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 Poplar Bluff during CMS and state inspections, most recent first.
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.
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.
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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 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 |
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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.