Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ash Grove Healthcare Facility during CMS and state inspections, most recent first.
A resident admitted with multiple lower extremity wounds and a recent surgical site did not receive timely or complete wound care as required. Staff failed to obtain and document physician orders for all wounds, did not consistently document wound treatments, and missed or incompletely performed weekly skin assessments. Interviews confirmed lapses in assessment, documentation, and follow-through on wound care responsibilities, and the facility lacked a specific wound care policy.
Two residents with pressure ulcers did not receive care in accordance with standards of practice, as staff failed to complete and document weekly skin and wound assessments, did not obtain or follow all physician orders in a timely manner, and omitted documentation of wound care on multiple occasions. Care plans did not specifically address all wounds, and interviews confirmed that required assessments and documentation were not consistently performed.
A facility failed to administer insulin according to a resident's care plan due to the absence of clear blood sugar parameters. The resident, with diabetes mellitus type II, experienced frequent out-of-range blood glucose levels, and staff administered insulin inconsistently. Interviews revealed staff uncertainty about insulin administration due to unclear orders, leading to deviations from the care plan and facility policy.
The facility failed to properly handle, secure, and manage residents' personal funds deposited with the nursing home, as identified by surveyors under event ID 6ACP12. This deficiency highlights a breach in fiduciary responsibilities towards residents' financial assets.
The facility failed to provide quarterly statements of resident trust fund balances to three residents or their representatives, leading to financial confusion. Interviews revealed that the Business Office Manager did not track statement distribution, and the Director of Nursing and Administrator were unaware of the issue.
A resident with severe cognitive impairment resisted a shower, but a CNA continued without attempting alternative interventions, leading to distress and bruising. The resident, known for resisting care, was not informed about the shower, and the CNA did not seek assistance despite the resident's distress. Staff interviews indicated the CNA's actions were against the facility's policy on resident rights.
A resident on Plavix, a blood-thinning medication, developed a bruise that was not promptly documented or investigated by the LTC facility staff. Despite the resident's increased risk of bleeding, the bruise was only documented six days after it was first noted. Interviews with staff revealed inconsistencies in procedures for handling bruises, and the facility lacked a specific policy for monitoring and documenting such incidents.
A CNA verbally and emotionally abused a resident by yelling and cursing at them, telling them they wished the resident would die. The incident was corroborated by multiple staff members and residents, and the resident expressed feeling unsafe and upset. The CNA left the facility immediately after the incident.
Failure to Complete and Document Wound Care and Assessments
Penalty
Summary
Staff failed to provide care according to standards of practice for a resident admitted with multiple wounds. Upon admission, the resident had several wounds to both lower extremities, including calluses with black eschar, abrasions, and skin tears, as well as a recent surgical site from a toe amputation. Despite these findings, staff did not obtain or document timely physician orders for wound care, particularly for the skin tears, and did not consistently document wound treatments as required. There were multiple instances where wound treatments were not documented on specific dates, and weekly skin assessments were either incomplete or missing, with some assessments lacking measurements of the wounds. The facility's own policies required licensed nursing staff to initiate admission assessments, update care plans based on identified needs, and carry out physician orders for medication and treatment. However, review of the resident's records showed that treatment orders were delayed, not all wounds were included in the care plan, and documentation of wound care was inconsistent. Interviews with nursing staff and the DON confirmed that there were lapses in completing and documenting wound assessments and treatments, and that the electronic medical record system was not always used as intended to prompt timely assessments and interventions. The resident reported that wound care was not consistently provided, with periods where wounds were not seen or treated by nursing staff. Observations and interviews with staff revealed that not all wounds were measured or assessed as required, and that communication and follow-through on wound care responsibilities were lacking. The facility did not provide a specific wound care policy, and the documentation and care provided did not meet the standards outlined in the facility's general assessment and medication order policies.
Failure to Provide and Document Pressure Ulcer Care per Standards of Practice
Penalty
Summary
The facility failed to provide pressure ulcer care according to standards of practice for two residents with existing pressure ulcers. Staff did not complete weekly skin assessments, failed to document accurate and complete wound assessments, and did not obtain or follow physician orders in a timely manner. For one resident, there were multiple instances where wound care was not documented as provided, and wound assessments lacked full descriptions of the wounds, including size and appearance. Orders for wound care were delayed, and not all identified wounds had corresponding treatment orders. The care plan did not specifically address all pressure ulcers present, and documentation of wound care was missing on several dates. Another resident with a history of coronary artery disease, high blood pressure, and diabetes was identified as having a stage 2 pressure ulcer to the sacrum. Staff did not consistently document wound care as ordered on multiple dates, despite having a physician's order for specific wound treatment. The care plan indicated a risk for impaired skin integrity and the presence of a pressure ulcer, but documentation gaps persisted in the treatment records. Interviews with nursing staff and facility leadership confirmed that weekly skin and wound assessments were not always completed as required, and that documentation of wound care was inconsistent. Staff acknowledged being behind on wound assessments and described a process where tasks for skin assessments were generated in the electronic medical record, but these were not always completed or documented. The Director of Nursing and Administrator both stated that wound care should be provided and documented as ordered, and that all wounds should be included in the care plan and updated regularly, but this was not consistently done.
Failure to Administer Insulin According to Care Plan
Penalty
Summary
The facility failed to ensure that all residents received care according to their care plans and standards of practice. Specifically, the staff did not obtain blood sugar parameters for the administration of as-needed insulin for a resident with diabetes mellitus, type II, who was insulin-dependent. The resident's blood glucose levels were frequently out of range, and the staff administered insulin without clear parameters, leading to inconsistent insulin administration. The resident's care plan required staff to monitor for signs of altered glucose metabolism and to complete accu-checks as ordered, but the lack of specific parameters for insulin administration resulted in deviations from the care plan. The resident's blood glucose levels were often above the normal range, with several instances of levels exceeding 400 mg/dL. Despite this, the staff administered insulin without documented parameters, and there were multiple occasions where insulin was not administered or was administered incorrectly. The nurse practitioner had advised to continue the current care plan, but the absence of a sliding scale or specific instructions for insulin administration led to confusion among the staff. Interviews with the nursing staff revealed that they were unsure about when to administer insulin due to the lack of clear parameters, and they often had to make judgment calls based on the resident's blood sugar levels. Additionally, the facility's policy required that unclear or incomplete orders be clarified with the attending physician and documented in the medical record. However, the staff did not consistently follow this policy, as evidenced by the lack of documentation for insulin administration and the absence of blood sugar parameters. This failure to adhere to the facility's policy and the resident's care plan contributed to the deficiency in providing appropriate treatment and care for the resident.
Improper Management of Residents' Personal Funds
Penalty
Summary
The deficiency involves the improper handling, securing, and management of residents' personal funds deposited with the nursing home. The report references an event identified by surveyors, indicating a failure in the facility's fiduciary responsibilities towards the residents' financial assets. This deficiency was documented under event ID 6ACP12, with an exit date of 10/10/24, and is associated with citation number MO00241896.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to maintain a full accounting and record system of resident trust funds by not providing quarterly written statements of each resident's trust fund balance and activity to the residents or their responsible parties. This deficiency affected three residents, each with different medical conditions and cognitive statuses. Resident #1, diagnosed with Alzheimer's disease, had a Durable Power of Attorney invoked, and the family member was supposed to receive the statements. However, neither the resident nor the family member received the statements regularly, causing financial confusion and hardship. Resident #2, with intact cognition and no power of attorney on file, also did not receive the required quarterly statements. The resident expressed that it had been over a year since receiving a paper copy of the account balance, which was a source of concern. Similarly, Resident #3, who had a family member appointed as a financial power of attorney, reported that statements were not being sent to the family member as expected, and the resident wished to receive them personally. Interviews with the Business Office Manager (BOM), Director of Nursing (DON), and the Administrator revealed a lack of tracking and accountability in the distribution of these statements. The BOM admitted to not having a system to track when statements were mailed, and the DON and Administrator were unaware if the residents or their representatives were receiving the statements as required. This lack of oversight and communication led to the deficiency in managing resident trust accounts effectively.
Resident's Dignity Compromised During Shower
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during a showering incident. A Certified Nurse Aide (CNA) proceeded to give a shower to a resident who resisted and called out, without attempting alternative interventions to calm the resident. The resident, who had severe cognitive impairment due to chronic Alzheimer's disease, was known to require substantial assistance with bathing and had a history of resisting care. Despite this, the CNA did not follow the care plan instructions to explain the process to the resident or to step back and reapproach if the resident became agitated. On the day of the incident, the resident was taken to the shower room by the CNA, who did not inform the resident that they were going for a shower. The resident resisted and became combative during the shower, yelling and calling out for their mother. The CNA continued with the shower, holding the resident's hands down to prevent self-harm, which resulted in bruising on the resident's arms. The CNA did not seek assistance from other staff until the end of the shower, despite the resident's distress and the presence of a call light in the shower room. Interviews with other staff members revealed that the resident's behavior during the shower was more severe than usual, and that the CNA's actions were not in line with the facility's policy on resident rights. Staff members stated that it would have been appropriate to stop the shower and reapproach later or to seek assistance from another staff member. The incident was reported to the facility's administration, and the bruising on the resident's arms was documented after the shower.
Failure to Document and Monitor Bruise in Resident on Blood Thinner
Penalty
Summary
The facility failed to provide care per standards of practice by not completing timely follow-up, assessment, documentation, and monitoring of a bruise discovered on a resident who was taking Plavix, a medication that increases the risk of bleeding. The resident, who had a history of stroke and required assistance with daily activities, was noted to have a bruise on the upper left leg during a skin monitoring shower sheet review. However, there was no documentation or investigation of the bruise for several days, despite the resident being on a blood-thinning medication. Interviews with various staff members, including LPNs, RNs, and the Director of Nursing, revealed inconsistencies in the facility's procedures for handling bruises. Staff members indicated that they would typically document the size, location, and color of bruises and notify the charge nurse, but this was not done in this case. The facility lacked a specific policy regarding the monitoring and documentation of bruises, which contributed to the oversight. The facility's failure to document and investigate the bruise promptly was evident in the lack of communication among staff and the absence of a clear protocol for handling such incidents. The resident's bruise was eventually documented six days after it was first reported, highlighting a significant delay in care and monitoring. This deficiency underscores the need for consistent documentation and communication practices within the facility to ensure resident safety, especially for those on medications that increase bleeding risk.
Verbal and Emotional Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and emotional abuse by staff. On the evening of 03/02/24, a Certified Nurse Aide (CNA) yelled and cursed at a resident, telling them that they wished the resident would die. This incident was reported by multiple staff members and residents who witnessed or heard the altercation. The resident involved had moderate cognitive impairment and required substantial assistance for transfers, which contributed to the conflict with the CNA. The resident expressed feeling unsafe and upset by the CNA's behavior, which included yelling and derogatory language. The incident began when the CNA was assisting the resident to bed using a sit-to-stand lift. The resident, who has difficulty walking and other chronic conditions, became upset when the lift's wheel got stuck. The resident allegedly called the CNA a derogatory name, which led to the CNA losing their temper and verbally abusing the resident. Other staff members, including another CNA and an LPN, confirmed that the CNA used inappropriate language and expressed a wish for the resident to die. The CNA left the facility immediately after the incident. Interviews with other residents and staff corroborated the resident's account of the verbal abuse. Multiple residents reported hearing loud yelling and cursing from the CNA directed at the resident. Staff members, including the LPN and the Director of Nursing (DON), acknowledged that the CNA's behavior was inappropriate and constituted verbal abuse. The facility's policies on abuse and neglect clearly state that such behavior is unacceptable and should be reported immediately, which was done in this case.
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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 Ash Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willard Care Center | 7 mi | ★★★★★ | 2 | 0 |
| Springfield Skilled Care Center | 14 mi | ★★★★★ | 7 | 0 |
| Brookhaven Nursing & Rehab | 14.4 mi | ★★★★★ | 4 | 0 |
| Wilson's Creek Nursing & Rehab | 14.4 mi | ★★★★★ | 4 | 0 |
| Republic Nursing & Rehab | 15.1 mi | ★★★★★ | 4 | 0 |
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