Below 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 Aspire Senior Living Oak Grove during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was physically abused by a cognitively intact roommate, who admitted to striking the resident in response to nighttime noises. The incident resulted in a black eye, dried blood, and bite marks, and was confirmed through staff observations, resident interviews, and facility investigation as resident-to-resident abuse.
The facility did not provide written notification to the DPOA for two cognitively impaired residents when one was moved to a secured care unit and the other received a new roommate. Instead, staff relied on verbal communication and did not document or issue written notices as required by policy, leaving the DPOA uninformed about changes except on one occasion.
The facility failed to ensure that the arbitration agreement was optional and clearly communicated to residents and their representatives. Two residents were affected, with one being cognitively intact and unable to recall being informed about the option to rescind the agreement, and another's representative unsure about the rescission period. The Social Services Director assumed understanding if no questions were asked, and the facility has since updated its admission packet to exclude the arbitration agreement.
A facility failed to offer a resident the opportunity to formulate advanced directives, specifically to designate a family member as their Durable Power of Attorney (DPOA) for health care decisions. The resident was alert and oriented upon admission, but the Social Service Director (SSD) did not inquire about establishing an advanced directive, contrary to facility policy. The Director of Nursing (DON) confirmed that the SSD was responsible for this task, which should occur during admission and care plan meetings.
The facility failed to provide timely and complete SNF ABN notices to three residents when their Medicare Part A coverage was expected to end. Residents were not informed of the per diem rate of services as soon as reasonably possible when the NOMNC was issued. The Social Services Director did not include estimated costs on the ABN forms, and the Administrator confirmed that this information should be shared by the Business Office Manager during clinical meetings.
A resident with severe cognitive impairment accessed and ingested medications from an unlocked cart, leading to hospitalization. The resident, who had high blood pressure, dementia, and depression, was found with medication cards and admitted to consuming two pills. The facility's policy requires medications to be stored securely, but the cart was left unlocked, allowing the resident to access the medications.
A resident with respiratory issues did not receive proper BiPAP therapy due to the facility's failure to obtain necessary physician orders and adhere to equipment maintenance protocols. The BiPAP machine was improperly stored, and staff did not follow guidelines for documenting and managing the resident's respiratory care.
A resident with broken and jagged teeth did not receive necessary dental services despite having a physician's order to see a dentist as needed. The resident, who was cognitively intact, had not seen a dentist since admission, and their dental care was not addressed in their care plan. Facility staff were unaware of the resident's dental needs, and there was no system in place to ensure routine dental visits.
The facility failed to protect a resident from abuse when another resident with known aggressive behavior physically assaulted them on two separate occasions. Despite the aggressor's history of mental health issues and verbal aggression, the facility did not increase oversight or implement additional measures to prevent further incidents.
The facility failed to provide an appropriate involuntary transfer discharge for a resident with Schizoaffective Disorder, Dementia, and Anxiety Disorder. The resident was transferred to the hospital and not allowed to return, without proper documentation, physician orders, or a 30-day notice and appeal process, as required by the facility's policy.
The facility failed to ensure the PASARR Level I and, if indicated, Level II was obtained for a resident with Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder. The resident's electronic medical record showed no PASARR, and the Social Service Director admitted to not following up on the request from the prior facility. The Administrator was unaware of the missing PASARR, despite the resident exhibiting moderate cognitive impairment and behavioral issues.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Parkinson's disease, dementia, and anxiety was physically abused by a cognitively intact roommate who also had a history of neurological and behavioral conditions. The incident took place during the early morning hours, when staff observed the aggressor sitting by the victim's bed. The aggressor admitted to striking the other resident in response to noises made during the night, stating that he had asked the resident to stop and ultimately slapped him on the face. The victim sustained a black eye, dried blood around the mouth, and bite marks on the tongue as a result of the altercation. Staff interviews and written statements revealed that the door to the shared room was often kept closed due to noise from the hallway, and that staff had checked on both residents during the night. At approximately 3:15 A.M., a staff member found the aggressor by the victim's bed and was told he was trying to get the other resident to stop moving around. The staff member checked on the victim, who appeared tired but had no visible injuries at that time. Later, around 4:30 A.M., staff noticed bruising and blood on the victim's face, at which point the victim indicated that the roommate had hit him. The facility's investigation confirmed that an altercation had occurred, resulting in injury to the resident with severe cognitive impairment. The aggressor admitted to staff and during interviews that he had struck the other resident due to frustration with the noises made during the night. Staff and leadership interviews indicated that the incident was not anticipated, as the aggressor had no prior history of such behavior. The event was classified as resident-to-resident abuse, and the facility's abuse prevention policy defined such actions as the willful infliction of injury or harm.
Failure to Provide Written Notification of Room and Roommate Changes
Penalty
Summary
The facility failed to provide written notification to the Durable Power of Attorney (DPOA) for two residents regarding changes in room and roommate assignments, as required by both facility policy and federal regulations. Both residents were cognitively impaired, with one being moderately impaired due to depression, heart disease, and anxiety, and the other severely impaired with dementia and Alzheimer's disease. The DPOA had been invoked for both residents due to their incapacity. Despite this, when one resident was moved to a secured care unit due to wandering and elopement risk, and the other was assigned a new roommate, the facility only provided verbal notification to families and did not document or issue written notices as required. Interviews with facility staff, including the Social Services Designee, Administrator, and DON, confirmed that notifications regarding room and roommate changes were made verbally and not in writing. The DPOA for one of the residents reported not being informed about roommate changes except on one occasion and was not given a choice regarding new roommates. Facility policy explicitly requires written notification to residents and their representatives for such changes, but this was not followed or documented in these cases.
Failure to Provide Optional Arbitration Agreement
Penalty
Summary
The facility failed to provide a binding arbitration agreement that was optional and clearly communicated to residents and their representatives. The arbitration agreement was part of the admission packet and required residents to engage in mandatory non-binding mediation and arbitration before pursuing other remedies. However, the agreement did not inform residents or their representatives that signing was not a condition of admission and that they could rescind the agreement within 30 days. This affected two residents, one of whom was cognitively intact and could not recall being informed about the option to rescind the agreement, and another whose representative was unsure if they were informed about the rescission period or the non-mandatory nature of the agreement. Interviews with facility staff revealed that the Social Services Director (SSD) was responsible for ensuring residents understood the admission packet, but did not go over the arbitration agreement in detail, assuming understanding if no questions were asked. The SSD could not recall if the agreement mentioned the rescission period. The facility had since updated its admission packet to exclude the arbitration agreement, but agreements signed before this update remained in effect. The Administrator acknowledged that the agreement should have allowed for rescission and should not have been mandatory, while the Director of Operations noted that the outdated agreement was a result of using the previous company's admission packet after a change of ownership.
Failure to Offer Advanced Directive Formulation
Penalty
Summary
The facility failed to offer a resident the opportunity to formulate advanced directives, specifically to identify a family member as their Durable Power of Attorney (DPOA) for health care decisions. This deficiency was identified during an interview and record review, where it was noted that the resident was alert and oriented upon admission and had expressed a desire to have their family member designated as their DPOA. Despite this, the Social Service Director (SSD) did not inquire if the resident wanted to establish an advanced directive at the time of admission, nor was it reviewed annually as required by the facility's policy. The facility's policy mandates that residents be given the option to complete a DPOA for Health Care upon admission if they have not already done so. However, the SSD admitted to not being aware of this requirement and stated that they typically waited for residents or their families to approach them about formulating an advanced directive. The Director of Nursing (DON) confirmed that the SSD was responsible for offering to formulate advanced directives and that this should occur during admission and care plan meetings. This oversight resulted in the resident's wishes not being documented or honored as per the facility's policy.
Failure to Provide Timely and Complete SNF ABN Notices
Penalty
Summary
The facility failed to provide timely and complete Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) to three residents when their Medicare Part A coverage was expected to end. Residents were not informed in writing of the per diem rate of services as soon as reasonably possible when the Notice of Medicare Non-Coverage (NOMNC) was issued. Specifically, Resident #537 received the NOMNC indicating the end of Medicare Part A skilled services on 5/6/24, but the SNF ABN was not provided until the same day, lacking the estimated cost for continued services. Similarly, Resident #64 received the NOMNC on 5/23/24, but the SNF ABN was delayed until 5/28/24, also missing the cost estimate. Resident #43 received both the NOMNC and SNF ABN on 1/28/24, but the SNF ABN did not include the estimated cost. Interviews revealed that the Social Services Director (SSD) was responsible for issuing the SNF ABN and ensuring it contained all required information, including the estimated costs for continued services. However, the SSD admitted to not including these costs on the ABN forms. The Administrator confirmed that the cost per day should be included on the ABN form and that the Business Office Manager (BOM) shares this information during morning clinical meetings. The SSD was expected to issue the SNF ABN concurrently with the NOMNC, but this procedure was not followed, leading to the deficiency.
Medication Cart Security Breach Leads to Resident Ingesting Unprescribed Medications
Penalty
Summary
The facility failed to ensure that medication carts were locked at all times when not in use, leading to a resident with severe cognitive impairment accessing and ingesting medications from an unlocked cart. The resident, who had diagnoses of high blood pressure, dementia, and depression, was found with medication cards in their wheelchair and admitted to consuming two pills. This incident occurred despite the facility's policy requiring all medications to be stored securely in locked cabinets or carts. On the morning of the incident, a registered nurse discovered the resident with medication cards belonging to another resident. The resident had taken medications that included amlodipine and carvedilol, which were already prescribed to them, albeit at different dosages, and donepezil, which was not prescribed. The resident's blood pressure was monitored hourly, and when it became elevated, along with symptoms of diaphoresis and clamminess, the on-call physician was contacted, and the resident was sent to the hospital. The investigation revealed that the medication cart was likely left unlocked, allowing the resident to access the medications. The Director of Nursing was notified shortly after the incident, and it was determined that the cart had been left unattended and unlocked, contrary to the facility's policy. The incident was reported to the state agency, and statements were obtained from staff to understand how the resident accessed the medications.
Failure to Ensure Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident requiring BiPAP therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation, did not have a physician's order for BiPAP administration, settings, cleaning, or storage. Observations revealed that the BiPAP machine was not stored in a bag as required, and there was no bag available in the resident's room. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of necessary orders and highlighted lapses in the documentation and storage procedures for the BiPAP equipment. The facility's policies required obtaining a practitioner's order for BiPAP use and settings, following manufacturer instructions for machine use and maintenance, and documenting the resident's response to the therapy. However, these protocols were not followed, as evidenced by the lack of orders and improper storage of the BiPAP machine. Additionally, the staff responsible for managing the BiPAP and oxygen equipment, including the Staffing Coordinator and Certified Nursing Assistants, did not adhere to the facility's guidelines for equipment maintenance and storage, contributing to the deficiency in care provided to the resident.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident with teeth in poor repair. The resident, who was cognitively intact, had obvious or likely cavities or broken natural teeth as noted in their Minimum Data Set (MDS) assessments. Despite being admitted to the facility and having a physician's order indicating the resident may see a dentist as needed, there was no record of any dental visits or care being addressed in the resident's care plan. The resident expressed a desire to see a dentist and reported not having seen one since admission, although they did not experience any tooth pain. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's dental needs. The MDS Coordinator believed the resident had been seen by a dentist but could not find documentation in the Electronic Medical Record (EMR). The Social Services Director (SSD) was unaware of the resident's need for dental care and stated that residents only saw a dentist if there was a specific concern, as there was no routine schedule for dental visits. The Director of Nursing (DON) indicated that the SSD was responsible for ensuring routine dental care and that any dental concerns should be communicated by licensed nurses. However, there was no evidence of such communication or follow-up to ensure the resident received the necessary dental care.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that Resident #1 was free from abuse when Resident #2, who had known aggressive behavior, physically assaulted Resident #1 on two separate occasions. On the first incident, Resident #2 grabbed Resident #1 by the right arm, twisted it, and pushed the resident. Shortly after, Resident #2 approached Resident #1 again and pushed their head into the nurse's station desk. Despite Resident #2's history of verbal and physical aggression, the facility staff did not increase oversight or implement additional measures to prevent further incidents. Resident #2 had a history of mental health issues, including Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder, and had exhibited verbal aggression four to six days during the look-back period. Resident #1, who was severely cognitively impaired and used a wheelchair, had a history of fear related to past neglect and abandonment. The facility's failure to adequately monitor and manage Resident #2's aggressive behavior resulted in harm to Resident #1, highlighting a deficiency in protecting residents from abuse.
Inappropriate Involuntary Transfer Discharge
Penalty
Summary
The facility failed to provide an appropriate involuntary transfer discharge for a resident when they transferred the resident to the hospital and did not allow them to return. The resident, who had diagnoses including Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder, was noted to have moderate cognitive impairment and exhibited verbal and physical aggression. Despite these challenges, the facility did not follow proper procedures for discharge, including failing to provide a 30-day notice or an appeal process to the resident or their representative. The facility's policy required specific documentation and communication when transferring or discharging a resident, including obtaining physician orders, notifying the resident and their representative, and providing detailed transfer forms. However, the facility did not comply with these requirements. The administrator admitted that they did not send adequate discharge information or written physician orders explaining why the facility could not care for the resident and what had been attempted to meet the resident's needs. The resident's care plan indicated that the facility staff was to assess the resident for placement in a specially designed therapeutic unit and intervene as necessary to ensure safety. Despite this, the facility decided not to readmit the resident after their hospital stay, citing the inability to provide adequate care and ensure the safety of others. This decision was made without following the proper discharge procedures, leading to the deficiency noted in the report.
Failure to Ensure PASARR Completion for Resident with Mental Condition
Penalty
Summary
The facility failed to ensure the PreAdmission Screen and Resident Review (PASARR) Level I and, if indicated, Level II was obtained for a resident with a mental condition. The resident, who was admitted from another nursing home, had diagnoses including Schizoaffective Disorder, Dementia with Behavioral Disturbances, and Anxiety Disorder. The resident's electronic medical record showed no PASARR Level I or Level II, despite the resident exhibiting moderate cognitive impairment, verbal aggression, and requiring anti-anxiety medication daily. The facility's policy mandates that the receiving facility must ensure the PASARR is included in the transfer packet and admission should not be completed without it. However, the Social Service Director (SSD) admitted to not following up on the PASARR request from the prior facility, and the Administrator was unaware of the missing PASARR. The resident's care plan indicated several behavioral issues, including verbal and physical aggression, and outlined interventions such as administering medications, monitoring effectiveness, and assessing the resident for placement in a specially designed therapeutic unit. Despite these documented needs, the lack of a PASARR assessment indicates a failure to comply with federal requirements designed to ensure appropriate placement and care for individuals with mental conditions. The SSD acknowledged the responsibility for ensuring PASARR completion and admitted to not verifying its receipt, while the Administrator confirmed that both he/she and the SSD are responsible for auditing PASARR compliance.
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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 Oak Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Springs Wellness & Rehabilitation | 7 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Resort St Marys Llc | 7.3 mi | ★★★★★ | 0 | 0 |
| Odessa Health Care Center | 9.2 mi | ★★★★★ | 34 | 0 |
| Ignite Medical Resort Blue Springs | 11.4 mi | ★★★★★ | 0 | 0 |
| Monterey Park Rehabilitation & Health Care Center | 11.8 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.