Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Roaring River during CMS and state inspections, most recent first.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
The facility failed to provide and document wound care and weekly skin assessments according to physician orders and facility policy for multiple residents with venous wounds, surgical wounds, skin tears, and skin cancer excision sites. Policies required evidence-based wound treatments, weekly and as-needed wound assessments, and complete TAR documentation, but TARs for several residents showed multiple missing entries for ordered dressing changes and compression wraps, with no corresponding notes of refusals or alternative explanations. Observations found residents with undated leg wraps or facial wounds without bandages, while wound physician notes documented specific venous and other wounds that required ongoing care. Staff interviews, including with an LPN, RN, ADON, DON, and Administrator, confirmed that wound care was sometimes not completed or not charted, that weekly skin assessments were not consistently performed, and that if care was not documented it was considered not done.
Staff failed to consistently provide and document ordered pressure ulcer and wound care, as well as weekly skin and wound assessments, for multiple residents with stage 2–4 pressure injuries and other wounds. Despite policies requiring weekly assessments, detailed wound measurements, and documentation of each treatment, TARs showed numerous missing entries for daily and scheduled wound care, including complex regimens for sacral, ischial, stump, scrotal, coccyx, and posterior thigh wounds. Dressings were frequently found undated, and during observation a nurse acknowledged that wound care sometimes was not completed or charted due to other work demands. No nursing notes documented resident refusals or missed care, even when residents reported that wound care was sometimes not done, demonstrating a pattern of noncompliance with the facility’s own wound management and documentation standards.
Failure to provide required written transfer/discharge notices and bed-hold information: the facility transferred two residents to the hospital and discharged one resident to ALF without documented written notices to the resident or representative that included appeal rights, Ombudsman contact information, or bed-hold details. Staff reported only verbal notification by phone and monthly Ombudsman reporting by category counts, while records showed no written notices were sent.
Failure to Post Daily Nurse Staffing Information: Facility staff did not consistently post nurse staffing information in a prominent, readily accessible area each day. Surveyors observed postings that were outdated, incomplete, missing, or posted for the following day instead of the current day, and one posting was placed high on the wall near the nurses' station. Interviews with RN B, the DON, the ADON, and the Administrator confirmed that the staffing form should be posted daily and that the DON and ADON were responsible for ensuring it was posted.
Failure to Perform Bed Rail Safety Checks for Two Residents: The facility did not have an initial or periodic process to measure bed frames, mattresses, and bed rails for entrapment risk for two residents using enabler bars. One resident had schizophrenia, severe intellectual disabilities, muscle weakness, and back pain; the other had TBI, cerebellar ataxia, dysphagia, and a history of falls. Staff had orders, assessments, and care plans for the rails, but records did not show required measurements or ongoing safety checks, and the Maintenance Director said he had no rail measurements and was not doing entrapment assessments.
Surveyors found that the DON, whose job description emphasized full-time leadership, oversight, regulatory compliance, and quality monitoring responsibilities, was frequently scheduled and working as a floor/charge nurse despite a census near 70. Review of assignment sheets showed the DON covering multiple day and night shifts as charge nurse over a short period, while interviews with an LPN, the ADON, the DON, and the Administrator confirmed that ongoing staffing shortages led the DON and ADON to work many hours on the floor. As a result, key DON and ADON duties such as audits of TARs, MARs, wound care, and CNA charting were not being completed, demonstrating that the DON was not functioning in a full-time administrative capacity as required when the census was 60 or more.
Medication destruction and accountability failures were observed when unused and expired meds were found stored in boxes and bags in the med room without timely destruction or logging. A CMT said non-narcotic meds were only disposed of when he/she worked Sundays and that no logbook entries were made, while the DON said non-narcotic meds should be destroyed weekly and logged before destruction. A sample included multiple residents’ meds, expired stock warfarin, and refused meds placed into drug buster liquid without documentation.
Pureed Diets Not Prepared or Served Per Approved Recipes: A dietary staff member prepared pureed beef stew without consulting the recipe and used 4-oz scoops to portion the food into the processor, even though the approved recipe called for 6 oz per serving before pureeing and 4 oz per pureed serving. The staff member stated he/she had not been trained to prepare purees and did not use the menu or recipe for serving sizes; the DM said staff should use the recipe book, and the RD stated staff were expected to follow the portion sizes on the spreadsheet and menus.
Food storage and sanitation practices were not followed when dry goods and frozen items were found open to air or missing proper labels, expired or undated food remained in storage, dishes and cups were stacked while still wet, and the dish machine log did not include required wash and rinse temps. Staff interviews confirmed that food should be sealed, dated, and discarded when past use-by dates, dishes should be air dried before stacking, and dishwasher temps should be monitored and recorded.
A resident with cognitive impairment and a pressure ulcer experienced a significant decline in wound condition, progressing from stage two to stage four with necrotic tissue. Although the physician was notified and new treatment orders were received, the resident's representative was not informed of the change until two days later, when the family was present at the bedside and requested hospital evaluation. Staff interviews confirmed that required notifications and documentation were not completed in a timely manner.
A resident with diabetes experienced multiple instances of elevated blood glucose levels above 500 mg/dL, but the facility staff failed to notify the physician or document insulin administration as required by the facility's protocol. Interviews revealed inconsistencies in staff understanding of the protocol, and the Director of Nursing confirmed the lack of documentation and adherence to physician orders.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Provide and Document Ordered Wound Care and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document wound care and weekly skin assessments according to physician orders, facility policy, and standards of practice for multiple residents with skin conditions and wounds. Facility policies required evidence-based wound treatments per physician orders, weekly and as-needed wound assessments, and complete documentation of wound characteristics and treatments on the TAR or in the electronic health record. Policies also required weekly skin assessments by licensed nurses, use of a weekly schedule for skin checks, and documentation of wound status each shift when no treatment was due. Interviews with nursing leadership and staff confirmed that if care was not documented, it was considered not done, and that there should not be blank spaces on the TAR. For one resident with diffuse traumatic brain injury, peripheral vascular disease, and dermatitis, the MDS showed severe cognitive impairment and risk for pressure injuries, and the care plan identified fragile skin and potential for skin impairment. This resident had physician orders for a light two-layer compression wrap to the left lower extremity, later revised to include cleansing with wound cleanser and continued compression wraps. The TAR for February showed multiple dates where these ordered treatments were not documented as completed, and there were no nursing notes indicating that wound care was not provided or was refused. The ADON’s wound measurement list contained no measurements for this resident, and no weekly skin assessment was documented, despite observations of undated wraps on both lower legs and subsequent wound physician notes describing bilateral stasis dermatitis and recommendations for doppler testing and continued wrapping. For another resident with CHF, an infected right lower extremity amputation stump, and an open wound on the right lower leg, the weekly skin observation documented multiple existing skin issues, including a wound vac to the right stump and ulcers and scabs on the left lower extremity and foot. The care plan required weekly skin assessments, wound treatments as ordered, and weekly skin audits by a licensed nurse. The wound care provider documented a skin tear on the left lateral calf present on admission, and the admission MDS showed the resident was cognitively intact, at risk for pressure injuries, and had open lesions and a surgical wound. Physician orders directed daily dressing changes to the left lower extremity and daily dressing changes to the right stump incision. The February TAR showed several days where these treatments were not documented as completed. The ADON’s wound measurement list showed an improved left calf wound, and observation with the wound physician and DON revealed undated bandages on the right stump and left lower leg, with the left leg wound improved and new orders initiated. A third resident with acute and chronic respiratory failure with hypoxia, COPD, and end stage renal disease had a quarterly MDS indicating cognitive intactness, risk for pressure injuries, and no open wounds at that time, with substantial to moderate assistance needed for ADLs. Later physician orders directed cleansing and dressing of venous wounds on both lower extremities three times per week and as needed, and then daily cleansing and skin prep to the right lower leg. The February TAR showed multiple dates where these ordered treatments were not documented as completed. Nursing progress notes contained no documentation of wound care not being provided or refused, and no weekly skin assessments were noted. Wound physician notes documented full-thickness venous wounds on both legs with specific measurements and no signs of infection, and later measurements showed changes in wound size. Observations showed the resident’s bilateral lower legs wrapped with undated gauze, and during wound rounds the DON removed undated dressings, revealing a scabbed right leg and a draining left leg wound. Another resident with COPD, CHF, cardiac arrhythmias, chronic kidney disease, and mitral insufficiency had a care plan identifying risk for impaired skin integrity and requiring weekly skin assessments and reporting of issues to the physician. Physician orders directed daily cleansing of facial sutures from a skin cancer excision with antibacterial soap and water, removal of crusts, and application of Bacitracin with a nonadherent dressing for two weeks on the evening shift. The February TAR showed that this treatment was documented on only two dates, with several ordered days lacking documentation. During an observation and interview, the resident reported recent skin cancer removal from the face and concern that staff were not treating and bandaging the area daily; at that time, the resident had no bandage on the face. The quarterly MDS indicated moderate cognitive impairment, open lesions requiring non-surgical dressings and ointments, and dependence on staff for transfers, bed mobility, and showers. Interviews with nursing staff and leadership confirmed systemic issues with completing and documenting wound care and weekly skin assessments. An LPN reported that residents had complained that wound care was not completed at times and that some days it was difficult to complete all resident care. An RN stated that nurses were responsible for weekly wound assessments using a binder schedule, that the TAR showed when wound care was due, and that if care was not charted it was considered not done; the RN would not expect to see gaps on the TAR without notes or handoff in report. The ADON acknowledged monitoring wound tracking, stated that dressings should be dated and documented on the TAR, and admitted that some days wound care was not charted even though he/she believed it was done, and that he/she had been doing most wound care until floor nurses took over. The DON stated that floor nurses complete weekly skin assessments, that TARs should always be completed including refusals, and that she had not been able to audit TARs weekly due to staffing issues. The Medical Director, primary care physician, wound physician, and Administrator all stated that staff were expected to follow physician orders and document care, and that if it was not documented, it was considered not done.
Failure to Provide and Document Ordered Pressure Ulcer Care and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care and weekly skin and wound assessments in accordance with its own policies, physician orders, and accepted standards of practice for multiple residents with pressure injuries and other wounds. Facility policies required evidence‑based wound treatments per physician orders, weekly and as‑needed wound assessments with detailed measurements and descriptions, and documentation of each treatment or dressing status. Despite these requirements, treatment administration records (TARs), weekly skin observation tools, and nursing notes showed repeated gaps in documentation of ordered wound care and incomplete weekly skin assessments, with no corresponding documentation that care was refused or not provided. One resident with diabetes, neuropathy, osteomyelitis, a stage 4 sacral pressure ulcer, and other wounds had numerous wound care orders for the coccyx, right ischium, scrotum, and right stump that were not documented as completed on many ordered days across January and February. For example, daily wound care orders to cleanse and dress the coccyx and right ischium, and daily hydrocolloid paste to the scrotum, showed large numbers of days with no TAR documentation, and there were no nursing notes indicating refusals or missed care. Observations showed undated dressings on the coccyx, right ischium, and right stump, and a nurse stated that the stump bandage appeared unchanged since several days earlier and acknowledged that wound care sometimes did not get completed and was not charted due to other work. The DON and wound provider were also observed removing undated dressings and reapplying new dressings without dating them. Another resident with Arnold Chiari syndrome, spina bifida, paraplegia, and two stage 4 pressure ulcers to the sacrum and left ischium had daily wound care orders that were not documented on multiple days in January and February, including a period in February where documentation was missing on most ordered days after the treatment time was changed to afternoons. There were no progress notes indicating that wound care was refused or not provided. A cognitively intact resident with a stage 3 pressure ulcer on the posterior right thigh had an order for wound care three times weekly, yet TARs showed most ordered treatment days in January and February without documentation, and the bandage observed on the wound was dated several days prior; the DON again completed wound care without dating the new dressing. A resident with a stage 2 coccyx pressure ulcer had every‑other‑day and then nightly wound care orders with multiple undocumented treatment days, while weekly skin observation and wound physician notes documented the presence and progression of the coccyx wound. Across these residents, the facility’s own weekly skin assessment schedule and wound documentation policies were not consistently followed, as evidenced by missing weekly full‑body skin assessment details and repeated failures to document ordered wound treatments or dressing status. A further resident, identified as at risk for skin breakdown with significant medical comorbidities, was also included in the facility’s census of affected residents, though the excerpted report section ends before detailing that resident’s specific wound orders and documentation gaps. Overall, the survey findings show that for at least five residents with pressure ulcers or other wounds, staff did not ensure weekly skin and wound assessments were completed and documented, did not consistently date dressings, and did not consistently document completion of ordered wound care on the TARs, despite facility policies and care plans requiring weekly assessments, measurement of wound progress, and documentation of each treatment or dressing status.
Failure to Provide Required Written Transfer, Discharge, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents and/or their representatives that included appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman, and it also failed to include bed-hold policy information in the transfer notices for two residents. The facility also failed to send a copy of the transfer or discharge notice to the Ombudsman for three residents. Review of the facility’s Transfer and Discharge policy stated that residents should receive transfer notice as soon as practicable and that the Social Services Director or designee would provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. Review of the Bed Hold Policy stated that before and at the time of transfer for hospitalization or therapeutic leave, the facility would provide the resident or resident’s representative with written notice explaining the duration of the bed-hold policy. For one resident with diagnoses including a displaced intertrochanteric fracture of the left femur and sepsis, staff documented an emergency transfer to the hospital after a fall and later documented that the resident returned to the facility. The resident had a guardian and was not his/her own responsible party. The record did not contain documentation that a written transfer notice was given or mailed to the resident or representative for the hospital transfer. The Bed Hold Acknowledgement Form showed the resident was transferred out of the facility and that bed hold was acknowledged at discharge, but the form did not include bed-hold policy information or the duration of the bed-hold rights. For another resident with diagnoses including cerebral infarction, hemiplegia, hemiparesis, and aphasia, the record showed two hospital transfers with return anticipated and later re-admission. The resident was not his/her own responsible party. The Bed Hold Acknowledgement Forms documented that notification was made to the resident’s representative by phone and that bed hold was acknowledged at discharge, but the forms did not include bed-hold policy information or the duration of the bed-hold rights. The record did not contain documentation that a written transfer notice was given or mailed for either hospital transfer. For a third resident with diagnoses including a resistant bacterial infection and unspecified psychosis, the record showed discharge not anticipated and a discharge planning review indicating the resident would return to an assisted living facility. The resident had a guardian and was not his/her own responsible party. The record did not contain documentation that a written transfer or discharge notice was given or mailed to the resident or representative for the discharge to assisted living, and the Ombudsman record did not show information related to that discharge.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to post nursing staff information in a prominent, readily accessible area on a daily basis. The census was 69. Review of facility records did not show a policy regarding posted nurse staffing. On 02/17/26, surveyors observed a nurse staff hours posting near the nurses' station next to the dining room window, placed on the wall about 5 feet high, dated 02/12/26 and showing day shift hours only, with no night shift hours listed. Additional observations showed inconsistent and missing postings. On 02/18/26 and 02/19/26, staff hours forms were posted near the nurses' station with census and shift hours listed, but on 02/20/26 and 02/23/26 at 11:00 A.M. no nurse staff hours were posted. On 02/23/26 at 1:00 P.M., a posting was found on a clipboard behind the front sheet with the top sheet dated 02/24/26, showing staffing for the following day. On 02/24/26 at 11:00 A.M., a nurse staff hours posting was again observed near the nurses' station. During interviews, RN B said the night nurse posted the hours and administration followed up in the morning, the DON said the night shift nurses should post the daily staffing hours and that the form should be posted daily, the ADON said she was responsible for posting it daily, and the Administrator said the DON and ADON were responsible for ensuring it was posted.
Failure to Perform Bed Rail Safety Measurements and Entrapment Checks
Penalty
Summary
The facility failed to have a process in place for initial and periodic bed rail safety checks, including measurements of the bed frame and bed rails for risk of entrapment, for two residents. The cited policy required bed rails or assist bars to be used only with a provider order, a resident-specific assessment, informed consent, and ongoing monitoring, and the facility’s bed rail and mattress safety assessment form included measurements for the gap between the mattress and bed rail and the inside surface of the rail and mattress. Resident #9 had diagnoses including schizophrenia, severe intellectual disabilities, muscle weakness, and discogenic back pain. The resident had a bed rail assessment signed on 11/17/25 and a physician order dated 11/19/25 for enabler bars to enhance independence with bed mobility. The care plan stated the resident had enabler bars to assist with repositioning in bed. Staff records did not show documentation of initial or periodic assessments or measurements of the rails to ensure they were placed appropriately and maintained. During observation, bilateral grab bars were seen in the upright position on the resident’s bed, and the resident stated the grab bars were used to help with repositioning in bed. Resident #18 had diagnoses including a personal history of traumatic brain injury, cerebellar ataxia, dysphagia, and a history of falling. The resident had a bed rail assessment signed on 11/17/25 and a physician order dated 11/18/25 for enabler bars to enhance independence with bed mobility. The care plan stated the resident used enabler bars on the bed to assist with repositioning in bed. Staff records did not provide documentation of initial or periodic assessments and measurements of the rails to ensure they were placed appropriately and maintained or in good repair. During observation, grab bars were seen in the upright position on the resident’s bed, and the resident stated the grab bar was used to assist with repositioning in bed. Interviews with nursing, maintenance, the DON, and the Administrator showed that staff did not have an ongoing process for measuring the bed frame, mattress, and bed rails, and the Maintenance Director stated he had no measurements of any side rails in the building and had not been doing entrapment assessments.
DON Frequently Assigned as Charge Nurse Instead of Full-Time Administrative Role
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) worked full time in the DON role and did not function as a charge nurse when the facility’s average daily census was 60 or more residents. The facility census was 69–70 during the reviewed period. The DON job description outlined extensive leadership, oversight, regulatory compliance, quality monitoring, staff education, and interdisciplinary collaboration responsibilities, emphasizing that the DON is responsible for providing strategic direction and operational oversight to the nursing department and ensuring high-quality, resident-centered care. Review of the nursing schedules and Daily Assignment Sheets showed that the DON was scheduled and worked as a floor/charge nurse on multiple shifts despite the high census. Specifically, the DON was listed as charge nurse on night shift with a census of 70, and on several day and night shifts with censuses of 69–70, and was scheduled to work 5 shifts out of 9 days as a floor/charge nurse. Staff interviews corroborated that the DON was often filling in as a charge nurse. An LPN reported uncertainty about when the DON would have time to complete DON duties, indicating that the DON’s time was being diverted from administrative and oversight responsibilities to direct floor coverage. Further interviews with the Assistant Director of Nursing (ADON) and the DON confirmed that both the DON and ADON were frequently working as charge nurses due to staffing issues, including staff not showing up for scheduled shifts. The ADON stated she worked more than 40 hours per week, was often on the floor, and had not had time to complete audits on wound care and CNA charting. The DON reported working most weekends and one to two nights per week, sometimes staying through the morning meeting, and acknowledged that she had not had time to audit Treatment Administration Records (TARs) or Medication Administration Records (MARs) weekly because of her frequent floor assignments. The Administrator confirmed awareness that the DON was often working on the floor and expected that when she did so, she was the nurse in charge, further demonstrating that the DON was not functioning in a full-time administrative DON capacity as required when the census was 60 or more residents.
Medication destruction and accountability failures
Penalty
Summary
The facility failed to provide pharmaceutical services in a manner that ensured proper storage, destruction, and accountability of medications. During observation of the medication room, surveyors found one cardboard box and three grocery-style brown bags under the sink that were full of unused medication cards, bags, and liquids. Review of the pile showed medications with dispense dates from multiple dates, and the facility policy required discontinued, expired, or unused medications to be documented in a ledger before destruction and maintained for inspection. An interview with a CMT revealed that medications were disposed of only on Sundays when that staff member worked, that he/she no longer worked Sundays, and that he/she had helped another CMT dispose of unused medications only once in the prior six months. The CMT said no information about destroyed medications was written in any logbook, although cameras were present in the medication room. The DON later removed the box and bags and stated that non-narcotic medications should be destroyed at least once per week, logged before destruction, and placed in drug buster liquid, but she was unaware of the amount waiting to be destroyed in the medication room. A sample of medications pending destruction included medications for multiple residents, such as Solu-Medrol injectable, Meropenem, Apixaban, Meclizine, Omeprazole, vitamin B complex with vitamin C, Gentamicin, Augmentin, Trazodone, Duloxetine, Pantoprazole, Losartan, Gabapentin, Spironolactone, Nitroglycerin, Ceftriaxone, Nafcillin with sodium chloride reconstitution, Metronidazole, Atorvastatin, Carvedilol, Sertraline, and expired stock Warfarin. During another observation, a CMT placed refused medications, Tylenol and magnesium oxide, into drug buster liquid but did not log the destruction and stated there was no logbook for destroyed medications. An LPN also stated there was no process for disposal of non-narcotic medications and that non-narcotic destructions were never written in a logbook.
Pureed Diets Not Prepared or Served Per Approved Recipes
Penalty
Summary
The facility failed to ensure that pureed diets were prepared according to approved recipes and served in the approved portion sizes for residents on puree diets. The facility policy stated that pureed diet menus should follow the regular menu as closely as possible, use an appropriate recipe, and refer to the recipe and spreadsheet for directions. The recipe for pureed beef stew required the regular beef stew recipe to be prepared first, then the needed number of servings to be placed into the food processor, blended until smooth, and served as two #8 scoops, or 4 oz per serving. During observation, Dietary staff began pureeing the lunch meal for four puree diets and used four 4-oz scoops to place four servings of beef stew into the processor, even though the recipe called for 6 oz of beef stew per serving before pureeing. The staff member said he/she did not consult a recipe during the puree process and later served one 4-oz scoop for a pureed portion of beef stew. In interviews, the staff member stated he/she had not been trained to prepare purees, did not consult the menu or recipe for serving sizes, and relied on the Dietary Manager for correct serving sizes as needed. The Dietary Manager stated staff should use the recipe book for puree preparation and serve out, but he had not been able to train the staff member on preparing purees correctly or using the recipe for correct servings. The Registered Dietician stated staff were expected to follow the portion size indicated on the spreadsheet and menus for food preparation and serve out.
Food Storage, Dish Drying, and Dishwasher Monitoring Failures
Penalty
Summary
The facility failed to appropriately store and label food items in the dry storage area and walk-in freezer. During observation, a 16-ounce box of corn starch was open to air and not labeled with a date. In the walk-in freezer, a large plastic bag of beef patties, a large plastic bag of waffles, and a large plastic bag of broccoli were all open to air inside boxes, exposing the food to possible contamination. Staff interviewed after the observation stated that stored food should be sealed and labeled with the date opened and use-by date, and that no food should be open to air. The facility also failed to discard food items that were past their expiration or use-by dates. Observations in the dry storage area showed a nearly empty 128-ounce container of soy sauce with a date of 05/27/24 written on it, a black plastic bin of pinto beans with no dates, and a black plastic bin of rice labeled with a date of 01/07/25 and a use-by date of 06/07/25. Staff interviews confirmed that food past the use-by or expiration date should be thrown out, and the RD stated no food should be available past its use-by date. In addition, the facility failed to air dry dishes before stacking and failed to check dishwasher temperatures. Observations showed blue coffee cups, plastic bowls, and small plastic drinking cups stacked with visible water inside or at the bottom. A DA stated the cups had not had enough time to dry between meal services and that the facility did not have enough cups, so wet cups were used. The dish machine log documented sanitizer PPM twice daily but did not document temperatures. During operation, the dishwasher wash and rinse cycles were observed at temperatures below the manufacturer minimum for wash, and staff stated temperatures had not been logged since November of the prior year.
Failure to Timely Notify Resident Representative of Wound Decline
Penalty
Summary
The facility failed to promptly notify a resident's representative of a significant decline in the resident's wound condition. The resident, who was cognitively impaired and required substantial assistance with daily activities, had a history of a stage two pressure ulcer on the sacrum/coccyx upon admission. Over the course of the stay, the wound deteriorated from a stage two to a stage four pressure area with necrotic tissue, as documented by the Assistant Director of Nursing (ADON). Although the physician was notified and new treatment orders were received, there was no documentation that the resident's representative was informed of the change in the wound's condition or the new orders at the time the decline was identified. The facility's policy required prompt notification of the resident, physician, and representative in the event of significant changes in condition, including wound deterioration. Despite this, the resident's family was not informed of the wound's decline until two days after the deterioration was documented, when they were present at the bedside. At that time, the family requested the resident be sent to the emergency room for wound evaluation. Interviews with facility staff, including the ADON, LPN, DON, and Administrator, confirmed that the family was not notified of the wound's decline or new treatment orders until the family was physically present at the facility. Staff interviews revealed a lack of clarity and follow-through regarding notification responsibilities. The ADON admitted to not notifying the family when the wound began to decline or when new orders were received. The LPN and DON both stated that family notification and documentation are required when there are changes in a resident's wound condition. The Administrator was unaware that the family had not been notified until after the fact and stated an expectation for timely notification of both the physician and family in such situations.
Failure to Follow Physician Orders for Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders and document insulin administration for a resident with diabetes, leading to a deficiency in care. The resident, diagnosed with type 2 diabetes mellitus with hyperglycemia, had several instances where blood glucose readings exceeded 500 mg/dL. According to the facility's policy and physician orders, staff were required to notify the physician and document the insulin administered when blood glucose levels were above this threshold. On multiple occasions, including specific dates in October and November 2024, the resident's blood glucose levels were recorded above 500 mg/dL. However, staff failed to document any notification to the physician, the orders received, or the amount of insulin administered. Interviews with nursing staff revealed inconsistencies in their understanding and execution of the protocol for handling elevated blood glucose levels, with some staff indicating they would administer insulin without contacting the physician, contrary to the established protocol. The Director of Nursing and the Administrator confirmed that the expected procedure was not followed, as there was no documentation of physician notification or insulin administration for the elevated readings. This lack of documentation and adherence to physician orders represents a failure in providing care per standards of practice, as outlined in the facility's blood glucose monitoring policy.
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Nursing homes near Cassville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cassville Health Care Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Lacoba Homes Inc | 17 mi | ★★★★★ | 2 | 0 |
| Ascend At Aurora | 21.6 mi | ★★★★★ | 4 | 0 |
| The Blossoms At Eureka Springs Rehab & Nursing Cen | 21.7 mi | ★★★★★ | 1 | 0 |
| Concordia Nursing & Rehab, Llc | 25 mi | ★★★★★ | 0 | 0 |
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