverage during a 32-day period. The staffing coordinator and DON were aware of the issue, which was attributed to a shortage of available RNs, and the administrator confirmed the facility was not meeting regulatory requirements.
A resident with severe cognitive impairment and behavioral symptoms was administered an antipsychotic medication by an LPN who was unaware of the medication's contents, after the medication had been prepared by another nurse and unsuccessfully offered by a CNA. The administration was not documented in the MAR, and there was no record of the resident's condition or the medication's effectiveness, contrary to facility policy requiring licensed staff to both administer and document medications.
A resident experienced increased depression due to an uncomfortable wheelchair, which was not addressed by staff, leading to feelings of abandonment and reduced participation in activities. Additionally, call lights were not within reach for three residents with cognitive impairments, preventing them from calling for help. The facility's leadership was unaware of these issues, contributing to the deficiencies.
The facility was found deficient in food safety and hygiene practices, including improper food labeling and storage, inadequate hair and beard restraints, and failure to follow handwashing and glove use protocols. Additionally, the walk-in cooler had debris buildup, and the ice machine lacked an air gap.
The facility failed to identify a disqualifying criminal offense in the background check of an employee, Housekeeper H, who had a previous conviction for first-degree burglary. Despite policies requiring criminal background checks, the Business Office Manager missed the offense, allowing the employee to continue working without a good cause waiver. Interviews revealed a breakdown in the hiring process, with the Director of Housekeeping and Administrator unaware of the disqualifying offense.
The facility failed to provide a meaningful activity program for several residents, including those with dementia and depression, as per their care plans. Residents were not engaged in activities at the required frequency, and observations showed they often remained in their rooms instead of participating in scheduled group activities. The facility did not adequately address barriers to participation, such as discomfort in wheelchairs, leading to a lack of engagement in meaningful activities.
The facility failed to provide adequate staffing in the memory care unit, leading to insufficient supervision and care for residents. Despite having a staffing plan, only one CNA was assigned to the unit, which was inadequate for the needs of the residents. Observations showed residents were left unattended, and there were no activities provided due to reduced staffing. The decision to decrease staffing was based on the overall facility census and budget constraints, resulting in a deficiency.
The facility failed to maintain residents' privacy by opening mail without permission. Two residents reported receiving opened mail, despite the facility's policy requiring mail to be delivered unopened unless requested otherwise. Interviews with staff confirmed the policy, but the mail was still opened, indicating a breach of protocol.
Two residents were subjected to physical restraints without proper documentation or medical justification. One resident was placed in a locked wheelchair against a dining table, preventing movement and left unattended, while another was reclined in a chair with a pommel cushion. Both lacked restraint assessments, consent, or documented interventions for safe use. Staff interviews revealed these measures were used to prevent falls, but no formal restraint policy was followed.
The facility failed to develop comprehensive care plans for two residents, leading to inadequate oral hygiene care. One resident, cognitively intact, required partial assistance but did not receive necessary dental care, resulting in plaque accumulation. Another resident, with moderate cognitive impairment, needed substantial assistance but only received oral care on shower days. The MDS Coordinator and DON acknowledged that care plans lacked specificity, contributing to these deficiencies.
Two residents requiring assistance with ADLs were not provided adequate oral hygiene care. One resident with hemiplegia had poor oral hygiene, with heavy plaque and gingivitis, and reported that staff did not regularly offer to brush his/her teeth. Another resident with dementia had teeth brushed only on shower days, leading to plaque buildup. Interviews with the DON and Administrator revealed that CNAs were expected to provide oral hygiene twice daily, but this was not consistently done.
A facility failed to ensure an approved indication for the use of psychotropic medications for a resident with dementia-related psychosis. The resident was prescribed risperidone, an antipsychotic contraindicated for dementia-related psychosis, without proper documentation of the root cause of behaviors or attempts at non-pharmacological interventions. The resident's dosage was increased after a single day of behavioral issues, without a comprehensive assessment or documentation of non-pharmacological interventions. The facility did not document education or consent from the resident's responsible party regarding the use of antipsychotic medication.
The facility failed to include required components in its arbitration agreements, affecting all residents. The agreements lacked statements that signing was not a condition for admission, did not allow communication with officials, and omitted a 30-day rescission period. Staff were unaware of these requirements.
Medication Administration and Catheter Care Failures
Penalty
Summary
The facility failed to administer medications according to physician orders, manufacturer instructions, and professional standards for four residents. One resident with hypokalemia had an order for potassium chloride to be diluted in liquid before administration, but a CMT gave the 7.5 ml dose without diluting it. Another resident with severe cognitive impairment and chronic lung disease had an order for a Combivent inhaler with instructions to rinse and spit after each use, but the CMT assisted with the inhaler and gave the resident water without instructing the resident to rinse and spit. Two residents receiving insulin by pen were also affected. One resident had an order for NovoLog FlexPen based on blood sugar levels, and an LPN administered the ordered dose but removed the pen immediately instead of holding it under the skin for the manufacturer-recommended six seconds. Another resident had an order for Humalog Junior KwikPen sliding-scale insulin, and the LPN administered the ordered dose but removed the needle immediately rather than holding it in place and slowly counting to five as directed by the manufacturer. The facility also failed to provide proper catheter care for a resident with severe cognitive impairment, dementia, neurogenic bladder, and an indwelling urinary catheter. During a transfer with a mechanical lift, a CNA and a restorative aide hung the catheter drainage bag on the lift hooks, placing it higher than the resident's bladder, and dark yellow urine in the tubing flowed back toward the bladder. The facility policy required catheter tubing and drainage to be kept below the level of the bladder.
Failure to Provide Consistent ADL Hygiene, Showering, and Shaving Assistance
Penalty
Summary
The facility failed to ensure residents who required assistance with ADLs received necessary care and services to maintain grooming and personal hygiene. In a review of 23 sampled residents, seven residents were identified as not receiving consistent showers, shaving, or hygiene assistance as reflected in care plans, MDS assessments, shower documentation, and direct observations. The facility policy stated that residents should be assisted with bathing and grooming facial hair to maintain proper hygiene, but the records showed repeated gaps in documented showers and shaving for multiple residents who were dependent on staff for these needs. Resident #7 had severe cognitive impairment, was dependent on staff for showering, and required partial/moderate assistance with personal hygiene. Shower records showed long gaps between showers, including a 25-day gap in May, and no documentation of showers or shaving for several days afterward. Observations showed the resident with greasy hair and facial stubble on multiple days, and the resident stated he/she had not had a shower in a week and wanted one. Resident #11 required extensive assistance with showering and personal hygiene and total assistance from two staff for transfers. Shower records showed no documented showers for more than two weeks in May before a shower and shave were documented, and the resident stated he/she had gone three weeks without a shower and wanted to be clean shaven, adding that there was only one person who usually gave showers and that shaving did not happen very often. Resident #24 required limited assistance with showering and partial to moderate assistance with bathing. Shower records showed a 19-day gap between showers in May, and observation found chin hair approximately 0.25 to 0.5 inches long. The resident stated he/she got one shower a week if lucky, used wet wipes to stay clean, did not like the chin hair, and said staff never offered to shave the chin. Resident #13 required substantial/maximal assistance for showering and supervision or touch assistance for personal hygiene. Shower records showed repeated showers without documentation of shaving, and observations showed chin hair approximately 1 inch long and body odor. The resident stated staff were supposed to provide two showers a week and only shaved him/her on shower days. Resident #60 had severe cognitive impairment, required substantial/maximal assistance for showering, and partial/moderate assistance for personal hygiene. Shower records showed inconsistent bathing and limited shaving documentation, and observations showed stubble and white flaky skin on the shirt over several days. Resident #5 was severely cognitively impaired, incontinent of bowel and bladder, and required substantial/maximal assistance with showering and transfer. Shower records showed only two showers over a 20-day span with no documentation of refusals, and observation showed foul body odor and untrimmed fingernails. Resident #15 was dependent on staff for bathing and toilet hygiene and always incontinent of bowel and bladder. Shower records showed no documented showers for more than two weeks early in the month, and during observation CNA staff cleaned the resident after incontinence but did not allow the resident to finish urinating before placing a clean brief. A CNA stated there was not enough time because there were not enough staff and he/she was rushed to care for other residents. Staff interviews also confirmed that there was usually only one CNA on the special care unit, the shower aide was often pulled to the floor, residents rarely received two showers a week, and residents were only shaved on shower days. The DON stated she was unaware the shower aide was being pulled to the floor and residents were not receiving their showers.
Insufficient Staffing Led to Missed Restorative Care and Infrequent Showers
Penalty
Summary
The facility failed to provide sufficient staffing to meet residents’ needs, including restorative nursing, showers, and assistance with activities of daily living. The facility assessment stated staffing decisions were to be based on resident needs, with staffing adjusted by shift and contingency planning for staffing shortages, and the facility policy required sufficient staff on a 24-hour basis with licensed nursing staff available at all times. Despite this, staff reported that the restorative aide was frequently pulled from restorative duties to work as a CNA on the floor, and the Director of Rehabilitation stated he increased restorative orders to three to six times per week because the restorative aide was being pulled away from those duties. Residents who were ordered restorative therapy did not consistently receive it. Resident #71 had an order for restorative therapy beginning 4/28/26, but the log showed therapy was provided only on 5/1/26 and 5/13/26, while the restorative aide was pulled to the floor on multiple other days. Resident #6 had restorative therapy orders in April and May 2026, but the log showed only intermittent sessions, with the aide pulled to work as a CNA on several dates in both months. Resident #43 also had restorative therapy orders in April and May 2026, but the log showed limited sessions and multiple days when the aide was pulled to the floor. During interviews, the restorative aide said he/she was often pulled from restorative duties and could not complete therapy sessions when working on the floor. The facility also failed to provide routine showers and personal hygiene care for several residents. Resident #7 had long gaps between documented showers, including no documented shower or shave for much of April and several days in May, and was observed with stubble and greasy, disheveled hair; the resident said he/she had not had a shower in a week and wanted one. Resident #11, who preferred showers and required extensive assistance, had no documented showers for more than two weeks in May before receiving one, and said staff woke him/her at 4:00 A.M. for the shower and that there was usually only one person who gave showers. Resident #24, Resident #15, and Resident #5 also had shower schedules that were not met, with long intervals between showers, and were observed with hygiene concerns such as chin hair, foul odor, untrimmed fingernails, and reddened perineal area. Staff interviews described being rushed, not having enough time to complete care properly, and being unable to complete showers because the shower aide was often pulled to the floor and there was not enough staff, including on the secured unit where residents needed assistance from two staff and showers required leaving the unit.
Failure to Restrict Access to Structurally Unsound Common Area
Penalty
Summary
The facility failed to ensure a safe environment for all residents by not restricting access to a structurally unsound area after being notified by a structural engineer. On 8/22/25, the facility received a report from a structural engineer indicating that the middle common area, including the nurses station, sitting area, and access to multiple hallways and the dining room, was not structurally sound. The engineer explicitly advised that the area below the compromised framing should remain unoccupied until all deficiencies were addressed. Despite this, the facility continued to allow residents, staff, and visitors to access and occupy the area. Observations and interviews revealed that the area remained accessible and in use by residents and staff for several days after the engineer's warning. Staff were present at the nurses station, and residents were observed sitting in the main common area watching television, even though this area had visible cracks and sagging in the ceiling. Multiple staff members, including CNAs, LPNs, and the MDS Coordinator, confirmed that the area was only roped off with caution tape days after the initial warning, and even then, the tape was inconsistently maintained, allowing continued access to the unsafe area. Communication failures contributed to the deficiency. The Administrator did not review the engineer's report or contractor recommendations until several days after they were received, and the regional project manager assumed the Administrator had taken appropriate action without confirming. The maintenance director and other staff were aware of the structural concerns but did not ensure the area was fully restricted. As a result, the facility did not act promptly to protect residents, staff, and visitors from the identified structural hazard, leading to a determination of immediate jeopardy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours a day, seven days a week, as required by regulation and the facility's own policy. Review of posted staffing sheets over a 32-day period revealed that there was no RN coverage on 15 separate days. The facility census during this period was 70 residents. The facility's staffing plan called for eight RN hours per resident day on the day shift, but this was not met on multiple occasions. Interviews with the staffing coordinator, Director of Nursing (DON), and administrator confirmed awareness of the RN coverage issue. The staffing coordinator, responsible for scheduling, reported the lack of RN coverage to the administrator after the previous DON resigned and a new one was hired. The DON acknowledged the ongoing issue and attributed it to a shortage of available RNs. The administrator confirmed that the facility was not meeting the regulatory requirement for RN coverage and was unaware of the extent of the missed days until informed.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that medication administration was performed according to professional standards of practice for one resident. Specifically, an LPN administered an antipsychotic medication that had been prepared by another nurse and was unaware of the contents of the medication cup at the time of administration. The medication was initially refused by the resident, and after a CNA was unsuccessful in administering it, the LPN administered the medication without verifying what it was. The LPN also failed to document the administration of the medication on the Medication Administration Record (MAR). The resident involved had severe cognitive impairment, a history of dementia with agitation, and was frequently agitated and resistive to care. The care plan indicated the resident could be forgetful, confused, and sometimes resistive, with behaviors worsening in the late afternoon and evening. The resident had recent medication changes, including as-needed orders for antipsychotic and antianxiety medications. Documentation was lacking regarding the resident's condition, behaviors, and the effectiveness of the medications administered, particularly for the as-needed antipsychotic medication. Facility policy required that medications be administered by licensed nurses or authorized staff, with the nurse who prepared the medication responsible for its administration and documentation. The policy also specified that CNAs were not permitted to administer medications. Despite this, the medication was passed between staff, including a CNA, before being administered by an LPN who did not know what the medication was. There was no documentation in the MAR or nurses' notes regarding the administration, the resident's condition, or the effectiveness of the medication at the relevant time.
Failure to Accommodate Resident Needs and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident who did not have a comfortable wheelchair, leading to increased depression symptoms. The resident, who had a history of osteoarthritis, anxiety disorder, depression, and legal blindness, reported that the wheelchair caused significant discomfort and pain, particularly in the back, hips, and shoulders. Despite expressing these concerns to staff, no action was taken to address the issue, resulting in the resident staying in bed, feeling abandoned, and unable to participate in activities or smoke as desired. Additionally, the facility did not ensure that call lights were within reach for three residents, all of whom had cognitive impairments and required assistance with activities of daily living. Observations showed that the call lights were placed out of reach, preventing these residents from being able to call for help when needed. Interviews with staff confirmed that the call lights were not consistently placed within reach, despite the facility's policy requiring it. The Director of Nursing and the Administrator were unaware of the specific issues related to the resident's wheelchair discomfort and the placement of call lights. The lack of awareness and action from the facility's leadership contributed to the ongoing deficiencies in accommodating the needs and preferences of the residents, as outlined in the facility's policies.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a survey. Several food items in the refrigerator and walk-in cooler were either not dated, improperly sealed, or left open to air. This included containers of macaroni salad, pepper gravy, jelly, green beans, and cheese. Additionally, items such as potato chips and cheese puffs were not dated. These actions were in violation of the facility's policy on labeling and dating foods, which requires all stored foods to be properly labeled and dated. The facility also did not comply with its policy on hair restraints and hand hygiene. Dietary staff were observed not wearing appropriate hair and beard restraints while handling food, and one staff member's hair was not fully covered. Furthermore, staff failed to follow proper handwashing and glove use procedures. Instances were noted where staff did not wash hands before donning gloves, did not change gloves after touching non-food surfaces, and handled food with potentially contaminated gloves. These actions were contrary to the facility's policy, which mandates handwashing before and after glove use and changing gloves when contaminated. Additional deficiencies were noted in the maintenance of kitchen equipment. The walk-in cooler fan shrouds had a significant buildup of debris and rust, and the ice machine lacked an appropriate air gap, which is necessary to prevent contamination. The Maintenance Director was unaware of the requirement for an air gap. The Dietary Manager acknowledged the issues, noting that some container lids did not fit properly and that there was uncertainty about who was responsible for cleaning the fan shrouds.
Failure to Identify Disqualifying Criminal Offense in Employee Background Check
Penalty
Summary
The facility failed to identify a disqualifying criminal offense in the background check of an employee, Housekeeper H, who had a previous conviction for first-degree burglary, a class B felony. This oversight occurred despite the facility's policy requiring criminal background checks for all prospective employees and annual checks thereafter. The Business Office Manager (BOM) was responsible for reviewing these checks and was supposed to alert the administrator and relevant department heads if any disqualifying offenses were found. However, the BOM missed the criminal offense in both the initial and subsequent background checks, allowing the employee to continue working at the facility without a good cause waiver. Interviews with the BOM, Director of Housekeeping, and the Administrator revealed a breakdown in the facility's hiring process. The BOM admitted to seeing the employee's criminal background but could not explain how the offense was overlooked. The Director of Housekeeping relied on the BOM to flag any concerning background checks, and the Administrator was unaware of the employee's disqualifying offense. Despite having a system where at least two people reviewed background checks, the facility failed to prevent the hiring of an individual with a criminal history that should have disqualified them from employment, as per the facility's policy and state regulations.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to design a meaningful activity program to meet the needs and interests of six residents, as observed through a review of 24 sampled residents. The facility did not provide activities at a frequency consistent with the residents' plan of care and activity assessment. Specifically, three residents in the memory care unit did not receive a structured activities program focused on their individualized needs to keep them engaged in meaningful activities. Resident #3, diagnosed with Alzheimer's Disease, vascular dementia, major depressive disorder, and anxiety disorder, was not provided with the required frequency of activities as per their care plan. The resident's activity assessment indicated a preference for one-on-one activities three times a week, yet documentation showed a lack of consistent engagement in such activities. Observations revealed the resident often remained in their room, not participating in scheduled group activities like manicures and yoga. Resident #4, who is legally blind and suffers from anxiety and depression, also did not receive the necessary activities as outlined in their care plan. The resident expressed a preference for audio books and social interaction, yet the activity logs showed minimal engagement in meaningful activities. The resident's reluctance to participate in group activities due to discomfort in their wheelchair was noted, but the facility did not adequately address these barriers to ensure the resident's participation in activities.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to provide adequate staffing to monitor and care for residents in the memory care unit, which led to a deficiency. The facility was licensed for 120 beds, with 14 beds designated for dementia care. At the time of the survey, the facility had a census of 64 residents, with 10 residents in the locked dementia care unit. The staffing plan indicated that there should be five CNAs on both the day and evening shifts, and three CNAs on the night shift. However, only one CNA was assigned to the memory care unit during these shifts, which was insufficient to meet the needs of the residents. Observations and interviews revealed that the single CNA on duty was unable to adequately supervise and assist all residents. For instance, one CNA was observed leaving residents unattended in the dining area while assisting others with toileting and meals. Residents were seen wandering unsupervised, and there were no activities provided for them due to the reduced staffing. The CNA reported feeling overwhelmed and unable to keep up with the residents' needs, as most required assistance with toileting and were at risk of falling. The decision to reduce staffing was made by the facility's administration due to a decrease in the overall census and budget constraints. The Director of Nursing and the Administrator acknowledged the staffing reduction, which was based on the facility's census rather than the specific needs of the memory care unit. This reduction in staffing led to inadequate supervision and care for the residents, contributing to the deficiency identified during the survey.
Failure to Ensure Privacy in Resident Mail Delivery
Penalty
Summary
The facility failed to ensure residents' right to privacy in communication by opening personal mail without permission. Two residents reported receiving opened mail, with one resident mentioning a financial statement and the other personal mail. Neither resident had any restrictions on their mail nor had they given the facility permission to open it. The facility's policy, revised in May 2017, clearly states that residents are allowed to communicate privately and receive mail unopened unless they request assistance, which should be documented in their care plan. Interviews with facility staff, including the Social Services Director, Business Office Manager, and Activity Director, confirmed that mail should be delivered unopened unless requested otherwise by the resident. The staff involved in mail delivery, including activity staff and the business office manager, acknowledged this policy. However, the residents' mail was still opened, indicating a failure to adhere to the established protocol. The administrator also confirmed that the residents should have received their mail unopened and had no restrictions in place.
Failure to Document and Monitor Use of Physical Restraints
Penalty
Summary
The facility failed to provide documentation of a medical diagnosis that warranted the use of physical restraints for two residents, prior to their initiation, assessment, and monitoring. The facility did not document other interventions attempted or the consent of the residents or their representatives. Observations showed that Resident #50 was placed in a wheelchair with brakes locked against a dining table, preventing the resident from moving freely. The resident was left unattended for extended periods, with no staff present to monitor or assist, despite the resident's attempts to move and verbal expressions of discomfort. Resident #50 had a history of severe cognitive impairment, dementia, and unspecified mood disorder, requiring substantial assistance for daily activities. The resident's care plan indicated a high risk for falls and a need for assistance with transfers. However, there was no restraint assessment, consent, or documentation of interventions for the safe use of restraints in the resident's medical record. Staff interviews revealed that the resident's wheelchair was locked to prevent falls, but no formal restraint policy was followed. Similarly, Resident #22, who had severe cognitive impairment, dementia with behaviors, and Parkinson's disease, was observed in a recliner with feet elevated and a pommel cushion in a high-back wheelchair. The resident's medical record lacked a restraint assessment, consent, or documentation of interventions for safe restraint use. Staff interviews indicated that the resident was reclined to manage behaviors and prevent falls, but again, no formal restraint policy was adhered to. The Director of Nursing was unaware of the restraint practices being used and confirmed that the facility did not have any restraints in use at the time.
Deficiency in Person-Centered Care Planning for Oral Hygiene
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan specific to the needs of two residents, leading to deficiencies in oral hygiene care. Resident #42, who is cognitively intact and requires partial assistance for oral hygiene, was not provided with the necessary support for dental care as recommended by their dentist. Despite having a history of poor oral hygiene and dental extractions, the resident's care plan did not include specific interventions for oral hygiene, resulting in moderate plaque and debris accumulation. Similarly, Resident #36, who has moderate cognitive impairment and requires substantial assistance for oral hygiene, was not receiving adequate oral care. The resident's care plan failed to specify the need for assistance with oral hygiene, despite dental notes indicating poor oral hygiene and the need for teeth brushing twice daily. The resident reported that staff only brushed their teeth on shower days, which was insufficient to meet their dental care needs. Interviews with the MDS Coordinator and the Director of Nursing revealed that the care plans were not individualized to address specific ADL needs, such as oral hygiene. The MDS Coordinator was responsible for developing care plans based on brief interviews and records, but the plans only listed general ADL assistance without detailing specific needs. This lack of specificity in care plans contributed to the failure to provide adequate oral hygiene care for the residents.
Failure to Provide Adequate Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary oral hygiene care for two residents, Resident #42 and Resident #36, who required assistance with activities of daily living (ADLs). Resident #42, who had hemiplegia and hemiparesis following a stroke, was observed to have poor oral hygiene with heavy plaque and calculus buildup, as well as marginal gingivitis. Despite being cognitively intact and requiring partial assistance for oral hygiene, the resident reported that staff did not offer to brush his/her teeth regularly, and observations confirmed that the resident's toothbrush was dry and unused. Dental notes consistently indicated poor oral hygiene and the need for staff assistance in brushing the resident's teeth twice daily. Resident #36, diagnosed with dementia and muscle weakness, also required substantial assistance for oral hygiene. The resident's care plan indicated the need for staff assistance with all ADLs, including oral hygiene. However, interviews with CNAs revealed that the resident's teeth were only brushed on shower days, which occurred twice a week. Observations and dental notes confirmed poor oral hygiene, with heavy plaque and calculus buildup, and the need for staff to brush the resident's teeth twice daily. Interviews with the Director of Nursing (DON) and the Administrator highlighted a lack of adherence to the facility's policy on oral hygiene care. The DON stated that staff should brush residents' teeth in the morning and evening, and the Administrator confirmed that CNAs were responsible for ensuring oral hygiene was offered and provided. Despite these expectations, the facility failed to ensure that the necessary oral hygiene care was consistently provided to the residents, leading to the observed deficiencies.
Failure to Ensure Approved Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure an approved indication for the use of psychotropic medications for a resident with dementia-related psychosis. The resident was prescribed risperidone, an antipsychotic medication contraindicated for dementia-related psychosis, without proper documentation of the root cause of behaviors or attempts at non-pharmacological interventions. The resident's dosage of risperidone was increased after a single day of behavioral issues, without a comprehensive assessment or documentation of non-pharmacological interventions. The facility's policy on antipsychotic medication use requires that such medications be prescribed only after identifying and addressing medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms. However, the resident's medical record lacked documentation of these assessments or any non-pharmacological interventions prior to the increase in medication. Additionally, the facility did not document any education or consent from the resident's responsible party regarding the use of antipsychotic medication. The resident's care plan did not include specific interventions for behaviors, and there was no documentation of monitoring for side effects or other behaviors beyond wandering. The facility's Director of Nursing acknowledged that the resident was on risperidone for unspecified psychosis, not dementia, but expected staff to follow the psychotropic drug use policy. The resident's responsible party reported not being informed of medication changes or behavioral issues, indicating a lack of communication from the facility.
Deficient Arbitration Agreement Components
Penalty
Summary
The facility failed to ensure that all required components of an arbitration agreement were included in their policy, affecting all 64 residents who had signed such agreements. The Admission Agreement Packet included an Alternative Dispute Resolution Addendum, which outlined procedures for mandatory non-binding mediation and arbitration. However, the arbitration agreement lacked critical components, such as a statement that signing the agreement was not a condition for admission or continued care, language allowing communication with federal, state, or local officials, and a clause allowing residents or their representatives to rescind the agreement within 30 days of signing. Interviews with the Social Services Director and the administrator revealed a lack of awareness regarding the specific language required in the arbitration agreement. The Social Services Director, responsible for obtaining signatures, was unaware of the 30-day rescission period and relied on corporate-produced agreements. Similarly, the administrator was unaware of the necessary components of the arbitration agreement until the survey date. This oversight resulted in all residents having signed agreements that did not meet regulatory requirements.
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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.
Illustrative
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Illustrative
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Nursing homes near Moberly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Health & Rehabilitation | 1.7 mi | ★★★★★ | 0 | 0 |
| North Village Park | 3.4 mi | ★★★★★ | 52 | 3 |
| Heritage Hall Nursing Center | 19.7 mi | ★★★★★ | 5 | 0 |
| Chariton Park Health Care Center | 20.2 mi | ★★★★★ | 7 | 1 |
| Monroe Manor | 23.8 mi | ★★★★★ | 0 | 0 |
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