Aspire Senior Living Roaring River: Wound Care Failures - MO
Fifteen minutes after being told, the family asked that the resident be sent to the emergency room. A second family member arrived at the bedside at 7:36 p.m. and made the same request. The resident left for the ER at 7:46 p.m.
Federal inspectors, who visited the facility on November 14, documented what had happened in the weeks before that night.
On October 15, the Assistant Director of Nursing recorded a stage two pressure wound to the resident's sacrum and coccyx, measuring 1.4 centimeters long, half a centimeter wide, and a tenth of a centimeter deep. A stage two wound means partial-thickness skin loss, an exposed layer of dermis, a shallow open ulcer. It is serious, but it is also the kind of wound that, with proper care and monitoring, does not have to get worse.
It got worse.
On October 29, the ADON documented the wound again. Still stage two, dark pink, no open area. On November 1, the resident refused treatment. On November 5, the ADON measured what was now a stage four wound: 5.5 centimeters long, 5 centimeters wide, half a centimeter deep, with necrotic tissue present. Stage four means full-thickness loss of skin and underlying tissue. The wound had grown to roughly the size of a playing card. Dead tissue had formed. The physician was notified and new orders were written.
The family was not notified. Not on November 5. Not when the wound was first documented on October 15. Not when new treatment orders arrived on November 7.
The ADON, interviewed by inspectors on November 13, was direct about what had not happened. He or she had served as the wound care nurse for the facility, handling wound treatments alongside charge nurses and measuring wounds for residents not seen by the wound care physician. November 7 was the only time he or she had spoken to the family about the resident's wound. He or she had not notified the family when new orders were received. He or she had not notified the family when the wound began to decline.
When asked whether the family even knew about the wound at admission, the ADON said he or she did not know.
LPN A, interviewed the same day, described how things were supposed to work. Changes to wounds were to be reported to the ADON, the Director of Nursing, the physician, and the family. Family notifications were to be documented in the nurses' notes. Nursing interventions for residents with wounds included turning and repositioning, and when a resident refused care, involving the family.
The Director of Nursing told inspectors that all residents are assessed for wounds on admission, and that if a wound is present, staff should notify the wound nurse, get physician orders if none exist, document the site, and notify the family. He or she said the expectation was clear: family should be notified when a resident has a change of condition, and when a resident is frequently refusing treatments.
The resident had refused treatment on November 1. Four days later, the wound had reached stage four.
The Administrator told inspectors on November 14 that he or she had not been aware the family was kept in the dark until November 7. The expectation, the Administrator said, was that staff notify both the physician and the family as soon as possible when a resident's condition changes.
The inspection report notes the violation caused minimal harm or potential for actual harm to a small number of residents. The wound itself told a different story. Between October 15 and November 5, it transformed from a shallow ulcer smaller than a fingernail to a stage four wound with dead tissue, the kind of deterioration that signals something went wrong with monitoring, with intervention, or both.
The family did not wait for a phone call that was never going to come. They showed up, saw what had happened, and within fifteen minutes made a decision that staff had not made for them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aspire Senior Living Roaring River from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
ASPIRE SENIOR LIVING ROARING RIVER in CASSVILLE, MO was cited for violations during a health inspection on November 14, 2025.
Fifteen minutes after being told, the family asked that the resident be sent to the emergency room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.