Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspire Senior Living Jonesburg during CMS and state inspections, most recent first.
Staff failed to complete and document ordered weekly skin assessments for a resident with moderate cognitive impairment and identified risk for skin breakdown. Facility policies required weekly head-to-to-toe skin observations and documentation in the medical record, and physician orders specified weekly skin assessments on designated shifts. Review of records showed multiple weeks with no documented assessments, during which time a DTI on the sacrum and a pressure ulcer on the left heel, both described as facility-acquired, were present. Interviews with the MDS nurse, RN, DON, and Administrator confirmed that the charge nurse was responsible for these assessments, that the EHR would have prompted them, and that all physician orders were expected to be followed, yet leadership was unaware the assessments had not been completed or documented.
A resident with severe cognitive and physical impairments developed an open area on the knee that progressed to bone protrusion and significant drainage. Nursing staff documented the change and notified the physician, but failed to promptly inform the resident's legal representative of the condition change, resulting in delayed communication about the resident's health status.
Staff did not report a resident-to-resident altercation involving two residents with dementia to DHSS within the required two-hour timeframe. The incident was only brought to the administrator's attention through an anonymous note days later, and documentation and interviews confirmed that the required reporting procedures were not followed.
A resident with Parkinson's disease and impaired mobility was subjected to verbal and physical abuse by a CNA, who threatened rough treatment and handled the resident aggressively during care. The incident was witnessed by a social worker, and the resident reported distress and pain. The CNA admitted to inappropriate behavior, leading to their suspension and termination.
A resident was issued an immediate discharge from a facility without proper notice or a specified new location, following an incident where the resident allegedly hit someone. The facility's discharge notice lacked required information, and the resident was left in a hospital ER without a clear relocation plan. The facility administrator confirmed the resident would not be readmitted.
The facility failed to maintain a homelike environment for residents, with observations of disrepair such as gaps in flooring, missing tiles, stains, and non-functional lighting in several rooms. Staff interviews revealed a lack of awareness and communication regarding needed repairs, despite a system for reporting issues. The Maintenance Supervisor was unaware of specific repairs needed, and the administrator acknowledged responsibility for ensuring repairs are completed.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon hospital transfer, as required by their policy. This issue was identified for three residents, with staff interviews revealing inconsistent practices in handling bed hold notifications. The administrator was unaware that bed holds were not being signed or copied for the medical record.
The facility failed to develop comprehensive care plans for three residents, neglecting to address their medical, nursing, mental, and psychosocial needs. One resident with severe cognitive impairment and hospice care had behaviors not reflected in the care plan. Another resident with moderate cognitive impairment had a care plan lacking directions for wound care and swelling. A newly admitted resident's care plan did not address elopement and psychosocial concerns. Lack of communication and oversight in updating care plans was evident.
The facility did not maintain the required RN coverage for at least eight hours daily, seven days a week. Staffing records showed gaps in RN coverage on specific dates, and interviews with staff confirmed the challenge in maintaining consistent RN presence. The facility has been advertising for the position and hired an RN for weekend coverage.
A survey revealed deficiencies in medication management at an LTC facility, including failure to destroy discontinued medications for several residents and the presence of expired and loose medications on medication carts. Interviews with staff, including an LPN, DON, and administrator, indicated a lack of awareness and responsibility for maintaining medication storage and carts, leading to oversight and non-compliance with facility policies.
The facility did not have a qualified Director of Food and Nutrition Services, as the Dietary Supervisor (DS) had not completed the required Certified Dietary Manager (CDM) course. The DS quit without notice during the survey, and the facility's registered dietitian only worked part-time as a consultant. This deficiency could impact all 60 residents.
Facility staff failed to protect resident privacy by leaving computer screens unattended and visible, displaying personal and medical information. An RN and an LPN admitted to not locking screens on treatment and medication carts, acknowledging the privacy violation. The DON and administrator confirmed the requirement to lock screens when unattended.
The facility failed to post required nurse staffing information daily, as mandated by policy. Reviews of staff hour postings for July and August 2024 showed missing census and actual hours worked for most days. Observations and interviews confirmed that postings lacked total hours and were not updated as required. The DON and an LPN acknowledged the issue, with the night shift nurse responsible for completing the postings, but this was not consistently done.
Facility staff failed to follow infection control procedures during wound care for four residents, leading to a risk of spreading bacteria. An LPN did not perform hand hygiene between glove changes and did not use gloves appropriately, as confirmed by the DON and the facility administrator.
Failure to Complete and Document Ordered Weekly Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of practice by not completing ordered weekly skin assessments for one resident. Facility policies on Skin Integrity and Skin Observation required that the medical record contain all documentation regarding skin assessments and that a full head-to-toe skin observation be conducted by an RN or LPN upon admission/re-admission and weekly thereafter. The resident’s care plan identified impaired cognition and risk for skin breakdown and pressure ulcers, and the Quarterly MDS documented moderate cognitive impairment. Physician’s orders directed weekly skin assessments on specific days and shifts. Review of the resident’s December weekly skin assessment documentation showed no recorded assessments on 12/05/25, 12/12/25, and 12/19/25, and the MDS nurse confirmed that no weekly skin assessments were documented from 11/28/25 through 12/21/25 despite existing orders. Nursing documentation showed that on 12/21/25 a deep tissue injury (DTI) was identified on the resident’s sacrum, and the resident also had a pressure ulcer on the left heel, both described by RN A as facility-acquired and expected to be documented on the weekly skin assessments. Additional physician’s orders on 01/02/26 included topical treatments to the buttocks and left heel. Interviews with the MDS nurse, RN A, the DON, and the Administrator confirmed that the charge nurse was responsible for completing and documenting weekly skin assessments, that the electronic system would have prompted these assessments, and that all physician’s orders were expected to be followed. The DON and Administrator stated they were not aware that the weekly skin assessments had not been documented during the identified period and acknowledged that if it is not documented, it is considered not completed.
Failure to Timely Notify Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's legal representative in a timely manner following a significant change in the resident's condition. The resident, who had severe cognitive impairment, lower extremity impairment on both sides, and was dependent on staff for transfers, toileting, and hygiene, was assessed with an open area on the right knee. Nurse notes documented the presence of a 0.5 cm open area with a white center, which progressed to a pinpoint hole with a large amount of pink-tinged drainage and bone protruding under the skin. Despite these significant findings, there was no documentation that the resident's representative was notified of the change in condition at the time it was identified. Further review showed that while the physician was notified and new orders were received for pain management and antibiotics, the resident's representative was not informed until later, after the wound had worsened and infection was suspected. Interviews with facility leadership confirmed that staff are expected to notify the resident's representative promptly after a change in condition, but in this case, notification was delayed without a valid reason. The deficiency centers on the lack of timely communication to the resident's representative regarding a significant change in the resident's health status.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to report a resident-to-resident altercation to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. According to the facility's policy, all alleged violations of abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made. The incident involved one resident with severe cognitive impairment and dementia who slapped another resident with mild cognitive impairment and dementia. Documentation showed that after the noon meal, the altercation occurred, but there was no evidence that it was reported to DHSS within the mandated timeframe. The incident came to the attention of the facility administrator via an anonymous note left under her door two days after the event. Interviews revealed that a CNA witnessed the altercation and reported it to the charge nurse, who assumed that social services had reported the incident to the administrator. The charge nurse did not follow up or ensure the incident was reported, and the administrator only became aware of the situation upon reading the anonymous note. Review of progress notes and investigation forms confirmed the lack of timely reporting to DHSS.
Resident Subjected to Verbal and Physical Abuse by CNA
Penalty
Summary
The facility staff failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact but had a diagnosis of Parkinson's disease, compression fractures, and impaired mobility. The resident required moderate assistance for transfers and had a care plan indicating a risk of falls due to weakness and impaired balance. On the day of the incident, the CNA threatened the resident with rough treatment if they did not cooperate with care, which was witnessed by a social worker. The social worker observed the CNA handling the resident aggressively, including grabbing the resident's legs, sitting them up on the bed, and moving them abruptly to a wheelchair. The CNA then pushed the resident to the bathroom and attempted to have them hold the grab bars, but when the resident was unable to do so, the CNA lifted the resident by yanking their pants and placed them on the toilet without allowing them to pivot their feet. The resident reported feeling hurt and was crying during the incident. Interviews with the CNA and the resident confirmed the aggressive handling and verbal threat. The CNA admitted to using the term "manhandle" and acknowledged that it was inappropriate. The resident expressed distress and did not recall all the details due to crying. The facility's investigation documented the social worker's observations and the resident's account of the incident, leading to the CNA's suspension and eventual termination.
Failure to Provide Proper Discharge Notice and Refusal to Readmit Resident
Penalty
Summary
The facility staff failed to provide an appropriate emergency discharge notice for a resident and did not allow the resident to return to the facility after being discharged from the hospital. The facility's Transfer and Discharge policy requires that residents be notified at least thirty days prior to an anticipated transfer, except in cases where the safety of individuals in the facility is endangered. The policy also mandates that the notice include specific information such as the location to which the resident is being transferred, the right to appeal, and contact information for the State Long-Term Care Ombudsman. However, the Immediate Discharge Notice for the resident did not include this required information. The resident was issued an immediate discharge due to the facility's claim of being unable to provide adequate care and ensure the safety of others, following an incident where the resident allegedly hit someone. The discharge notice was given without specifying a new location for the resident, and the resident's family was informed by phone. The resident was left in a hospital emergency room without a clear plan for relocation, and the facility administrator confirmed that they would not be taking the resident back. This situation left the resident without a proper discharge plan or location, violating the facility's own policies and regulatory requirements.
Facility Fails to Maintain Homelike Environment Due to Disrepair
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents, as evidenced by multiple observations of disrepair in resident rooms. Observations included gaps in flooring between rooms and hallways, missing tiles in bathrooms, brown stains on floors and toilet bowls, peeled baseboards, frayed and cracked fall mats, and a damaged sink vanity top with exposed particle board. Additionally, a bathroom light was found to be non-functional. These issues were noted in several occupied resident rooms over a span of three days. Interviews with facility staff revealed a lack of awareness and communication regarding the needed repairs. Although staff were instructed to write repair requests in a maintenance log book located at the nurses' desk, the Maintenance Supervisor was unaware of the specific repairs needed in the resident rooms despite conducting daily rounds. The administrator confirmed that maintenance is responsible for repairs, but ultimately, the administrator is accountable for ensuring repairs are completed. Despite a system in place for reporting and addressing maintenance issues, the deficiencies persisted, indicating a breakdown in the process.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for three residents who were discharged to the hospital. The facility's policy mandates that residents or their representatives be informed of the bed hold policy upon admission, at the time of transfer, and during non-covered therapeutic leave. Additionally, a signed authorization for bed hold must be obtained within 48 hours of transfer or by the next business day if the transfer occurs on a weekend or holiday. However, the medical records for the three residents did not contain documentation of such notifications. Interviews with facility staff revealed a lack of consistent practice in handling bed hold notifications. The administrator believed that bed hold paperwork was sent with residents upon discharge but acknowledged that copies were not made for the medical record. A registered nurse expressed uncertainty about whether bed holds were being completed, and the Director of Nursing mentioned a bed hold book at the nurse station but was unsure if the forms were being sent with residents. The administrator admitted responsibility for ensuring bed holds were completed but was unaware that they were not being signed or copied for the medical record.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #41, who had severe cognitive impairment and was on hospice care, exhibited disruptive behaviors such as clapping and yelling, but the care plan lacked guidance for these behaviors and hospice services. Despite observations of the resident's behaviors and interviews indicating a decline in condition, the care plan was not updated due to a lack of communication between staff and the MDS Coordinator. Resident #44, with moderate cognitive impairment and a diagnosis of dementia, had a care plan that did not address the resident's lower extremity swelling or wound care needs. The resident had an order for wound care on the right shin, but the care plan failed to include directions for managing the swelling or wound. Observations showed the resident with swollen legs and a bandage, and interviews revealed that the resident often refused to lay down, which could have benefited the healing process. Resident #164, newly admitted to the facility, had a baseline care plan that did not address risks of elopement, wandering, or psychosocial concerns. The resident was documented as exit-seeking and displaying aggressive behavior towards staff, yet these issues were not reflected in the care plan. Interviews with the MDS Coordinator, DON, and administrator highlighted a lack of communication and oversight in updating care plans, which are essential for directing staff in providing appropriate care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's assessment indicated that an RN should be present for at least 8 hours daily, but a review of the nurse staffing records from August 1 to August 22, 2024, revealed that there was no RN coverage for the required hours on August 3, 4, and 17. Interviews with RN K, the Director of Nursing (DON), and the Administrator confirmed the lack of consistent RN coverage. RN K mentioned that there are times when no RN is present in the building, and the DON acknowledged the difficulty in maintaining RN coverage, especially on weekends. The Administrator stated that while they attempt to have RN coverage daily, they sometimes rely on phone availability when an RN is not physically present. The facility has been actively advertising for the position, and a new RN has been hired to work every other weekend.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to destroy medications in a timely manner for several residents, as observed during a survey. Medications for seven residents were found in a storage room cabinet labeled 'To be destroyed,' including antipsychotics, antispasmodics, opioids, antihistamines, antiemetics, antidepressants, and antidiabetics. These medications had been discontinued but were not returned to the issuing pharmacy or destroyed as per the facility's policy. Interviews with the LPN and DON revealed a lack of awareness and responsibility regarding the medications' prolonged presence in the cabinet. Additionally, the survey identified expired medications and improperly stored medications on the facility's medication carts. An expired bottle of gas relief pills was found on the evening shift medication cart, and loose pills were observed on both the day and evening shift carts. The RN and DON acknowledged that maintaining the medication carts is a shared responsibility among staff, but there were no set days for checking the carts, leading to oversight and the presence of expired and loose medications. Interviews with the DON and the administrator highlighted a lack of consistent oversight and accountability for maintaining medication storage and carts. The DON stated that any CMT or nurse on the medication cart is responsible for its maintenance, while the administrator emphasized that the DON and charge nurses should ensure daily checks. However, both were unaware of the deficiencies found, indicating a gap in communication and adherence to the facility's medication management policies.
Lack of Qualified Nutrition Services Director
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The Dietary Supervisor (DS), who had been in the position for about three years, had not completed the Certified Dietary Manager (CDM) course or any other dietary management training, despite being aware of the requirement. The DS quit without notice during the survey, leaving the housekeeping supervisor to assist in the kitchen. The facility's registered dietitian only worked as a consultant on a part-time basis, and there were no certified or clinically qualified nutritional staff employed full-time. This deficiency has the potential to affect all 60 residents of the facility.
Failure to Protect Resident Privacy
Penalty
Summary
Facility staff failed to maintain the confidentiality of residents' personal and medical records by leaving computer screens unattended and visible to the public. Specifically, a registered nurse (RN) did not minimize or lock the computer screens on treatment carts when entering the rooms of two residents, resulting in their medical information being displayed. The RN acknowledged the oversight, attributing it to nervousness and a lapse in judgment. Additionally, medication carts on two different halls were observed unattended with computer screens open, displaying resident medication information. A licensed practical nurse (LPN) admitted to forgetting to close the screen, recognizing it as a privacy violation. The Director of Nursing (DON) and the facility administrator confirmed that computer screens should be locked when unattended to protect resident privacy, and they were unaware of staff leaving screens open.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a manner that is easily accessible to residents and visitors. The facility's policy mandates that the nurse staffing information should include the facility name, current date, total number, and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) per shift, along with the resident census. This information must be posted at the beginning of each shift in a prominent place. However, a review of the facility's Staff Hour Posting for July and August 2024 revealed significant omissions. In July, the census and actual hours worked were not documented for 28 out of 31 days, and in August, the census was missing for 19 out of 22 days, with actual hours not documented for all 22 days reviewed. Observations and interviews further highlighted the deficiency. On August 22, 2024, the nurse staff posting was observed to lack the total number of hours. Interviews with an LPN and the Director of Nursing (DON) confirmed that the postings were incomplete and not updated as required. The LPN acknowledged that the postings should include the total number of workers and actual hours worked, while the DON admitted awareness of the issue and stated that the night shift nurse is responsible for completing the staff hour posting. The administrator also confirmed that the charge nurse should update the staff posting at the beginning of each shift, but this was not being done consistently, leading to incomplete and inaccurate postings.
Infection Control Deficiency During Wound Care
Penalty
Summary
Facility staff failed to use appropriate infection control procedures during wound care for four residents, leading to a risk of spreading bacteria. The facility's policy on wound care and treatment, dated 03/2015, requires staff to wash their hands between glove changes and before and after wound care tasks. However, observations showed that an LPN did not follow these procedures. For Resident #1, the LPN did not perform hand hygiene between glove changes while providing wound care to the resident's left foot toe. Similarly, for Resident #2, the LPN did not wash hands between glove changes while treating a pressure ulcer on the resident's left heel. The same pattern was observed with Resident #3, where the LPN did not perform hand hygiene while treating a pressure ulcer on the resident's right ankle. For Resident #4, the LPN failed to wash hands before and after handling wound packing sponge and did not use gloves appropriately, leading to potential contamination of the wound care supplies. Interviews with the LPN and the Director of Nursing (DON) confirmed that the staff did not adhere to the facility's infection control policies. The LPN admitted to not performing hand hygiene due to nervousness and acknowledged the risk of spreading germs and infection. The DON and the facility administrator both stated that it is their expectation for staff to perform hand hygiene when entering and exiting a resident's room and between tasks during wound care. They also emphasized the importance of using gloves when handling wound care supplies to prevent infection control concerns.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jonesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warrenton Manor | 9.5 mi | — | 3 | 0 |
| Aspire Senior Living New Florence | 9.5 mi | — | 18 | 0 |
| Stonebridge Hermann | 13.9 mi | — | 0 | 0 |
| New Haven Care Center | 18 mi | — | 0 | 0 |
| Troy Manor | 20 mi | — | 0 | 0 |
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