Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspire Senior Living Poplar Bluff during CMS and state inspections, most recent first.
Infection prevention and control failures were observed during resident care, including missed hand hygiene and glove changes during incontinent care and other high-contact tasks, and failure to follow EBP for residents with indwelling devices or wounds. The facility also lacked annual TB screenings for several residents and documented hot water temperatures below the range listed in its water management checklist, with multiple sink and shower readings well under the expected level.
Failure to obtain informed consent for psychotropic medications: The facility did not document that residents and/or their representatives were informed in advance of the risks, benefits, and alternatives before psychotropic medications were started for multiple residents. Records showed missing or incomplete consents for medications such as buspirone, antidepressants, antipsychotics, and lorazepam in residents with diagnoses including dementia, anxiety, depression, psychotic disorder, Parkinson’s disease, COPD, and atrial fibrillation. Staff interviews showed confusion about psychotropic evaluations versus consents, and the QA Nurse reported that some consents were completed, some were incorrect, and some were not completed.
A resident’s code status was not consistently documented across the medical record. The EMR showed full code, while the hospice binder still listed DNR, even though the resident had a DNR order, hospice admission, and later a full code order after the RP requested the change. Staff interviews confirmed the mismatch between the EMR and hospice binder and stated code status should be documented consistently throughout the record.
Late Issuance of Medicare Non-Coverage Notices: The facility failed to provide a SNF ABN and NOMNC to a resident at least two calendar days before skilled Medicare services ended. The resident remained in the facility after discharge from skilled services, but both notices were issued on the same day the skilled stay ended, contrary to facility policy and staff expectations.
The facility failed to complete GDRs for psychotropic meds, failed to obtain a physician response to pharmacist GDR recommendations, and used an antipsychotic without an appropriate diagnosis for a resident. One resident with dementia, depression, and anxiety had orders for buspirone, duloxetine, and Rexulti, but the GDR request was sent to psychiatry with no documented response. Another resident with anxiety and amnesia had pharmacist recommendations to reduce buspirone or mirtazapine with no documented physician response or GDR, and a third resident had aripiprazole, buspirone, and mirtazapine ordered for altered mental status, which the consultant pharmacist said was too vague a diagnosis.
Failure to provide written transfer and bed hold notices: Multiple residents were transferred to the hospital, but the transfer/discharge forms did not include the reason for transfer and the bed hold notices did not include the daily rate. For one resident, there was also no documentation that the resident or representative was informed in writing of the transfer. Staff interviews showed inconsistent understanding of Bed Hold Notices, and the facility had no policy for transfer/discharge or bed hold notices.
The facility failed to complete a significant change MDS for a resident after hospice admission within the required timeframe. Record review showed no significant change MDS after the resident entered hospice, and interviews revealed the MDS Coordinator had not completed MDS training, the DON had been without an on-site MDS Coordinator for several months, and a nurse had been filling in during the MDS Coordinator’s medical leave.
Failure to Obtain Orders and Diagnoses for Urinary Catheters: The facility failed to obtain a physician order and diagnosis for urinary catheter use for two residents. One resident returned from the hospital with a catheter, and another had an order only to monitor urine output, but neither record showed a catheter diagnosis or order. Both care plans did not address the catheter use, and both residents were observed in bed with urinary catheters while stating or indicating they were unsure why the catheter was in place.
Missing dialysis orders and incomplete monitoring documentation. A resident with ESRD received dialysis several times weekly, but the POS lacked an order for dialysis and orders to assess the dialysis access site and obtain vital signs before and after treatment. The care plan called for monitoring the port, fistula, vital signs, and weight, but dialysis communication reports showed multiple missed pre- and post-dialysis assessments, including site/dressing checks, vital signs, and weights. The resident reported that staff only sometimes checked the port/access and vital signs, and the LPN and DON confirmed the expected monitoring and documentation process.
A resident receiving PRN morphine had discrepancies between the MAR, Narcotic Record, and the actual amount remaining in the bottle. Staff observed an opened morphine bottle with an unreadable label and an amount remaining that did not match the documented count, and an LPN stated several doses appeared on the MAR without being documented on the Narcotic Record. The DON and Regional Nurse said the Narcotic Record should align with the MAR, but the cart count did not reflect the discrepancy.
Medication error rate exceeded 5% after multiple insulin administration errors were found. Two residents did not receive ordered blood sugar checks or insulin before lunch, and two LPNs were observed giving insulin without priming the insulin pens as required by the orders and manufacturer guidance. The DON and Administrator stated they expected the medication error rate to be less than 5% and insulin pens to be primed before administration.
Drugs and biologicals were not labeled according to accepted practice, and controlled meds were not stored securely. An unlocked refrigerator lock box contained lorazepam and tuberculin vials that were opened and undated, and a narcotic cart contained an opened morphine bottle with an unreadable label and no date. The refrigerator temperature log also showed multiple missed daily checks, and an LPN and the DON stated meds should be dated and initialed when opened and narcotics should be kept behind two locks.
A resident with multiple cardiac, respiratory, neurologic, and other chronic conditions had numerous prescribed medications, including Eliquis, Lasix, Midodrine, Methocarbamol, Gabapentin, Protonix, a protein supplement, Finasteride, and PRN Hydrocodone-Acetaminophen. Review of the MAR and progress notes showed that several scheduled doses of these medications were not administered and were repeatedly documented as "on order," indicating they were not available. Facility policy required staff to determine the cause and duration of unavailability, contact the pharmacy, notify the physician, obtain alternative or monitoring orders, and treat missed doses as medication errors with appropriate notifications and monitoring, but the report contains no evidence these steps were taken. In interviews, the DON, Administrator, and FNP all stated they expected nursing staff to follow this policy and notify the prescriber when medications were unavailable, confirming that these actions did not occur.
A resident with multiple psychiatric diagnoses did not receive a scheduled IM injection of Invega Sustenna because the order was entered on the CMT MAR, and the CMT, who could not administer the injection, failed to notify the charge nurse. The missed dose was not documented or reported, and the DON only became aware after the resident's family inquired.
A facility failed to assess and document the use of a merry walker for a resident with severe cognitive impairment, leading to a deficiency in ensuring the resident was free from physical restraints unless medically necessary. The resident's medical records lacked documentation of alternatives tried, the least restrictive use, and ongoing re-evaluations. Interviews with staff revealed an expectation for quarterly assessments, which were not conducted, resulting in the deficiency.
The facility failed to provide scheduled showers for three residents, leading to missed opportunities for personal hygiene care. A resident missed nine out of eleven scheduled showers, while two other residents missed six out of eleven. Observations showed unkempt grooming, and interviews confirmed the issue, with staff acknowledging the problem.
A resident with spinal stenosis and total dependence on staff for transfers was not transferred using a gait belt as required by facility policy. Instead, a CNA lifted the resident under the arms, causing potential harm. The facility's policy mandates the use of a gait belt or a Hoyer lift if the resident experiences pain or cannot bear weight.
A resident with severe cognitive impairment and total dependence on staff for personal hygiene was left without incontinence care for over six hours, resulting in a soaked brief with dark urine and a strong odor. The facility's policy required checks every two hours, but this was not followed, leading to the deficiency.
A resident's G-tube was replaced in the ER, but upon return to the facility, staff failed to assess the tube, leading to a misunderstanding that it was a urinary catheter. This resulted in the resident's feedings and flushes being held for 11 days without a physician's order. The DON did not verify the tube type or review discharge paperwork, and the physician was not informed until much later. The resident, who could eat orally, did not suffer immediate harm, but the facility's actions posed a risk to their nutritional needs.
A facility failed to document and monitor dialysis care for a resident with ESRD. The resident lacked physician orders for dialysis and assessments of the dialysis site and vital signs were inconsistently documented. Despite using a Dialysis Communication form, multiple instances of incomplete documentation were noted, indicating a failure to adhere to the facility's policy.
The facility failed to limit PRN orders for psychotropic medications to 14 days for three residents, despite pharmacy requests for stop dates. A resident with restlessness and insomnia, another with COPD and anxiety, and a third with an anxiety disorder had PRN orders without 14-day stop dates. The DON had not completed necessary reviews due to other duties, and the facility lacked a policy for 14-day stop dates.
The facility failed to properly label and store medications, with insulin pens found undated and a medication cart left unlocked and unattended. Staff interviews confirmed that carts should be locked and insulin dated, but these practices were not followed, affecting all residents.
The facility did not update its facility-wide assessment annually, failing to include a resident with a feeding tube and inaccurately reporting the number of residents with intellectual disabilities. The assessment was based on an incorrect census, affecting the identification of necessary resources for resident care.
The facility failed to maintain proper infection control practices during meal pass, incontinent care, and medication administration, with staff not performing hand hygiene or changing gloves as required. Additionally, the facility did not correctly screen residents for tuberculosis, missing or incomplete screenings were noted in medical records.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to perform hand hygiene and change gloves during resident care for multiple residents during observed care activities. During incontinent care, staff entered rooms, performed hand hygiene, and put on gloves, but then continued care without performing hand hygiene or changing gloves between dirty and clean tasks. This occurred during care for residents who were being cleaned after incontinence, had clean briefs and clothing applied, and had items in the room handled during the same episode of care. In several observations, staff also touched resident belongings and room surfaces after providing personal care without documented hand hygiene between tasks. The facility also failed to follow Enhanced Barrier Precautions for residents who had indwelling devices or wounds. One resident receiving IV antibiotic administration had no EBP signage or PPE outside the room, and the LPN entered, performed hand hygiene, put on gloves, but did not put on a gown. Another resident receiving g-tube feeding, water flushes, and a g-tube site dressing change had EBP signage outside the room, but the LPNs entered with hand hygiene and gloves only and did not wear gowns. For another resident with a urinary catheter and incontinent care, CNA staff entered with gowns and gloves, but during catheter and brief care did not perform hand hygiene or change gloves between contaminated and clean tasks. A resident with urinary catheter care and incontinent care also had no EBP signage outside the room, and staff performed catheter and brief care without hand hygiene or glove changes between tasks. The facility failed to complete annual TB screenings for three residents whose records showed no annual screening for February 2025 through April 2026. The facility also failed to maintain hot water temperatures within the range identified in its monthly water management checklist. Water temperature checks documented multiple sinks and showers with temperatures below the stated 110°F to 120°F range, including readings as low as 70°F, 73.7°F, 80°F, 84.7°F, 90°F, 92°F, and 96°F. The Maintenance Supervisor stated water temperatures for Legionella growth were 105°F to 110°F and that temperatures were adjusted at the water heater when out of range, while the Administrator stated hot water temperatures should be between 105°F and 120°F to inhibit Legionella growth.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks, benefits, and alternatives of proposed psychotropic medications, and failed to obtain written consent before starting these medications for five of seven sampled residents. The facility policy titled, Use of Psychotropic Medications, required that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative be informed of the benefits, risks, and alternatives, and that the resident has the right to accept or decline the medication. Resident #4 had diagnoses including unspecified dementia, major depressive disorder, cognitive communication deficit, and anxiety disorder, and was prescribed buspirone, doxepin, duloxetine, and Rexulti. The record contained no documentation of consent or education on the risks and benefits for any of these medications. Resident #6 had diagnoses of adjustment disorder with depressed mood, anxiety disorder, and other amnesia, and was prescribed buspirone, citalopram, and mirtazapine. The record included a psychotropic medication informed consent for citalopram, but it did not list non-pharmacological approaches, beneficial effects, or possible side effects, and there was no documentation of consent or education for mirtazapine or buspirone. Resident #18 had diagnoses of dementia, psychotic disorder with delusions, and anxiety, and was prescribed Seroquel, Zoloft, and lorazepam, with no documentation of consent or education for those medications. Resident #24 had diagnoses of Parkinson's disease and psychophysiologic insomnia and was prescribed buspirone, fluoxetine, olanzapine, and trazodone, with no documentation of consent or education. Resident #57 had diagnoses of COPD and atrial fibrillation and was prescribed amitriptyline, with no documentation of consent or education. During interviews, LPNs stated they did psychotropic evaluations on admission but did not know if that was the same as consents, the Regional QA Nurse said some consents were completed, some were filled out wrong, and some were not completed, and the DON stated the facility expected residents and/or representatives to be informed in advance of the risks, benefits, and alternatives for psychotropic medications.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that one resident’s code status was consistently documented throughout the medical record. Resident #58 had an Outside the Hospital Do Not Resuscitate (DNR) order signed by the physician with verbal consent from the resident representative, an order to admit to hospice, and later an order for full code status. The resident’s care plan stated the resident would be a full code and receive full CPR interventions in the event of cardiac or respiratory arrest, and that code status would be reassessed quarterly and as needed. Despite the full code order in the EMR, the resident’s hospice binder still showed DNR. The DON stated the resident had previously been DNR while under hospice care, but the responsible party requested a change to full code because they were worried the resident would not get good care as a DNR. Staff interviews confirmed the inconsistency: an LPN noted the hospice binder showed DNR while the EMR showed full code, and another LPN said code status should be consistently documented throughout the medical record. The Medical Records Director said she updated the EMR with changes and verified it weekly, and the Administrator said code status should be consistently documented throughout the medical record.
Late Issuance of Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) in writing at least two calendar days before skilled services ended for one resident. Resident #29 discharged from skilled Medicare services on 04/11/26 and remained in the facility, but the SNF ABN and NOMNC were both given on 04/11/26 rather than before the end of the Medicare-covered stay. The facility policy titled "Advance Beneficiary Notices" stated that Medicare beneficiaries are to be informed of potential liability for payment, that a NOMNC is to be issued when Medicare covered services are ending, and that the notice is to be provided at least two days before the end of a Medicare covered stay. During interview, the Business Office Manager stated the SNF ABN and NOMNC were to be given at least two days before a resident's benefits ended, and the Administrator stated he would expect the forms to be given two days before the end of skilled Medicare services.
Psychotropic Medication GDRs Not Completed and Diagnosis Not Supported
Penalty
Summary
The facility failed to attempt gradual dose reductions (GDRs) for psychotropic medications for one resident, failed to provide an appropriate diagnosis for the use of an antipsychotic medication for one resident, and failed to obtain a physician response to GDR recommendations for one resident. The report cites a facility policy requiring residents who use psychotropic drugs to receive GDRs and behavioral interventions unless clinically contraindicated, including attempts within the first year of use and annually thereafter. For one resident with unspecified dementia, major depressive disorder, cognitive communication deficit, and anxiety disorder, the record showed orders for buspirone, duloxetine, and Rexulti. The pharmacist recommended reducing these medications to ensure the resident was using the lowest possible effective dose, but the physician response indicated the request should be sent to psychiatry, and no psychiatrist response was documented. The DON stated nurses would be expected to ensure physicians responded to GDR requests. For another resident with adjustment disorder with depressed mood, anxiety disorder, and other amnesia, the record showed orders for buspirone and mirtazapine. The pharmacist recommended reducing buspirone or mirtazapine on two occasions, but no physician response was documented for either recommendation and no GDRs or contraindications were documented. For a third resident with altered mental status, cerebral infarction, depression, and ataxia, the record showed orders for aripiprazole, buspirone, and mirtazapine related to altered mental status, but the consultant pharmacist stated the diagnosis was too vague and that the resident did not have an appropriate diagnosis for those medications.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of transfers to the hospital, including the reason for transfer and the bed hold daily rate, for five sampled residents. Review of records showed that Resident #1, Resident #4, Resident #5, Resident #12, and Resident #26 each had hospital transfers and readmissions documented, but the Transfer/Discharge Notices did not include the reason for transfer for multiple events, and the Bed Hold Notices did not include the daily bed hold rate. For Resident #12, there was also no documentation that the resident and/or representative was informed in writing of the transfer/discharge for two hospital transfers. The facility did not provide a policy for Transfer/Discharge Notices or Bed Hold Notices. During interviews, an LPN stated he/she completed the Transfer/Discharge Notice when a resident was sent to the hospital but did not give a copy of the Bed Hold Notice, and another LPN said he/she had never heard of a Bed Hold Notice. The Regional QA Nurse stated residents' representatives were notified by phone and that the Bed Hold Notice was mailed to the responsible party, while the SSD stated nurses completed the Transfer/Discharge Notice and she completed the Bed Hold Notice and either gave both forms to the resident or mailed them to the responsible party. The Administrator and DON stated they would expect the resident and representative to be informed in writing, and in a language they understood, of the hospital transfer and the Bed Hold Notice, including the daily rate.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days for a resident who was admitted to hospice. Resident #22 was admitted to the facility on 09/09/24 and later admitted to hospice on 10/21/25. The record review showed no significant change MDS dated on or after the hospice admission date, and the facility did not provide a policy regarding MDS submission timeframes. The MDS 3.0 RAI Users Manual states that for a Significant Change in Status Assessment, the CAA completion date must be no later than 14 days from the ARD and no later than 14 days from the determination date of the significant change in status. During interviews, the MDS Coordinator said she had not completed MDS training and believed a significant change MDS should be completed seven days after hospice admission. The DON said the facility had not had an on-site MDS Coordinator for several months and a nurse had helped fill in while the MDS Coordinator was on medical leave. The Administrator said he would expect the significant change MDS to be completed in the appropriate timeframe.
Failure to Obtain Orders and Diagnoses for Urinary Catheters
Penalty
Summary
The facility failed to obtain a physician order and a diagnosis for the use of a urinary catheter for two residents. The report states that Resident #33 returned to the facility from the hospital with a urinary catheter, but the medical record did not show a diagnosis for the catheter or a physician order for it. The resident’s care plan was undated and did not address the urinary catheter with individualized goals and interventions. During observation on 04/20/26, the resident was lying in bed with the urinary catheter in place, and the resident’s representative later said he/she was unsure why the resident had the catheter. Resident #44 was admitted on 03/27/26, and the medical record did not contain a physician order for the urinary catheter or a diagnosis for its use. The record did include an order dated 03/30/26 to monitor urine output collected in the urinary catheter every shift. The resident’s care plan, dated 04/23/26, did not address the urinary catheter with individualized goals and interventions. During observation on 04/20/26, the resident was lying in bed with a urinary catheter, and during interview the resident said he/she was unsure of the reason for the catheter. An LPN and the DON both stated that residents with urinary catheters should have an order and a diagnosis for the catheter.
Missing dialysis orders and incomplete monitoring documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not fully provided for a resident with ESRD who received dialysis three times weekly. The facility did not have a physician's order for dialysis, and the physician's order sheet also lacked orders to assess the dialysis site and dressing before and after dialysis and to obtain vital signs before and after dialysis. The resident's annual MDS indicated that the resident received dialysis, and the care plan documented dialysis-related interventions including assessment of the thrill and bruit, monitoring the dialysis port and fistula, and checking vital signs and weight before and after dialysis. Review of the dialysis communication reports showed missed documentation and monitoring on multiple dialysis occasions, including missed pre-dialysis assessment of the dialysis site/dressing and missed post-dialysis vital signs, weights, and site/dressing assessments. During interview, the resident stated that staff sometimes looked at the port and access and sometimes took vital signs, but not always on dialysis days. Staff interviews confirmed that residents on dialysis should have orders for dialysis and access-site monitoring, and that vital signs, weights, and access assessments were to be documented on the dialysis communication forms before and after each treatment.
Narcotic Record Did Not Match MAR or Bottle Count
Penalty
Summary
The facility failed to implement procedures to ensure medications were accurately documented and reconciled for one resident receiving morphine. The resident had an order for morphine 20 mg/1 ml, 0.25 ml sublingually every one hour as needed for pain. Review of the resident’s Narcotic Record for a morphine 100 mg/5 ml bottle showed one documented administration on 04/21/26 at 6:30 A.M., with 7.25 ml remaining in the bottle. However, when the nurse’s narcotic medication cart was observed on 04/22/26 at 11:11 A.M., the opened bottle was undated, had an unreadable label, and contained approximately 5 ml remaining. During interview, the LPN who administered the dose stated that at least four doses of the resident’s morphine appeared on the MAR for April that were not documented on the Narcotic Record and said the Narcotic Record should match the MAR. The Regional Nurse and DON also stated they would expect the Narcotic Record to align with the MAR. Another LPN said he/she had counted the cart that morning and did not notice the discrepancy between the recorded 7.25 ml remaining and the approximately 5 ml observed in the bottle, and said the Narcotic Record should match the amount in the bottle. The report also stated the narcotic cart was counted at the end of each shift by the oncoming and offgoing nurses, with both signing that it was counted.
Medication error rate exceeded 5% with insulin administration errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with 34 opportunities and 6 errors for an error rate of 17.6%, affecting three of four sampled residents. The report states the facility did not provide a policy for insulin administration, and manufacturer guidance for Humalog and NovoLog insulin pens required priming the pen with 2 units before each injection and confirming a drop of insulin at the needle tip before administration. Resident #12 had diabetes mellitus with diabetic peripheral angiopathy and an order for Humalog insulin by sliding scale, along with an order to prime the insulin pen with 2 units before use. The resident did not receive a blood sugar check and did not receive insulin before lunch on 04/21/26. Resident #29 had diabetes mellitus and an order for NovoLog insulin by sliding scale, along with an order to prime the pen with 2 units before use; the resident also did not receive a blood sugar check and did not receive insulin before lunch on 04/21/26. During observation, an LPN did not prime the NovoLog pen before giving 12 units to Resident #29, and stated the pen did not require anything to be done before dialing up the dose and that there was not time to complete the blood sugar checks and insulin administration for the lunch meal. Resident #32 had diabetes mellitus with diabetic polyneuropathy and an order for insulin lispro by sliding scale, along with an order to prime the pen with 2 units before use; during observation, an LPN did not prime the insulin pen before administering 4 units for a blood sugar of 336 and stated nothing needed to be done before dialing up the dose.
Medication Labeling and Controlled Substance Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted practices, and controlled medications were not consistently stored in a secure manner. During observation of the medication storage room, the lock box in the medication refrigerator was found unlocked with three 30 mL bottles of lorazepam 2 mg/mL inside, including two opened bottles that were undated. The same refrigerator also contained four opened and undated 5 mL tuberculin vials. In addition, the facility’s refrigerator temperature log showed multiple missed daily checks across February, March, and April 2026. A separate observation of the nurse’s narcotic medication cart showed one opened bottle of morphine 100 mg/5 mL with an unreadable label and no date. During interview, an LPN stated the refrigerator narcotic medication should be locked at all times and said medications should be labeled with the date and staff initials when opened. The DON stated narcotic medications should be stored behind two locked devices, multidose vials should be labeled with a date and initials when opened, and refrigerator temperatures should be checked at least daily.
Failure to Administer Ordered Medications and Notify Prescriber When Drugs Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed medications as ordered and to notify the prescriber when medications were unavailable for one resident out of three sampled, in violation of the facility’s own policy on unavailable medications. The facility’s policy required staff to determine the reason and duration of medication unavailability, document efforts to obtain the medications, notify the physician when medications were not available, obtain alternative treatment or monitoring orders, and treat missed doses as medication errors with appropriate notifications and monitoring. These required actions were not carried out as specified in the policy. The affected resident had multiple significant diagnoses, including atrial fibrillation, atherosclerotic heart disease, hypertension, venous thrombosis and embolism, pulmonary embolism, pulmonary hypertension, osteoarthritis, anemia, orthostatic hypotension, myocardial infarction, benign prostatic hyperplasia, GERD, sciatica, neuropathy, congestive heart failure, postural orthostatic tachycardia syndrome, chronic respiratory failure, cellulitis of the left lower leg, and unstable angina. Physician orders dated in February 2026 included Eliquis, Midodrine, protein supplement, Methocarbamol, Finasteride, Lasix, Hydrocodone-Acetaminophen, Protonix, and Gabapentin. The Medication Administration Record for that month showed multiple missed doses: Eliquis, Gabapentin, Hydrocodone-Acetaminophen, Lasix, Protonix, and Midodrine each had missed administrations, and Methocarbamol and the protein supplement had multiple missed opportunities. Progress notes documented that upon the resident’s admission and over the following days, numerous ordered medications, including Eliquis, Midodrine, Methocarbamol, Finasteride, protein supplement, Hydrocodone-Acetaminophen, Lasix, Gabapentin, and Protonix, were repeatedly noted as “on order,” indicating they were not available for administration at the scheduled times. There is no documentation in the report that staff followed the facility’s policy to notify the physician or family, obtain alternative orders, or complete medication error reports for these missed doses. In interviews, the DON, Administrator, and Family Nurse Practitioner each stated they would have expected nursing staff to notify the pharmacy and prescriber when medications were not available and to follow the facility’s policy, confirming that these expectations were not met in this case.
Failure to Administer Medication as Ordered Due to Communication and Documentation Errors
Penalty
Summary
The facility failed to follow physician's orders for one resident by not administering a prescribed medication, Invega Sustenna, in a timely manner. The resident, who had diagnoses including dementia, schizoaffective disorder, anxiety, depression, and persistent mood disorder, had a physician's order for an intramuscular injection of Invega Sustenna to be given on a specific date each month. On the scheduled date, the medication order was entered into the medical record in such a way that it appeared on the Certified Medication Technician (CMT) Medication Administration Record (MAR), even though a CMT is not authorized to administer this injection. The CMT documented that the medication was not given but did not notify the charge nurse, as required by facility policy. The charge nurse on duty was not informed that the medication had not been administered, and there was no documentation in the resident's progress notes indicating that the missed dose was reported or addressed. The Director of Nursing was unaware of the missed administration until contacted by the resident's family. The failure to communicate and follow up on the missed medication resulted in the resident not receiving the prescribed injection as ordered by the physician.
Failure to Assess and Document Merry Walker Use as a Restraint
Penalty
Summary
The facility failed to properly assess and document the use of a merry walker for a resident, leading to a deficiency in ensuring the resident was free from physical restraints unless medically necessary. The resident, who had severe cognitive impairment and multiple diagnoses including intellectual disability and mood disorder, was using a merry walker due to an unsteady gait and inability to ambulate independently. However, the facility did not conduct an assessment to determine if the merry walker was being used as a restraint, nor did they document any ongoing re-evaluation of its use. The resident's medical records lacked documentation of alternatives tried before resorting to the merry walker, the least restrictive use of the device, and ongoing re-evaluations. Additionally, there was no consent documented for the use of the merry walker as a restraint. Observations showed the resident frequently sat in the merry walker and was assisted by staff for various activities, indicating a potential reliance on the device without proper assessment. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed an expectation for quarterly assessments and documentation regarding the use of the merry walker as a restraint. However, these assessments were not conducted, and the necessary documentation was not maintained, leading to the deficiency identified by the surveyors.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for three residents, resulting in a deficiency in the care and assistance for activities of daily living (ADLs). Resident #5, who is dependent on staff for personal hygiene and showers, missed nine out of eleven scheduled shower opportunities and ten out of eleven opportunities for facial shaving and hair washing. Observations showed the resident with unkempt facial hair and dry skin flakes, and the resident expressed dissatisfaction with their grooming. The care plan for Resident #5 did not address the frequency or assistance required for showers, contributing to the missed care. Similarly, Resident #24 and Resident #32 also did not receive their scheduled showers. Resident #24 missed six out of eleven scheduled showers, and Resident #32 missed six out of eleven scheduled showers, with both residents' care plans lacking details on shower frequency and assistance. Interviews with the residents and staff, including the Administrator and Director of Nursing, confirmed the issue of incomplete showers, with staff acknowledging the problem and the facility attempting to find a solution.
Failure to Use Gait Belt for Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as Resident #29, by not utilizing a gait belt as required by the facility's policy. The resident, who was moderately cognitively impaired and totally dependent on staff for mobility and transfers, experienced significant pain during an attempted transfer with a gait belt. The Certified Nursing Assistant (CNA) involved decided to transfer the resident without the gait belt, using an alternative method that involved lifting the resident under the arms, which is against the facility's policy and could potentially cause harm. The resident's medical history included spinal stenosis, muscle weakness, and a history of a wedge compression fracture, which contributed to their total dependence on staff for transfers. The facility's policy mandates the use of a gait belt for all transfers unless alternative methods are required due to pain or inability to bear weight, in which case a Hoyer lift should be used. Interviews with staff, including the Certified Occupational Therapy Assistant (COTA) and the Director of Nursing (DON), confirmed that the proper procedure was not followed, as a Hoyer lift should have been used instead of lifting the resident under the arms.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bowel and bladder, resulting in the resident being left without personal care for over six hours. The resident, who had severe cognitive impairment and was totally dependent on staff for personal hygiene, was observed with a brief soaked with dark urine and a strong urine odor. The facility's policy required residents to receive necessary services to maintain personal hygiene, but the resident's care plan did not address incontinence care. On the day of the incident, the resident was observed in various locations within the facility from morning until afternoon without being checked for incontinence. The Certified Nursing Assistant (CNA) assigned to the resident's hall confirmed that the resident was not changed until 2:48 P.M., despite being up since 6:45 A.M. The facility's Administrator and Director of Nursing both stated that residents should be checked for incontinence every two hours, which was not adhered to in this case.
Failure to Assess and Manage G-tube Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to adhere to standards of practice regarding the management of a resident's gastrostomy tube (G-tube) following the resident's readmission from the emergency room (ER). The resident, who had a history of abnormal weight loss and required enteral feeding, had their G-tube replaced in the ER after pulling it out. However, upon the resident's return to the facility, the staff did not assess the G-tube site or verify the type of tube inserted, leading to a misunderstanding that the resident had a urinary catheter instead of a G-tube. Consequently, the facility held the resident's feedings and water flushes for 11 days without a physician's order. The facility's documentation and communication were inadequate, as evidenced by the lack of physician notification regarding the holding of the resident's feedings and flushes until 12 days after the resident's return. The Director of Nursing (DON) relied on reports from ER nurses and did not personally verify the type of tube or review the ER discharge paperwork. This oversight resulted in missed opportunities for feeding and flushing the G-tube, as well as a failure to conduct necessary assessments and document the resident's weights as per physician orders. Interviews with facility staff, including the DON and the physician, revealed a breakdown in communication and responsibility. The DON admitted to not verifying the tube type or reviewing the discharge paperwork, while the physician was not informed of the situation until much later. The resident, who was able to eat orally, did not suffer immediate harm, but the potential for adverse outcomes was present due to the facility's failure to follow proper procedures and ensure the resident's nutritional needs were met.
Failure to Document and Monitor Dialysis Care
Penalty
Summary
The facility failed to provide adequate documentation and monitoring for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease (ESRD), did not have physician orders for dialysis, nor were there orders to assess the dialysis site and dressing or to take vital signs and weights before and after dialysis. The resident's care plan included interventions for assessing weight and vital signs before and after dialysis but did not address monitoring the dialysis port dressing/site. The facility's policy required monitoring of the dialysis resident's status before, during, and after treatments, but this was not consistently followed. Interviews with the resident and staff revealed that the facility used a Dialysis Communication form to document vital signs, weight, and changes before and after dialysis. However, there were multiple instances where vital signs, weights, and assessments of the dialysis site/dressing were not documented. The Director of Nursing (DON) and the Administrator acknowledged the use of the form and the responsibility of the receiving nurse to complete it upon the resident's return from dialysis. Despite this, the documentation was incomplete, indicating a failure to adhere to the facility's policy and ensure proper monitoring of the resident's dialysis care.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to adhere to the regulatory requirement of limiting the use of PRN orders for psychotropic medications to 14 days for three residents. Resident #9 had a diagnosis of restlessness, agitation, and insomnia, with PRN orders for lorazepam without a 14-day stop date. The pharmacy's Medication Record Reviews (MRR) requested a 14-day stop date, but the physician did not address this need. Similarly, Resident #17, diagnosed with COPD, major depressive disorder, and anxiety disorder, had a PRN lorazepam order without a 14-day stop date, despite the pharmacy's request for one. The physician again did not address the need for a stop date. Resident #30, diagnosed with an anxiety disorder, had a PRN order for hydroxyzine without a 14-day stop date. The pharmacy's Gradual Dose Reduction (GDR) request indicated the need for a stop date, but the physician did not address it. The Director of Nursing (DON) acknowledged responsibility for GDRs and MRRs but had not completed the reviews for November and December due to being occupied with floor duties. The facility also failed to provide a policy for the 14-day stop date on PRN psychotropic medications.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically insulin pens, and did not maintain secure medication carts. During observations, it was noted that the medication cart was left unlocked and unattended multiple times, contrary to the facility's policy that requires medication compartments to be locked when not in use. Additionally, several insulin pens, including lispro, Lantus, and Admelog, were found opened and undated, with one Admelog pen being six days past its 28-day shelf life. This indicates a failure to adhere to the manufacturer's recommendations for insulin storage and usage. Interviews with staff, including a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Administrator, confirmed that the medication carts should always be locked when unattended, and insulin pens should be dated upon opening and discarded after 28 days. The facility's policy on medication storage was not followed, and there was no specific policy provided regarding the dating of insulin pens. This deficiency had the potential to affect all residents in the facility, which had a census of 47 at the time of the survey.
Facility Assessment Not Updated Annually
Penalty
Summary
The facility failed to update its facility-wide assessment at least annually, as required by its policy. The assessment, dated 08/07/24, did not accurately reflect the current resident profile and needs. Specifically, it did not account for a resident with a feeding tube, despite the facility having such a resident for multiple years. Additionally, the assessment inaccurately reported the number of residents with intellectual and/or developmental disabilities and based the average care required for Activities of Daily Living (ADLs) on an incorrect census of 20 residents instead of the actual 40 residents. During an interview, the Administrator acknowledged that the facility assessment should have included the resident with a feeding tube and that the average care required for ADLs should have been based on the correct census. The facility's failure to update the assessment meant that the necessary resources, including staffing, equipment, and competencies, were not accurately identified to meet the residents' needs. This oversight indicates a deficiency in maintaining an up-to-date and comprehensive facility assessment to ensure competent care for residents during both day-to-day operations and emergencies.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during several routine care activities, including meal pass, incontinent care, and medication administration. During the hall tray meal pass, a CNA did not wear gloves or perform hand hygiene while handling meal trays and interacting with residents and their personal items. This lack of hand hygiene was observed consistently across multiple rooms, as the CNA touched various surfaces and resident items without sanitizing hands between tasks. In the case of incontinent care for two residents, CNAs failed to perform adequate hand hygiene and glove changes during the process. For one resident, the CNA did not clean all necessary areas during care and continued to handle items and assist the resident without changing gloves or sanitizing hands. Similarly, another CNA did not change gloves or perform hand hygiene between cleaning different areas of the resident's body, which is against the facility's expected procedures. Additionally, during medication administration for two residents, a CMT was observed handling medications with bare hands, transferring them from bubble packs and bottle lids directly into medication cups. This practice was acknowledged by the DON and Administrator as inappropriate, as staff should not touch medications with bare hands. Furthermore, the facility failed to correctly screen five residents for tuberculosis as required by state regulations, with missing or incomplete TB screenings noted in their medical records.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Poplar Bluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor, The | 0 mi | ★★★★★ | 0 | 0 |
| Cedargate Health Care Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Oakdale Care Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Westwood Hills Health & Rehabilitation Center | 4.2 mi | ★★★★★ | 6 | 0 |
| Puxico Nursing And Rehabilitation Center | 18.7 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.