Inspection Reports for Joplin Gardens
2810 S Jackson Ave, Joplin, MO 64804, United States, MO, 64804
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 12, 2025, identified deficiencies related to not honoring residents’ shower preferences and failing to provide RN coverage for at least eight consecutive hours daily. Earlier inspections showed a range of issues including inadequate assistance with bathing and personal hygiene, incomplete skin assessments, medication management errors, infection control lapses, and safety concerns such as improper transfer practices and food temperature problems. Complaint investigations related to shower preferences and RN coverage were substantiated, but enforcement actions such as fines or license suspensions were not listed in the available reports. Prior complaints were mostly unsubstantiated or not noted. The facility’s inspection history shows ongoing challenges with resident care and staffing, with no clear pattern of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
79 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
Date: Dec 12, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to honor residents' shower preferences and inadequate RN coverage.
Complaint Details
Complaints 2594960, 2607877, 2617974 were investigated related to shower preferences and RN coverage.
Findings
The facility failed to promote and facilitate residents' right to self-determination by not honoring reasonable shower preferences for six residents. Additionally, the facility failed to provide RN coverage for at least eight consecutive hours per day, seven days per week, as required.
Deficiencies (2)
Failure to promote and facilitate resident self-determination through support of resident choice regarding shower preferences for six residents.
Failure to provide the services of a registered nurse for at least eight consecutive hours per day, seven days per week.
Report Facts
Facility census: 79
RN coverage hours: 8
RN coverage hours: 4
RN coverage hours: 8
Residents per CNA: 30
Shower aide hours: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Tech B | Certified Medication Technician | Reported staffing and shower scheduling issues |
| Licensed Practical Nurse A | Licensed Practical Nurse | Reported shower assignments and RN coverage observations |
| Licensed Practical Nurse F | Licensed Practical Nurse | Reported insufficient aide staffing affecting showers |
| Licensed Practical Nurse D | Licensed Practical Nurse | Reported RN coverage and shower staffing issues |
| Director of Nursing | Director of Nursing | Provided information on shower scheduling and RN staffing |
| Administrator | Facility Administrator | Provided information on shower scheduling and RN staffing lapses |
| Certified Medication Tech G | Certified Medication Technician | Reported workload and shower completion challenges |
Inspection Report
Routine
Census: 71
Deficiencies: 2
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, pressure ulcer care, and skin assessments in a nursing home facility.
Findings
The facility failed to ensure dependent residents received adequate assistance with bathing and personal hygiene, as evidenced by three residents not receiving timely showers. Additionally, the facility did not perform a complete admission skin assessment or timely treatment for a pressure ulcer for one resident.
Deficiencies (2)
Failed to provide assistance with bathing to three residents out of a sample of thirteen.
Failed to perform a complete admission skin assessment and timely treatment for a pressure ulcer for one resident.
Report Facts
Residents affected: 3
Facility census: 71
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse E | Wound Care Nurse | Provided information about admission skin assessment responsibilities and timing |
| Licensed Practical Nurse C | Licensed Practical Nurse | Provided information about shower frequency and skin assessment timing |
| Licensed Practical Nurse D | Licensed Practical Nurse | Provided information about admission skin assessment documentation and responsibilities |
| Director of Nursing | Director of Nursing (DON) | Discussed new process to improve resident showers and skin assessment protocols |
| Administrator | Administrator | Provided information about shower frequency preferences and skin assessment requirements |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 23, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, medication administration, safety, food service, infection control, and other care standards at the nursing home.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to follow physician orders for blood sugar monitoring and insulin administration, unsafe transfer practices, improper labeling and storage of medications, serving food at unsafe temperatures, poor maintenance of kitchen vents, and failure to implement enhanced barrier precautions for infection control.
Deficiencies (7)
Failed to ensure the Minimum Data Set (MDS) assessment was accurate and complete for one resident (Resident #24).
Failed to provide care per standards of practice when staff failed to document and follow physician's orders related to blood sugar tests for one resident (Resident #23).
Failed to ensure environment free of hazards when staff failed to transfer one resident (Resident #38) with two staff members as care planned using mechanical lift.
Failed to ensure insulin pens were dated when opened for seven residents and failed to ensure expired influenza vaccines were removed from medication rooms.
Failed to maintain food at a palatable temperature on one hall when six residents complained of cold food.
Failed to maintain ceiling vents to prevent condensation and peeling paint from dropping onto food preparation area.
Failed to implement enhanced barrier precautions for one resident with a PICC line receiving antibiotics; staff did not wear gowns or gloves during high-contact care.
Report Facts
Residents reviewed for MDS accuracy: 22
Residents reviewed for insulin use: 22
Residents affected by insulin pen dating deficiency: 7
Expired influenza vaccine vials: 5
Residents affected by cold food complaint: 6
Residents affected by enhanced barrier precaution deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Responsible for coding Sections C, D, and E on MDS assessments; unsure why sections were not coded |
| MDS Coordinator | MDS Coordinator (MDSC) | Did not know why missing MDS sections were not coded; signed off assessment as complete |
| Licensed Practical Nurse #2 | LPN | Failed to document blood sugar checks and physician communications for Resident #23 |
| Licensed Practical Nurse #4 | LPN | Administered insulin to Resident #23 but did not document reason for blood sugar check |
| Licensed Practical Nurse #8 | LPN | Confirmed no documentation of blood sugar check at 4:00 PM for Resident #23 |
| Director of Nursing | Director of Nursing (DON) | Confirmed physician orders and blood sugar checks should be documented; responsible for ensuring insulin pens are dated |
| Certified Nurse Aide #2 | CNA | Transferred Resident #38 alone using Hoyer lift, causing injury |
| Dietary Manager | Dietary Manager (DM) | Responsible for food temperature monitoring; unaware of steamer bay malfunction |
| Maintenance Director | Maintenance Director (MD) | Responsible for maintenance of ceiling vents; aware of issues but had not fixed them |
| Licensed Practical Nurse #1 | LPN | Did not wear gown or gloves during high-contact care for Resident #216 with PICC line; lacked training on enhanced barrier precautions |
| Certified Nurse Aide #1 | CNA | Had not received training on enhanced barrier precautions |
| Infection Preventionist | Infection Preventionist (IP) | Provided training on enhanced barrier precautions; PPE located in lounge area |
| Regional Quality Assurance nurse | Regional QA nurse | Informed of lack of EBP knowledge and training |
Inspection Report
Routine
Census: 60
Deficiencies: 7
Date: Sep 13, 2022
Visit Reason
Routine inspection of Joplin Gardens nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, and safety measures.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of residents' code status, improper wound care infection control practices, incomplete catheter orders, lack of proper side rail assessments and consents, failure to reconcile controlled substance counts, medication administration errors related to insulin and missed oral medications, and failure to administer or offer pneumococcal vaccines to some residents.
Deficiencies (7)
Failed to ensure a resident's choice of code status was clearly and consistently documented throughout the medical record for three residents.
Failed to ensure proper infection control practices during wound care for a resident with a Stage 4 pressure ulcer.
Failed to ensure complete catheter orders including catheter size and balloon bulb for one resident.
Failed to document identification and use of alternatives, risk assessment, informed consent, physician orders, and ongoing assessments for side rail use for multiple residents.
Failed to ensure controlled drugs were reconciled and counted at shift changes with signatures on narcotic count records.
Failed to ensure medication error rate below 5 percent; insulin pens were not primed before administration and oral diabetes medication was missed for multiple days.
Failed to administer pneumococcal vaccine to one resident and failed to offer the vaccine to two residents.
Report Facts
Medication error rate: 11.11
Facility census: 60
Pressure ulcer measurement: 5.9
Pressure ulcer measurement: 5.2
Pressure ulcer measurement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in wound care infection control deficiency and medication administration observation |
| CNA D | Certified Nursing Assistant | Named in code status and side rail use interviews |
| DON | Director of Nursing | Named in multiple interviews regarding code status, side rails, medication administration, and vaccine policies |
| Administrator | Named in interviews regarding medication administration and vaccine policies | |
| CMT F | Certified Medication Technician | Named in medication reconciliation and medication administration interviews |
| LPN I | Licensed Practical Nurse | Named in insulin administration observation |
| ADON | Assistant Director of Nursing | Named in insulin administration observation |
Inspection Report
Routine
Census: 76
Deficiencies: 2
Date: Oct 15, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights postings and the availability of working call systems in resident bathrooms and bathing areas.
Findings
The facility failed to ensure required postings including resident rights, abuse/neglect hotline, and Ombudsman contact information were posted in a prominent and accessible location. Additionally, the facility failed to provide call light activation switches in two common-use restrooms accessible to residents.
Deficiencies (2)
Failed to ensure required postings including resident rights, abuse/neglect hotline, and Ombudsman contact information were posted in a prominent location accessible to residents, visitors, and staff.
Failed to provide a switch in two common-use restrooms that would activate the resident call light system.
Report Facts
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding the lack of call light activation switches in restrooms | |
| Administrator | Interviewed regarding the posting of Resident Rights and related information |
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