Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
67% occupied
Based on a October 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 8
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
The inspection was conducted to assess compliance with tuberculosis (TB) screening requirements for residents and staff at Ashbury Heights of Jefferson City, as required by Missouri state regulations for long-term care facilities.
Findings
The facility failed to ensure required annual one-step tuberculosis screening for one employee and six of eight sampled residents. The facility also lacked a policy for TB testing and documentation of annual TB evaluations to rule out signs and symptoms of TB disease.
Deficiencies (1)
19 CSR 30-86.042(18) TB Screen Resident/Staff: The facility did not ensure annual one-step tuberculosis screening was completed for one employee and six of eight sampled residents. The facility lacked a policy for TB testing and documentation of annual evaluations to rule out TB signs and symptoms.
Report Facts
Facility census: 8
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manager A | Referenced as employee who did not receive required TB screening | |
| Administrator | Responsible for TB testing and retrained by District Supervisor | |
| District Supervisor | Provided retraining and will monitor compliance |
Inspection Report
Plan of Correction
Census: 12
Deficiencies: 1
Date: Nov 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication destruction regulations at Ashbury Heights of Jefferson City.
Findings
The facility failed to ensure discontinued medications were destroyed within 30 days and did not maintain proper records of medication destruction. The facility also lacked a policy for medication destruction and record keeping.
Deficiencies (1)
19 CSR 30-86.042(60)(F)(2) Medications Destruction Record: The facility failed to destroy discontinued medications within 30 days and did not maintain records including resident name, medication details, and signatures of individuals destroying medications.
Report Facts
Facility census: 12
Inspection Report
Life Safety
Census: 5
Deficiencies: 4
Date: Jul 18, 2023
Visit Reason
The inspection was conducted as a fire safety inspection to assess compliance with fire hazard regulations and fire extinguisher maintenance requirements.
Findings
The facility failed to ensure no fire hazards were present, including a smashed dryer ventilation duct and improperly maintained fire extinguishers. Additionally, the building was not maintained in good repair with breaches in fire barriers and lack of required sprinkler system maintenance documentation.
Deficiencies (4)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard. The facility failed to ensure no portion of the building presented a fire hazard, evidenced by a smashed dryer ventilation duct creating a lint accumulation risk.
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to ensure all fire extinguishers were installed and maintained per NFPA 10, 1998 edition, with one extinguisher found standing on the floor instead of mounted.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The building was not maintained in good repair, with holes and gaps in drywall and ceiling tiles breaking the required one-hour fire protection barriers.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to perform or record monthly maintenance checks and visual observations of the sprinkler system as required by NFPA 13.
Report Facts
Facility census: 5
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 7
Date: Nov 29, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding fire extinguisher maintenance, infection control procedures related to COVID-19, medication administration documentation, resident record keeping, menu planning, toxic material storage, and food safety practices at Ashbury Heights of Jefferson City.
Complaint Details
The inspection was complaint-driven, investigating multiple regulatory concerns including fire extinguisher maintenance, infection control, medication administration, resident records, menu planning, toxic material storage, and food safety. The facility census was 12 at the time of inspection.
Findings
The facility failed to perform monthly fire extinguisher inspections, did not follow proper infection control procedures including PPE use and social distancing, failed to document medication administration properly for sampled residents, did not maintain monthly summaries for residents, lacked advance menu planning, improperly stored toxic materials, and failed to protect food from contamination.
Deficiencies (7)
A2210 Fire Extinguishers UL/FM, Maintain/Check: Facility staff failed to perform and document monthly inspections of all fire extinguishers as required by NFPA 10, 1998 edition. Four out of four fire extinguishers lacked staff initials on maintenance tags for October to November 2021.
A4273 Disease/Infection Control Report Category III: Facility staff failed to screen staff, residents, and visitors for COVID-19 symptoms and failed to apply PPE and social distancing practices during the pandemic. The manager and staff were observed not wearing masks properly or at all times.
A4302 Medication Administration Documented: Facility staff failed to ensure medication administration was recorded in the resident's electronic medication administration record (eMAR) for four sampled residents. Documentation was incomplete or missing for multiple medications.
A4333 Resident Record Requirements: Facility staff failed to maintain monthly summaries for four sampled residents. Medical records lacked monthly summaries for multiple months in 2021.
A5206 Menus, Substitutes: Facility staff failed to have menus planned in advance. Only a 30-day menu was posted with no other menus available, and the manager lacked time to make menus.
A6005 Toxic Material Storage: Facility staff failed to ensure chemicals and toxic materials were stored locked and out of reach of residents. Multiple unlocked storage rooms contained hazardous materials accessible to residents.
A7015 Food-Protected, Temp, Need to Contact DHSS: Facility staff failed to protect food from contamination by not properly sealing, labeling, dating, or storing food. Food storage areas contained unsealed, undated, and improperly stored food items.
Report Facts
Facility census: 12
Deficiencies cited: 7
Inspection Report
Plan of Correction
Census: 9
Deficiencies: 2
Date: Aug 30, 2021
Visit Reason
The inspection was conducted to evaluate fire safety compliance, specifically testing and maintenance of the complete fire alarm system and electrical wiring inspection as required by regulations.
Findings
The facility failed to ensure the complete fire alarm system was tested and maintained according to NFPA standards and did not have electrical wiring inspected every two years by a qualified electrician. These deficiencies affected nine out of nine residents.
Deficiencies (2)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to ensure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition. The deficiency affected nine out of nine residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to ensure electrical wiring was inspected every two years by a qualified electrician. The deficiency affected nine out of nine residents.
Report Facts
Facility census: 9
Facility census: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Funnell | Senior Vp of Operations | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Census: 5
Deficiencies: 3
Date: Oct 4, 2018
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening, medication administration, and resident record maintenance regulations at Ashbury Heights of Jefferson City.
Findings
The facility failed to properly screen residents and staff for tuberculosis, did not implement a safe and effective medication administration system, and failed to maintain complete resident admission records.
Deficiencies (3)
19 CSR 30-86.042(18) TB Screen Resident/Staff: The facility failed to screen two of three sampled employees and one of two sampled residents for tuberculosis as required. The facility census was five.
19 CSR 30-86.042(51) Safe/Effective Medication System: Staff failed to ensure three residents received their noon medications properly, leaving medication unattended and not observing residents take medications.
19 CSR 30-86.042(62)(A) Resident Record Admission Info: Facility staff failed to ensure resident records included confidential number, previous address, marital status, and contact information for alternate physician, pharmacist, dentist, and funeral director for two residents.
Report Facts
Facility census: 5
Deficiencies cited: 3
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