Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Webb City during CMS and state inspections, most recent first.
Failure to Complete CNA Training and Competency Checks for Nurse Aides: The facility failed to ensure multiple nurse aides were enrolled in and completed required CNA training within the required timeframe, and several worked beyond four months without documentation of completion. Staff gave inconsistent accounts of who tracked training and competency, and the facility lacked a sign-off process to verify competency after OJT. One nurse aide was observed providing resident care, including showers and incontinent care, while still lacking proof of completed training.
Failure to implement an antibiotic stewardship program: The facility did not have a facility-wide system to monitor antibiotic use, reduce adverse events, or ensure residents prescribed antibiotics were receiving the appropriate agent. The infection control binder showed the last weekly infection analysis and antibiotic usage review were completed months earlier, an LPN said he/she was not on an infection control or antibiotic use committee, and the DON and Administrator gave inconsistent descriptions of how antibiotic stewardship and infection control were being monitored.
Unqualified Infection Preventionist Not Designated: The facility did not designate a qualified infection preventionist to oversee the infection prevention and control program. The Administrator said he/she did not know about antibiotic stewardship, and the corporate nurse, DON, and ADON each described different roles for infection control oversight. The facility had no certificate showing infection preventionist training for the DON or ADON, and the DON said he/she had not been told he/she was the infection preventionist and had only signed up for an infection prevention course that day.
The facility failed to fully follow its abuse and neglect prevention policy by not completing required CBC, EDL, and NA Registry checks for multiple staff members, including CNAs, NAs, an RN, dietary staff, an LPN, and the DM. Record review showed several personnel files lacked NA Registry verification, and one RN had a CBC request with no results received. Interviews with the BOM, DON, and Administrator showed inconsistent understanding of which staff required NA Registry checks and when background checks had to be completed.
Insulin pens for multiple residents were found without required labels, open dates, or expiration dates, and some pens had handwritten dates that staff could not identify as open or expiration dates. Additional insulin pens were stored in a cup with other residents’ pens without resident or prescriber information. The medication refrigerator also held insulin, vaccines, TB testing solution, and acetaminophen suppositories while the thermometer showed temperatures below the required range, and staff interviews showed confusion about the correct temperature and who was responsible for monitoring it.
The facility failed to maintain an effective infection prevention and control program when staff did not consistently use EBP PPE during catheter care and PEG tube feeding, and staff showed confusion about when EBP applied. A resident with a Foley catheter and a resident with a PEG tube were observed receiving care without gowns even though EBP signs and gowns were present. The facility also had incomplete and improperly documented TB screening for multiple new staff, with missing second-step tests, missing read documentation, and missing millimeter measurements.
Medication Error Rate Exceeded 5%: Surveyors found a 6.9% medication error rate after identifying two errors in 29 opportunities. A resident with HTN and DM had orders for metformin 1000 mg BID and dorzolamide-timolol eye drops BID, but the CMT gave only one metformin tablet instead of two and the eye drops were not available at the scheduled time. Interviews with the CMT, LPNs, DON, and Administrator confirmed that the wrong dose and omission of an ordered medication were medication errors.
A resident with dementia and multiple medical conditions was involved in an incident where a CNA forcefully restrained the resident's hands after being struck during care. The event was not reported immediately to management or the state agency, as required by policy. Instead, the witnessing NA delayed reporting, and staff interviews revealed confusion about proper reporting procedures and timeframes, resulting in a failure to meet mandated reporting requirements.
The facility did not adequately promote or facilitate a resident's right to self-determination by failing to support resident choice in care or daily activities, as required by regulation.
Staff failed to serve meals according to the approved menu, providing only chili and peaches instead of the full meal, and substituted Fritos for baked potatoes without ensuring nutritional adequacy. Multiple residents and staff reported that meal portions were consistently small and often left residents hungry, with substitutions made frequently due to supply and budget issues.
Staff did not keep kitchen non-food contact surfaces clean, resulting in grease and dust build-up on ceiling vents, pipes, oven and stove knobs, and the walk-in freezer. Interviews revealed staff were unclear about cleaning responsibilities and policies, despite facility and FDA requirements for regular cleaning to prevent unsanitary conditions.
Facility staff did not ensure the kitchen area was kept clean, with surveyors observing grease, dust, cobwebs, and food debris on various surfaces. Despite facility policy and FDA Food Code requirements for routine cleaning, there was no posted cleaning schedule, and the Dietary Manager did not see the need for one. The DON and Administrator expected regular cleaning, but the kitchen remained unclean during the survey.
A facility failed to provide an ongoing activity program and activity calendars for all residents, resulting in limited engagement opportunities. Multiple residents with various medical conditions reported that activities were important to them, but only BINGO and group exercise were offered regularly, both led by residents or non-activity staff. Staff confirmed the absence of an Activity Director for several months, and no one was assigned to oversee activities, leading to widespread resident dissatisfaction and unmet care plan interventions.
The facility did not consistently provide or document required neurological assessments for residents after falls with potential head injury. Several residents with cognitive impairment or complex medical conditions experienced unwitnessed or witnessed falls resulting in head trauma, but follow-up neurological checks were either missing or incomplete in the records. Nursing staff reported confusion about documentation procedures, leading to gaps in care and failure to follow facility policy.
The facility did not consistently implement or document weekly weights for three residents with identified weight loss, despite care plans and physician orders requiring this monitoring. Additionally, two residents did not receive needed meal assistance, such as help opening food packages, resulting in incomplete meal consumption. Staff interviews revealed that weight monitoring was not completed due to staffing shortages and lack of regular communication between departments.
Staff failed to serve appetizing and palatable meals, with multiple residents reporting that food was overcooked, under-seasoned, and difficult to eat. Two residents with significant medical conditions frequently declined meals due to poor quality, instead choosing snacks. Staff interviews confirmed ongoing complaints about food taste and texture, and dietary management had not reviewed resident feedback or consistently followed food quality policies.
Failure to Complete CNA Training and Competency Checks for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides were not used beyond four months without completing the required CNA training and evaluations. Surveyors found that the facility did not have an effective process to make sure CNA training programs were completed in a timely manner, and eleven nurse aides were working longer than four months without documentation that they had completed the CNA training course. The facility policy required trainees to enroll in a Missouri-approved CNA program, complete the initial 16 hours before direct resident contact, pass the CNA exam within the required timeframe, and be removed from resident care if they did not meet certification timelines or exam requirements. Record review showed multiple nurse aides had been employed for months beyond the allowed timeframe before being enrolled in the online nurse aide training program, and several had no documentation showing completion of the program. Examples included nurse aides hired in late 2024 and early 2025 who were not enrolled until October 2025, as well as a nurse aide who completed the online training but failed the exam. One nurse aide reported starting the online CNA class in the middle of November and said staff could only work on the class on days off between 8:00 A.M. and 5:00 P.M. Another nurse aide said he or she had not worked on the class in months because it was difficult to complete only on days off. Interviews with staff showed confusion and inconsistency about CNA training, competency checks, and enrollment responsibilities. The SDC said nurse aides should be enrolled immediately upon hire, had 120 days to complete the online program, and that the SDC and Corporate Nurse were responsible for monitoring progress, but also stated the facility did not have a sign-off or check-off list to ensure competency after on-the-job training and that competency evaluations were only completed if there had been a complaint. Other staff, including LPNs, the MRS, the DON, and the Administrator, gave differing accounts about when training should begin, who was responsible for competency checks, and how progress was tracked. One nurse aide was observed providing resident care, including showers and incontinent care, while still lacking documentation of completed CNA training.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that develops, promotes, and implements a facility-wide system to monitor antibiotic use, reduce the risk of adverse events associated with antibiotic use, and ensure residents prescribed an antibiotic are utilizing the appropriate one. Review of the facility policy showed that an antibiotic stewardship program, antibiotic use protocols, and a system to monitor antibiotic use were to be part of the infection prevention and control program, with the infection preventionist and DON providing oversight. However, the facility did not provide information regarding an antibiotic stewardship program. Review of the infection control binder showed the last weekly infection analysis review and the last antibiotic usage review occurred on 05/20/25. During interviews, an LPN stated he/she was the wound care nurse and was not on a committee for infection control or antibiotic use. The DON stated antibiotic stewardship should monitor the number of infections and recurring infections, staff should receive in-services based on antibiotic findings, and the ADON highlighted resident infections in a binder to assess clusters, but the binder was not up to date. The DON also stated antibiotic usage was reviewed weekly in infection control meetings, but the wound care nurse and ADON had those meetings without the DON present. The Administrator stated he/she did not know about antibiotic stewardship and said infection control was reviewed in QAPI meetings, while nurses should be conducting daily meetings that address a variety of topics.
Unqualified Infection Preventionist Not Designated
Penalty
Summary
The facility did not designate a qualified infection preventionist to be responsible for the infection prevention and control program. During interviews, the Administrator said he/she did not know about antibiotic stewardship and stated that infection control was reviewed in QAPI meetings, while nurses should be conducting daily meetings that address a variety of topics. A facility policy titled Infection Prevention and Control Program, dated October 2025, stated that the designated infection preventionist is responsible for oversight of the program, surveillance, investigations of exposures, reporting findings to the QAA committee, and serving as the leader of the antibiotic stewardship program with oversight of the DON. Review showed the facility did not provide a certificate of infection preventionist training for the DON or ADON. The corporate nurse said the ADON had been the infection preventionist until he/she quit on Monday, and the DON had been the infection preventionist until the facility hired someone else. The corporate nurse stated he/she was not the infection preventionist because he/she was not in the facility much and was only available to provide guidance to the DON. The Administrator said the ADON had been the infection control nurse but quit on the day of surveyors' arrival, and the corporate nurse was overseeing the DON, who had taken over as the infection preventionist until another nurse could be hired. The DON said he/she had not been advised he/she would be the infection preventionist, had signed up for an infection prevention course that day, and was not aware the ADON had not been trained for the infection preventionist role before quitting.
Missing Required Background and Registry Checks for Staff
Penalty
Summary
The facility failed to fully implement its abuse and neglect prevention policies when it did not complete required criminal background check (CBC), employee disqualification list (EDL), and Nurse Aide (NA) Registry checks for ten sampled staff members. The sampled employees included CNA A, NA B, NA C, RN D, Dietary Aide E, CMT F, LPN G, Laundry Aide H, NA I, and the Dietary Manager. The facility census was 106. Review of the facility policy titled Background Investigations stated that background investigations were to be completed for applicants, and that the human resources department would contact the NA registry for certified nurse aides. Record review showed multiple staff files missing required verification. CNA A, NA B, and the Dietary Manager had FCSR and EDL checks completed, but no verification of an NA Registry check. NA C had an EDL check and FCSR check, but no verification of a CBC request or receipt and no NA Registry verification. RN D had an EDL check and a CBC request with no results received, but no NA Registry verification. Dietary Aide E, CMT F, LPN G, Laundry Aide H, and NA I each had some combination of CBC, FCSR, and EDL checks, but none had verification of an NA Registry check. During interviews, the BOM stated he/she completed FCSR and EDL checks, verified nurse licenses, and checked the NA Registry on CNAs and CMTs, but did not check the NA Registry for non-nursing staff. The DON stated the BOM completed background checks including FCSR, EDL, CBC, NA Registry on nursing staff, and nurse license verification, but was unsure whether staff could work before results were received. The Administrator stated the facility only checked the NA Registry for CNA staff and that background checks needed to be complete prior to staff working the floor.
Unlabeled insulin pens and medication refrigerator temperature failures
Penalty
Summary
The facility failed to ensure insulin pens were labeled and dated according to policy and accepted practice. During observation of the medication cart, insulin pens for seven residents were found without required expiration dates or with unclear handwritten dates that staff could not identify as either an open date or an expiration date. For several residents, insulin glargine, Novolog, Basaglar, or insulin lispro pens had no expiration date noted at all. One resident’s Novolog pen and another resident’s Basaglar pen had dates written on them in marker, but staff did not indicate whether those dates represented the date opened or the expiration date. The medication cart also contained three Tresiba injection pens and one open insulin lispro pen that were not labeled with resident name, physician name, date dispensed, amount to be given, frequency, or expiration date. These pens were stored in a cup with other residents’ insulin pens. Facility policy stated insulin pens were for single resident use and must be clearly labeled with resident and physician information, date dispensed, type of insulin, dose, frequency, and expiration date, and that unlabeled pens should not be used. Staff interviews confirmed that insulin pens should have resident information, an open date, an expiration date, and be discarded if no name or date was present. The facility also failed to maintain the medication refrigerator at the temperatures required by policy and manufacturer guidance. The refrigerator thermometer was observed at 21 degrees F and 22 degrees F during separate observations, while the refrigerator contained resident insulins, vaccines, tuberculosis testing solution, and acetaminophen suppositories. Refrigerator logs showed repeated recorded temperatures of 32 to 33 degrees F across multiple days in October, November, and December. Staff interviews showed the LPNs and DON were unsure of the correct temperature range or who was responsible for monitoring it, while the Administrator stated the expected range was 32 degrees F to 35 degrees F.
Infection Control Program Failures with EBP Use and TB Screening
Penalty
Summary
The facility failed to maintain a complete and effective infection prevention and control program when staff were not educated on enhanced barrier precautions (EBP) and did not consistently use the required PPE during resident care. The facility’s policy stated that EBP was to be used for residents with wounds or indwelling medical devices, and the CDC guidance reviewed by surveyors stated that gown and glove use was indicated during high-contact care activities such as device care, including urinary catheter care and feeding tube care. However, the facility did not provide a list of current residents on EBP, and staff interviews showed confusion about when EBP applied and what PPE was required. Resident #46 had diagnoses including ESRD, neuromuscular dysfunction of the bladder, and multiple sclerosis, and had an indwelling Foley catheter. The resident’s orders included Foley catheter care every shift and an order requiring EBP due to the Foley catheter. During observation of catheter care, two nursing assistants provided care while wearing gloves but did not don gowns, even though gowns were available on the back of the door and an EBP sign was posted. One CNA stated that staff should wear a gown and gloves when caring for residents with catheters, feeding tubes, or open wounds, and acknowledged that a gown should have been worn during the observed care but was forgotten. Resident #62 had diagnoses including hemiplegia following cerebral infarction, aphasia, and dysphagia, and received nutrition through a PEG tube. The care plan stated that staff should utilize EBP when providing personal care, and the resident had an order for bolus tube feedings via PEG. During observation of tube feeding, an LPN entered the room, washed hands, donned gloves, and provided the feeding without wearing a gown, despite an EBP sign on the door and gowns being available. Staff interviews showed inconsistent understanding of EBP, with some staff stating it applied to feeding tubes, catheters, and wounds, while the DON stated that residents with intravenous lines, tube feeding, and catheters were not on EBP unless they had an infection. The facility also failed to maintain an effective infection prevention and control program related to tuberculosis screening for new staff. The facility policy required pre-placement TB screening and two-step Mantoux testing, with tests read within 48 to 72 hours and results documented in millimeters. Review of personnel records showed multiple employees with incomplete or improperly documented TB testing, including missing documentation that tests were read within the required timeframe, missing second-step testing, and missing millimeter measurements for test results. Interviews with the BOM, SDC, nurses, MR, DON, and Administrator showed inconsistent understanding of who conducted TB testing, when the tests were read, whether the second step was completed, and whether measurements had to be recorded.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% when surveyors identified 2 errors out of 29 opportunities, resulting in a 6.9% error rate. The errors involved Resident #47, whose diagnoses included high blood pressure and diabetes mellitus. The resident had physician orders for metformin 500 mg, two tablets twice daily for diabetes, and dorzolamide-timolol eye drops, one drop in both eyes twice daily for glaucoma. The facility procedure titled Safe Administration Practiced, Long-Term Care stated that daily, weekly, and monthly medications should be administered within two hours of the scheduled time and that documentation should include medication name, strength, and dose. During a medication pass observation, the CMT prepared metformin but placed only one 500 mg tablet in the medication cup instead of the ordered two tablets for a total of 1000 mg. The dorzolamide-timolol eye drops were not available in the medication cart at the scheduled time, and the CMT retrieved two boxes from the medication room but stated they were not the correct ones. The MAR showed the eye drops were not given because the drug was not available, while metformin was documented as given as ordered. Interviews with the CMT, LPNs, DON, and Administrator confirmed that the ordered dose should have been given and that omitting an ordered medication or giving the wrong dose constituted a medication error.
Failure to Timely Report Alleged Abuse to Management and State Agency
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the Survey Agency, as required by policy. An incident occurred involving a resident with moderate dementia, anxiety, and other significant medical conditions, where a certified nurse aide (CNA) forcefully held the resident's hands across their chest after the resident struck the CNA during incontinence care. The incident was witnessed by another nurse aide (NA), who did not immediately report the event to the charge nurse or management as required. Instead, the witnessing NA discussed the incident with another NA the following night, who then advised that it should be reported. The second NA delayed reporting the incident to the charge nurse until later that day, resulting in the allegation not being reported to facility management or the state agency within the required two-hour timeframe. Interviews revealed that both NAs were unclear about the proper reporting procedures and timeframes, with one NA being new and not knowing who to report to, and the other believing it was acceptable to wait since the incident had already been delayed. Further interviews with other staff, including CNAs, LPNs, and administrative personnel, confirmed that facility policy required immediate reporting of abuse allegations to supervisors and management, and that the state must be notified within two hours. However, there was inconsistency in staff knowledge regarding the reporting process and required timeframes, contributing to the delay in reporting the incident involving the resident. The deficiency was identified through review of records, staff interviews, and facility policy.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulation.
Failure to Provide Menu-Compliant, Adequate Meals to Residents
Penalty
Summary
The facility failed to provide residents with a nourishing, well-balanced diet that met their daily nutritional needs by not preparing and serving meals according to the facility-approved menu and by failing to make nutritionally adequate substitutions. On the observed lunch service, residents were supposed to receive chili, a baked potato, crackers, spiced peaches, iced tea, and water. Instead, residents were only served chili and peaches, with no baked potato, crackers, or iced tea provided. Staff interviews confirmed that the kitchen did not have potatoes available and substituted Fritos for the baked potato, placing them under the chili in the bowls. The amount of chili and Fritos was not measured, and the substitution was not considered nutritionally equivalent by staff. Multiple residents reported not receiving all the food items listed on the menu and described the portions as consistently small, sometimes leaving them hungry after meals. Staff, including dietary aides and nursing aides, corroborated these observations, noting that residents frequently complained about the lack of food or inadequate substitutions. The dietary manager acknowledged running out of potatoes and substituting Fritos due to time constraints and budget limitations, but did not consider or provide a more substantial replacement. The registered dietician stated that a more substantive substitute should have been provided to ensure residents had enough to eat. The facility did not have a policy regarding serving sizes or nutritional values, and staff reported that menu substitutions occurred frequently due to supply issues or budget restrictions. Despite some staff and residents raising concerns about the adequacy of meals, the dietary manager claimed not to have received complaints. The administrator expected the dietary manager to obtain appropriate substitutes or consult the registered dietician if unsure, but this protocol was not followed during the incident.
Failure to Maintain Cleanliness of Kitchen Non-Food Contact Surfaces
Penalty
Summary
Facility staff failed to maintain cleanliness and sanitation in the kitchen, resulting in multiple non-food contact surfaces being covered with grease and dust. Observations revealed that ceiling vents over the serve-out/steam table, white pipes running across the ceiling, the convection oven top and knobs, Vulcan stove knobs, and the back of the Vulcan stove all had significant build-up of grease and dust. Additionally, the walk-in freezer had a silvery-white build-up on the ceiling and walls. These conditions were directly observed during a kitchen inspection. Interviews with facility staff indicated a lack of clarity and adherence to cleaning policies. The Maintenance Director stated that kitchen staff were responsible for all cleaning duties, while the Dietary Manager was unaware of any cleaning policy. The DON and Administrator both expressed expectations that the kitchen should be kept clean, with the Administrator specifically expecting deep cleaning at least weekly, but was unsure why surfaces were not clean at the time of inspection. The facility's own sanitation policy and the FDA Food Code require regular cleaning of non-food contact surfaces to prevent unsanitary conditions, which was not followed.
Failure to Maintain Cleanliness in Kitchen Area
Penalty
Summary
Facility staff failed to maintain cleanliness in the kitchen area, as evidenced by observations of accumulated grease and dust on a light switch plate, fire extinguisher, and panel box, as well as a dirty window with cobwebs and unclean floorboards with food debris. These unsanitary conditions were noted during a survey when the facility census was 102. The facility's own sanitation policy requires routine cleaning of all kitchen surfaces, equipment, and utensils, and the FDA Food Code mandates that non-food contact surfaces be cleaned as frequently as necessary to prevent unsanitary conditions. Interviews revealed that the kitchen staff were responsible for cleaning duties, but there was no posted cleaning schedule, and the Dietary Manager did not believe one was necessary. The Regional Dietary Manager had previously discussed the need for a posted cleaning schedule with the Dietary Manager. The Director of Nursing and the Administrator both expressed expectations that the kitchen should be kept clean for resident safety and that deep cleaning should occur at least weekly, but were unsure why the kitchen was not clean at the time of the survey.
Failure to Provide Ongoing Activity Program and Activity Calendars
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the mental and psychosocial well-being of all residents. This deficiency was evidenced by the absence of an Activity Director, a lack of a complete activity program, and the failure to provide activity calendars to residents. Multiple residents, including those with diagnoses such as anoxic brain injury, major depressive disorder, dementia, Parkinson's disease, and chronic kidney disease, expressed that activities were important to them, yet reported that activities had not been consistently offered for several months. Residents described the environment as boring, with limited opportunities for engagement, and noted that they had not received activity calendars or information about available activities. Observations and interviews revealed that the only regular activities available were resident-led BINGO and group exercise sessions, both occurring three times per week. Other activities, such as church services and popcorn socials, were sporadic and not consistently available to all residents. Staff interviews confirmed that there had been no Activity Director for several months, and that staff did not have time to provide activities, especially in the Special Care Unit. Residents who required assistance with activities or who had specific interests, such as music, reading, or being outdoors, were not provided with individualized or group activities as outlined in their care plans. Additionally, residents who relied on staff to purchase personal items reported that this service was no longer available due to the lack of an Activity Director. Staff, including CNAs, LPNs, the DON, and the Administrator, acknowledged the lack of a structured activity program and the absence of an Activity Director. They reported that residents frequently complained about the lack of activities and expressed boredom and dissatisfaction. The Administrator confirmed that no current employee had been assigned to oversee resident activities, and that the facility did not have the staff to run a full-time activity program. The deficiency was further supported by the lack of posted or distributed activity calendars and the failure to implement care plan interventions related to activities for multiple residents.
Failure to Document and Perform Neurological Assessments After Resident Falls
Penalty
Summary
The facility failed to ensure that residents who sustained falls, particularly those with potential for head injury, received appropriate follow-up assessments, including neurological checks, as required by professional standards and facility policy. Multiple residents experienced unwitnessed or witnessed falls with evidence of head trauma, such as hematomas and bruising, yet documentation of ongoing neurological assessments was either absent or incomplete in the medical records. In several cases, initial assessments were performed, but there was no evidence of continued monitoring or documentation of neurological status in the days following the incidents, despite the presence of injuries that warranted such follow-up. For example, one resident with Alzheimer's disease and a history of wandering sustained a fall resulting in a hematoma to the forehead and a skin tear. While an initial assessment and physician notification were documented, there was no further documentation of neurological checks or follow-up assessments in the subsequent days, even as the resident continued to display visible bruising. Another resident, cognitively intact and dependent on supplemental oxygen, reported a fall with head impact and subsequent confusion and slurred speech. Although the resident was sent to the hospital, the documentation lacked a complete neurological assessment prior to transfer, and there was no follow-up documentation upon the resident's return to the facility. Additional residents with severe cognitive impairment and complex medical histories also experienced unwitnessed falls with head injuries or complaints of pain. In these cases, while some initial assessments and notifications were made, the records did not consistently reflect ongoing neurological monitoring as per facility protocol. Interviews with nursing staff revealed confusion about where and how to document neurological checks in the electronic health record, and several staff admitted to performing but not recording these assessments. This lack of consistent documentation and follow-up after falls with potential head injury constitutes a failure to provide care and treatment in accordance with professional standards and facility policy.
Failure to Monitor Weights and Provide Meal Assistance for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that all residents maintained acceptable parameters of nutritional status by not implementing and documenting recommended, care planned, or ordered weekly weights for three residents who had been identified as experiencing weight loss. Despite clear facility policies and Registered Dietitian (RD) recommendations for weekly weights in cases of weight loss, staff did not consistently record weights for these residents over several months. This lack of documentation included missing monthly and weekly weights, even when there were physician orders and care plan interventions in place to monitor and address weight loss. Additionally, staff failed to provide necessary meal assistance to two residents. Observations showed that residents who required help with meal set-up, such as opening food packages or supplement containers, did not receive timely assistance. In one instance, a resident struggled for several minutes to open a salad dressing packet and a supplement container without staff intervention. Another resident did not eat a portion of their meal because they were not assisted in opening a food packet. These lapses occurred despite care plans and physician orders specifying the need for meal assistance and monitoring of intake. Interviews with facility staff revealed systemic issues contributing to these deficiencies. The Restorative Nurse Aide (RNA), responsible for obtaining weights, reported being unable to complete this task due to being assigned to other duties. The Dietary Manager (DM) and RD indicated lapses in communication and a lack of regular weight meetings, which had previously been used to monitor and address weight loss. The Director of Nursing (DON) and Administrator confirmed that gaps in weight documentation and meal assistance were due to staffing issues and breakdowns in communication between departments.
Failure to Provide Palatable and Appetizing Meals
Penalty
Summary
Facility staff failed to provide appetizing and palatable meals to residents, as evidenced by multiple observations, interviews, and record reviews. Meals were frequently overcooked, under-seasoned, and sometimes held at improper temperatures or for excessive durations on the steam table, contrary to facility policy. Specific examples included hard rice, tough and chewy egg rolls, mushy vegetables with standing water, and spaghetti noodles that became overly soft from prolonged holding. Residents consistently reported that the food was unappealing, bland, and difficult to eat, with some stating they often skipped meals or substituted snacks due to the poor quality of the main offerings. Two residents, both cognitively intact and independent with eating, were directly affected by these deficiencies. One resident with Parkinson's disease and chronic kidney disease reported that meats, especially pork chops, were too hard to eat and that both main and alternate meal options were unpalatable. Another resident with hypertensive heart disease, chronic diastolic heart failure, and spinal stenosis frequently declined meals due to their poor quality, instead opting for snacks like crackers. Both residents had care plans that included maintaining a list of food preferences and monitoring intake, yet their complaints about food quality persisted. Staff interviews revealed a pattern of unaddressed complaints regarding food palatability. Dietary staff acknowledged overcooking and lack of seasoning, while other staff, including the DON and Administrator, were either unaware of the extent of the complaints or had not taken steps to address them. The Dietary Manager and Regional Dietary Manager had not reviewed resident council meeting notes where food concerns were documented. Despite policies requiring food taste tests and proper food holding procedures, these were not consistently followed, resulting in ongoing dissatisfaction among residents.
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Illustrative
What surveyors actually found near you
We read the 69 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Webb City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Joplin Gardens | 7.2 mi | ★★★★★ | 6 | 0 |
| Nhc Healthcare, Joplin | 7.2 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Joplin | 7.9 mi | ★★★★★ | 6 | 0 |
| Communities Of Wildwood Ranch | 9.2 mi | ★★★★★ | 0 | 0 |
| Westgate | 9.2 mi | ★★★★★ | 1 | 0 |
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