F
VALLEY MANOR AND REHABILITATION CENTER
26/100 score
0.29 hrs RN staffing
24 deficiencies
ASPIRE SENIOR LIVING EXCELSIOR SPRINGS
1003 MEADOWLARK LANE, EXCELSIOR SPRINGS, MO 64024
D
Facility Assessment
This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — elevated deficiency count.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.36 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
30
Outstanding
0
Actual harm or worse (G–L)
0
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★☆☆ (3/5)
Staffing: ★☆☆☆☆ (1/5)
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NursingHomeGrade Score
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48/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
30 deficiencies found. 30 corrected. None involved actual harm.
Most recent inspection (July 25, 2024)
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 29, 2024
D
Potential harm — isolated
F0881
Status: Corrected
Implement a program that monitors antibiotic use.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 29, 2024
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 29, 2024
E
Potential harm — pattern
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 29, 2024
E
Potential harm — pattern
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 2, 2026
Inspection cycle 2 (December 4, 2024)
D
Potential harm — isolated
F0839
Status: Corrected
Employ staff that are licensed, certified, or registered in accordance with state laws.
Administration Deficiencies — Deficient, Provider has date of correction, corrected December 19, 2024
F
Potential harm — widespread
F0838
Status: Corrected
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.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
F
Potential harm — widespread
F0865
Status: Corrected
Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
F
Potential harm — widespread
F0867
Status: Corrected
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
F
Potential harm — widespread
F0868
Status: Corrected
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
E
Potential harm — pattern
F0923
Status: Corrected
Have enough outside ventilation via a window or mechanical ventilation, or both.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
D
Potential harm — isolated
F0607
Status: Corrected
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
E
Potential harm — pattern
F0883
Status: Corrected
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
C
No harm — widespread
F0888
Status: Corrected
Ensure staff are vaccinated for COVID-19
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
E
Potential harm — pattern
F0727
Status: Corrected
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.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
E
Potential harm — pattern
F0730
Status: Corrected
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
E
Potential harm — pattern
F0804
Status: Corrected
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
E
Potential harm — pattern
F0756
Status: Corrected
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
D
Potential harm — isolated
F0660
Status: Corrected
Plan the resident's discharge to meet the resident's goals and needs.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
D
Potential harm — isolated
F0661
Status: Corrected
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
F
Potential harm — widespread
F0842
Status: Corrected
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
D
Potential harm — isolated
F0568
Status: Corrected
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
D
Potential harm — isolated
F0582
Status: Corrected
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2022
Inspection cycle 3 (April 5, 2019)
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2019
D
Potential harm — isolated
F0758
Status: Corrected
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2019
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2019
D
Potential harm — isolated
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2019
C
No harm — widespread
F0640
Status: Corrected
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2019
D
Potential harm — isolated
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2019
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