Aspire Senior Living Roaring River
ASPIRE SENIOR LIVING ROARING RIVER in CASSVILLE, MO — inspection on February 24, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 02/23/26, at 10:00 A.M., Administrator said
265538 02/24/2026
Aspire Senior Living Roaring River 812 Old Exeter Road Cassville, MO 65625
Review of the resident's care plan, last reviewed 12/18/25, showed the following:-Resident had potential for impairment to skin integrity related to fragile skin;-Staff should report any skin concerns to the physician;-Staff should complete weekly treatment documentation to include measurement of each area of skin breakdowns' width, length, depth, type of tissue and any other notable changes or observations.
Review of the Treatment Administration Record, for the Month of January 2026, showed the following:-An order with a start date of 01/26/26 and discontinue date of 02/06/26, showed to cleanse with the coccyx with wound cleanser, apply fibracol (soft, absorbent, non-adherent dressing designed to maintain moist environment that promotes new tissue and rapid healing) to wound bed, cover with bordered foam dressing every night shift every two days for wound care until resolved;-Staff did not document care completed on 01/28/26 or 01/30/26 (2 out of 3 days not documented).
Review of the Treatment Administration Record, for the Month of February 2026, showed the following:-An order with a start date of 01/26/26 and a discontinue date of 02/06/26, showed to cleanse the coccyx with wound cleanser, apply fibracol to wound bed, cover with bordered foam dressing every night shift every two days for wound care until resolved;-Staff did not document care completed on 02/01/26 or 02/05/26 (2 out of 3 days not documented);-An order dated 02/06/26, showed Triad hydrophilic wound dress external paste was to be applied to the coccyx topically at bedtime for wound care;-Staff did not document care completed on 02/06/26, 02/08/26, 02/12/26, 02/14/26, 02/15/26, or 02/20/26 (6 out of 17 days not documented).
Review of the weekly skin observation, dated 02/03/26, showed the following:-Existing skin issue - pressure ulcer stage 2 on coccyx and bilateral upper extremities have bruises that are in the healing process.
Review of the wound physician progress notes, dated 02/05/26, showed the following:-Site two - Stage 2 pressure wound coccyx partial thickness, 0.5 x 0.4 x 0.1 cm, present greater than 4 days.
Review of the ADON wound measurements list, dated 02/12/26, showed coccyx area closed, resolved, continue triad.
Review of the nursing progress notes showed staff documented the following:-No documentation for wound care not completed or resident refusal.
Review of the wound physician progress notes, dated 02/19/26, showed the following:-Site two - Stage 2 pressure wound coccyx partial thickness, 0.3 x 0.3 x not measurable cm, depth is unmeasurable due to presence of dried fibrinous exudate (scab - acting as a natural bandage), improved evidenced by decreased surface area.
Observation on 02/19/26, at 5:10 P.M., showed the following:-Wound Physician and DON entered the resident's room;-No bandage on the buttocks;-Scab observed on the buttock - continued triad. 5.
Review of Resident #25's face sheet showed the following: -admitted on [DATE];-Diagnoses included: chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), severe sepsis (life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, which triggers widespread inflammation, tissue damage, and organ failure) without septic shock, bacterial pneumonia (serious lung infection causing inflammation and fluid/pus accumulation in the air sacs).
Review of the resident's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Use of walker;-Use of wheelchair;-Partial to moderate assistance with toileting hygiene, showering , personal hygiene, dressing;-Resident at risk of developin
265538 02/24/2026
Aspire Senior Living Roaring River 812 Old Exeter Road Cassville, MO 65625
Review of the facility's nursing schedule, Daily Assignment Sheets, showed the DON
02/17/26, scheduled night shift with a census of 69; she did not work this shift due to state survey in
02/18/26 at 11:20 A.M., LPN B said the DON was often filling in as a charge nurse.
The LPN was unsure when the DON would have time to do the DON duties.
During an interview on 02/19/26 at 10:40 A.M., the Assistant Director of Nurses (ADON) said she currently worked more than 40 hours per week and was often a charge nurse on the floor.
She had not had time to complete audits on wound care and CNA charting.
Both her and the DON were putting a lot of hours on the floor and not completing the DON and ADON duties.
During an interview on 02/20/26 at 11:40 A.M., the DON said there have been staffing issues.
There were staff that would not show up when they said they would.
She has worked most weekends and one to two nights per week.
She would stay until the morning meeting and then leave.
They try to keep two nurses staffed for all shifts.
She had not been the only nurse on the days or nights she worked.
When she worked on the floor, she was still the DON.
She had not had time to audit Treatment Administration Records (TARs) or Medication Administration Records (MARs) weekly due to working on the floor often.
During an interview on 02/20/26 at 3:00 P.M., the Administrator said when the DON was working the floor he expected she was the nurse in charge. He was aware she was working on the floor often due to staffing challenges.