ASPIRE SENIOR LIVING EXCELSIOR SPRINGS Inspection Report, Violations & Safety Grade (EXCELSIOR SPRINGS, Missouri)

1003 MEADOWLARK LANE, EXCELSIOR SPRINGS, Missouri 64024

Phone: 8166303145

CMS Overall:3/5

Overview & Bed Count

Certified Beds

108

Avg Residents/Day

83.9

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Clay

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health3/5

Staffing2/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	Missouri Avg	Difference
RN Hours per Resident per Day	0.33	0.46	-0.13
Total Nurse Hours per Resident per Day	2.87	3.40	-0.53
CMS Staffing Rating	2/5	2.2/5	-
Nursing Staff Turnover	39.7%	56.9%	-

Health Citation History

34 health citations on record

Date	Category	Description	Severity
2026-01-08	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2026-01-08	Resident Rights Deficiencies	Ensure that residents are fully informed and understand their health status, care and treatments.	E – Moderate Harm Potential
2026-01-08	Resident Rights Deficiencies	Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.	E – Moderate Harm Potential
2026-01-08	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	E – Moderate Harm Potential
2026-01-08	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	E – Moderate Harm Potential
2026-01-08	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2026-01-08	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2026-01-08	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2026-01-08	Quality of Life and Care Deficiencies	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.	E – Moderate Harm Potential
2026-01-08	Environmental Deficiencies	Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.	E – Moderate Harm Potential
2026-01-08	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	D – Moderate Harm Potential
2024-12-04	Administration Deficiencies	Employ staff that are licensed, certified, or registered in accordance with state laws.	D – Moderate Harm Potential
2024-07-25	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2024-07-25	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2024-07-25	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2024-07-25	Infection Control Deficiencies	Implement a program that monitors antibiotic use.	D – Moderate Harm Potential
2022-06-23	Administration Deficiencies	Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.	F – Moderate Harm Potential
2022-06-23	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	F – Moderate Harm Potential
2022-06-23	Administration Deficiencies	Have a plan that describes the process for conducting QAPI and QAA activities.	F – Moderate Harm Potential
2022-06-23	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	F – Moderate Harm Potential
2022-06-23	Administration Deficiencies	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	F – Moderate Harm Potential
2022-06-23	Nursing and Physician Services Deficiencies	Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.	E – Moderate Harm Potential
2022-06-23	Nursing and Physician Services Deficiencies	Observe each nurse aide's job performance and give regular training.	E – Moderate Harm Potential
2022-06-23	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	E – Moderate Harm Potential
2022-06-23	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2022-06-23	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2022-06-23	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	E – Moderate Harm Potential
2022-06-23	Environmental Deficiencies	Have enough outside ventilation via a window or mechanical ventilation, or both.	E – Moderate Harm Potential
2022-06-23	Resident Rights Deficiencies	Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.	D – Moderate Harm Potential
2022-06-23	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	D – Moderate Harm Potential
2022-06-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	D – Moderate Harm Potential
2022-06-23	Resident Assessment and Care Planning Deficiencies	Plan the resident's discharge to meet the resident's goals and needs.	D – Moderate Harm Potential
2022-06-23	Resident Assessment and Care Planning Deficiencies	Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.	D – Moderate Harm Potential
2022-06-23	Infection Control Deficiencies	Ensure staff are vaccinated for COVID-19	C – Minimal Harm Potential

Fire Safety Citation History

28 fire safety citations on record

Date	Category	Description	Severity
2026-01-08	Smoke Deficiencies	Have an enclosure around a vertical opening shaft.	F – Moderate Harm Potential
2026-01-08	Smoke Deficiencies	Provide properly protected cooking facilities.	F – Moderate Harm Potential
2026-01-08	Smoke Deficiencies	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	F – Moderate Harm Potential
2026-01-08	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2026-01-08	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	F – Moderate Harm Potential
2026-01-08	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2026-01-08	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	F – Moderate Harm Potential
2026-01-08	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2026-01-08	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2026-01-08	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	D – Moderate Harm Potential
2024-07-25	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	F – Moderate Harm Potential
2024-07-25	Emergency Preparedness Deficiencies	Establish emergency prep training and testing.	F – Moderate Harm Potential
2024-07-25	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2024-07-25	Emergency Preparedness Deficiencies	Establish procedures for tracking staff and patients during an emergency.	E – Moderate Harm Potential
2024-07-25	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2024-07-25	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	D – Moderate Harm Potential
2022-06-23	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	F – Moderate Harm Potential
2022-06-23	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2022-06-23	Egress Deficiencies	Have horizontal exits used in accordance with safety requirements.	E – Moderate Harm Potential
2022-06-23	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	E – Moderate Harm Potential
2022-06-23	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2022-06-23	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2022-06-23	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2022-06-23	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2022-06-23	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2022-06-23	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2022-06-23	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential
2022-06-23	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	E – Moderate Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the EXCELSIOR SPRINGS area at no cost.

Find Safe, Vetted Facilities Near EXCELSIOR SPRINGS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the EXCELSIOR SPRINGS area at no cost.

Find Safe, Vetted Facilities Near EXCELSIOR SPRINGS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.