Inspection Reports for
Joplin Gardens
2810 S Jackson Ave, Joplin, MO 64804, United States, MO, 64804
Back to Facility Profile14 Reports
Inspection Report — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form; complaint investigation. Complaint numbers MO00246671, MO00246674, MO00246824 appear in the file.
Complaint Details
Complaint numbers MO00246671, MO00246674, MO00246824 are listed in the file; substantiation of the allegations is not stated in the documentation.
Findings
Five deficiencies were cited: two federal health deficiencies concerning inadequate assistance with activities of daily living/bathing and failure to perform admission skin assessment and timely pressure ulcer treatment, and three Missouri licensure deficiencies addressing cleanliness/odor, grooming/dressing, and pressure sore prevention/treatment.
Deficiencies (3)
19 CSR 30-85.042(67) Clean, Dry, Odor Free: 1. Please refer to F677. MO00246671, MO00246674, MO00246824.
19 CSR 30-85.042(68) Res Groomed/Dressed Appropriately: 1. Please refer to F677.
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: 1. Please refer to F686. MO00246671.
Report Facts
residents sampled: 13
residents affected: 3
Inspection Report — Jan 24, 2023
Routine
Date: Jan 24, 2023
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CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
2 deficiencies: one federal health deficiency for failing to monitor and follow up on STAT lab results leading to delayed culture follow-up and treatment for a resident, and one Missouri state licensure deficiency that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: See the deficiency cited at F658.
Report Facts
residents affected: 1
Inspection Report — Dec 15, 2022
Complaint Investigation
Date: Dec 15, 2022
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation with complaint number MO00210652.
Complaint Details
Complaint number MO00210652; substantiation not indicated in the document.
Findings
Two deficiencies were cited: one federal deficiency for failures in grievance documentation and follow-up, and one Missouri state citation for failures related to residents' exercise of rights/voice regarding grievances.
Deficiencies (1)
19 CSR 30-88.010(20) Exercise Rights/Voice Grievances: Please refer to F585.
Inspection Report — Sep 13, 2022
Routine
Date: Sep 13, 2022
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eight federal health deficiencies and four Missouri state licensure deficiencies were cited, addressing inconsistent code status documentation, pressure ulcer/wound care and infection control, catheter orders and care, bed rail/enabler assessments and documentation, pharmacy controlled substance reconciliation, medication administration errors (including insulin priming/administration), and lack of pneumococcal vaccine documentation.
Deficiencies (4)
19 CSR 30-85.042(46) Safe/Effective Medication System: Please refer to F755. Please refer to F759. Please refer to F760.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Please refer to F678. Please refer to F690. Please refer to F700.
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: Please refer to F686.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: See the deficiency cited at F686.
Report Facts
residents affected: 3
Inspection Report — Sep 13, 2022
Life Safety
Date: Sep 13, 2022
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Federal Life Safety (CMS-2567) and Missouri State licensure (State Form); life safety survey (K-tag deficiencies cited).
Findings
Six deficiencies were cited: three federal life safety deficiencies involving fire drills, electrical panel clearance, and improper use of power/extension cords, and three Missouri state deficiencies referencing the same fire drill, electrical wiring, and extension cord issues.
Deficiencies (3)
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: See the deficiency cited at K712.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: See the deficiency cited at K911.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: See the deficiency cited at K920.
Inspection Report — Jun 1, 2021
Complaint Investigation
Date: Jun 1, 2021
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) for Joplin Gardens; complaint investigation (MO00185962) is cited in the file.
Complaint Details
MO00185962; substantiation not stated.
Findings
Two deficiencies were cited: one federal deficiency for failure to promptly report alleged abuse involving multiple residents, and one Missouri state deficiency for failure to develop/implement abuse/neglect policies (state item refers to the federal finding).
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: See the deficiency cited at F609.
Report Facts
residents affected: 4
staff affected: 1
Inspection Report — Feb 18, 2021
Routine
Date: Feb 18, 2021
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Federal health survey (CMS-2567) and Missouri State licensure survey (State Form); the file documents a COVID-19 focused Emergency Preparedness survey completed 02/18/2021.
Findings
Two deficiencies were cited: one federal health deficiency for inadequate food temperature monitoring and hot foods served at unsafe or unappetizing temperatures, and one Missouri state licensure deficiency under 19 CSR 30-85.052(5) referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.052(5) Hot Food Hot, Cold Food Cold: Please refer to F804.
Inspection Report — Nov 15, 2020
Routine
Date: Nov 15, 2020
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Federal health survey (CMS-2567) and Missouri state licensure form; the survey is a COVID-19 Focused Emergency Preparedness (infection control) survey as stated in the Initial Comments.
Findings
Two deficiencies were cited: one federal infection prevention and control deficiency and one Missouri communicable disease rule referencing the federal finding. The findings relate to failures in infection prevention during the COVID-19 pandemic, including symptomatic staff allowed to work and inadequate screening/communication.
Deficiencies (1)
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Please see F880.
Report Facts
residents observed on COVID unit: 2
Inspection Report — Oct 18, 2019
Routine
Date: Oct 18, 2019
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies were cited: two federal deficiencies addressing required postings and the resident call system, and two Missouri state deficiencies addressing nurses' call system requirements (referencing the federal finding) and tuberculosis testing for staff.
Deficiencies (2)
19 CSR 30-85.012(124) Nurses' Call System Requirements: See the deficiency cited at F919.
19 CSR 20-20.100 General requirements for Tuberculosis Testing for Staff in Long-Term Care Facilities: The facility failed to complete the two-step tuberculosis testing and timely reading/documentation for selected staff members, as shown by review of personnel records.
Report Facts
staff sampled: 12
Inspection Report — Oct 18, 2019
Life Safety
Date: Oct 18, 2019
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Federal CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not otherwise stated in the forms.
Findings
Four deficiencies were cited: two Life Safety Code deficiencies concerning self-closing doors and exit signage, and two Missouri state licensure deficiencies regarding hazardous area separation and exit sign placement/letter size.
Deficiencies (2)
19 CSR 30-85.022(4) Hazardous Areas: Please refer to K-223.
19 CSR 30-85.022(23) Exit Sign Placement/Letter Size: Refer to K-293.
Inspection Report — Dec 13, 2018
Routine
Date: Dec 13, 2018
Visit Reason
CMS-2567 federal health survey and Missouri State Form (state licensure) are included in the file; the survey type is not stated in the documents.
Findings
There are 3 federal health deficiencies concerning nurse aide registry/background checks, notice requirements for transfers/discharges, and residents' code status/CPR documentation, and 1 Missouri state licensure deficiency referencing nursing care per resident condition.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Please refer to F678.
Report Facts
employees sampled: 10
residents sampled (transfer/discharge): 18
residents sampled (CPR/code status): 18
Inspection Report — Dec 13, 2018
Life Safety
Date: Dec 13, 2018
Visit Reason
CMS-2567 Life Safety survey and Missouri Department of Health and Senior Services State Form; the survey is an annual recertification as stated on the form.
Findings
There are 2 deficiencies: one life safety deficiency for electrical equipment/outlets with cords/devices under pressure from furniture and no maintenance program to check outlets, and one state licensure deficiency regarding electrical wiring/equipment (Class II*) referencing the same electrical issue.
Deficiencies (1)
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Please refer to K 919.
Inspection Report — Apr 24, 2018
Complaint Investigation
Date: Apr 24, 2018
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form licensure survey; file cites complaint MO00141033.
Complaint Details
MO00141033; substantiation not stated in the document.
Findings
Four deficiencies were cited: two federal deficiencies (SS=D) for failures in post-fall neurological monitoring and in monitoring anticoagulant/medication interactions, and two Missouri State Form Class II deficiencies referencing those federal findings.
Deficiencies (2)
19 CSR 30-85.042(47) Safe/Effective Medication System: Please refer to F757.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F689 for all examples.
Report Facts
residents referenced for post-fall monitoring issues: 4
residents affected by medication monitoring failure: 1
Inspection Report — Jan 4, 2018
Routine
Date: Jan 4, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failing to report and investigate alleged misappropriation of a resident's property, and one Missouri state licensure deficiency requiring development/implementation of policies that references the federal finding.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: See the deficiency cited at F609.
Report Facts
amount of money reported missing from resident's property: 100
23 CMS Surveys
Inspection Report — Dec 12, 2025
Complaint Investigation
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
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 — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form; complaint investigation. Complaint numbers MO00246671, MO00246674, MO00246824 appear in the file.
Complaint Details
Complaint numbers MO00246671, MO00246674, MO00246824 are listed in the file; substantiation of the allegations is not stated in the documentation.
Findings
Five deficiencies were cited: two federal health deficiencies concerning inadequate assistance with activities of daily living/bathing and failure to perform admission skin assessment and timely pressure ulcer treatment, and three Missouri licensure deficiencies addressing cleanliness/odor, grooming/dressing, and pressure sore prevention/treatment.
Deficiencies (2)
F 677 ADL Care Provided for Dependent Residents: Based on observation, interview, and record review, the facility failed to ensure dependent residents received services necessary to maintain good grooming and personal hygiene when staff failed to provide assistance with bathing to three residents from the sample.
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on record review and interviews, the facility failed to perform a complete admission skin assessment and did not identify and provide timely treatment for a pressure ulcer for one resident.
Report Facts
residents sampled: 13
residents affected: 3
Inspection Report — Aug 23, 2024
Complaint Investigation
Date: Aug 23, 2024
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Federal health (CMS-2567) recertification and complaint survey.
Complaint Details
Intake M000239642; the report states no deficiencies were issued related to that intake.
Findings
Seven federal deficiencies were cited addressing assessment accuracy (MDS), quality of care related to blood sugar/insulin management, unsafe transfer practices with mechanical lift, medication labeling and storage (insulin pens/expired vaccines), food temperatures and palatability, kitchen vent condition/food safety, and infection prevention and control including enhanced barrier precautions and PPE use.
Deficiencies (7)
F641 Accuracy of Assessments: The facility failed to ensure the Minimum Data Set (MDS) assessment was accurate and complete for Resident #24, with required sections not coded or documented.
F684 Quality of Care: The facility failed to provide and document care per standards when staff did not document and follow physician orders related to blood sugar testing and insulin administration for a resident receiving insulin.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure required assistance of two staff when transferring a resident with a mechanical (Hoyer) lift, resulting in an incident where the resident's toe was injured during transfer.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure insulin pens were dated when opened for multiple residents and failed to ensure refrigerated medications (influenza vaccine vials) were not expired in medication rooms.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to maintain hot foods at palatable/appropriate temperatures and residents complained of cold meals; an observed meal item (fried fish fillet) was cold and unpalatable.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Ceiling vents in the kitchen showed rust, dust, peeling paint, condensation dripping, and a vent observed falling, creating a potential contamination risk to meals served to facility residents.
F880 Infection Prevention & Control: The facility failed to implement and maintain required infection prevention practices, including enhanced barrier precautions for a resident with an indwelling device/PICC and failures in PPE use and staff training during IV/high-contact care.
Report Facts
survey sample size: 22
residents with undated insulin pens: 7
Inspection Report — Aug 22, 2024
Life Safety
Date: Aug 22, 2024
Visit Reason
Federal CMS-2567 health and life safety survey; the file contains an Emergency Preparedness survey and a Life Safety Code (NFPA) survey as stated on the forms.
Findings
Nine federal deficiencies were cited covering emergency preparedness policy review and testing, emergency preparedness exercises/training, delayed-egress signage and door operation, monthly kitchen hood checks, fire alarm and smoke detector/manual pull station installation, conspicuous marking of portable fire extinguishers, natural gas fireplace safety/controls, fire drill documentation and frequency, and essential electrical/generator maintenance and testing.
Deficiencies (9)
E004 Develop EP Plan, Review and Update Annually: The facility failed to ensure the emergency preparedness policy and procedure manual was reviewed and/or updated annually; the Administrator verified the emergency preparedness manual had not been reviewed annually.
E039 EP Testing Requirements: The facility failed to ensure testing and training on the emergency preparedness process had been performed and documented in the past 12 months; records showed no documented annual training and testing on the emergency preparedness policy and procedures.
K222 Egress Doors: The facility failed to ensure delayed-egress signage was legible and that delayed-egress doors met signage and operation requirements; multiple exit doors had severely faded/unreadable 'PUSH UNTIL ALARM SOUNDS' signage though doors were equipped with delayed egress 15-second devices.
K324 Cooking Facilities: The facility failed to ensure the kitchen hood system was checked monthly and documented; the kitchen hood pull station tag was blank and there was no record that the system had been checked monthly.
K341 Fire Alarm System - Installation: The facility failed to ensure required manual pull stations and smoke detectors were installed and located correctly for exits; observations and interviews identified missing manual pull stations at exit doors and a smoke detector installed 22 inches from an air diffuser.
K355 Portable Fire Extinguishers: The facility failed to conspicuously mark fire extinguishers throughout the care center; multiple wall-inverted cabinets housing extinguishers lacked conspicuous markings indicating 'fire extinguisher.'
K522 HVAC - Any Heating Device: The facility failed to ensure natural gas fueled fireplaces were installed and used with required safety features and documentation; ignition switches were not in view and manufacturer's documentation did not show required automatic shutoff features or other safety information.
K712 Fire Drills: The facility failed to conduct and document fire drills in accordance with NFPA requirements; untitled fire safety records showed no documented evidence of required drills for multiple quarters and shifts in the past 12 months.
K918 Electrical Systems - Essential Electric System: The facility failed to ensure essential electrical systems and generator maintenance/testing were performed and documented; the generator room lacked battery-powered lighting and monthly weekly inspections and many monthly load test records were not available for the past 12 months.
Report Facts
residents potentially affected: 66
residents potentially affected: 20
Inspection Report — Jan 24, 2023
Routine
Date: Jan 24, 2023
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
2 deficiencies: one federal health deficiency for failing to monitor and follow up on STAT lab results leading to delayed culture follow-up and treatment for a resident, and one Missouri state licensure deficiency that references the federal finding.
Deficiencies (1)
F 658 Services Provided Meet Professional Standards: Based on interview and record review the facility failed to monitor and follow-up on STAT (immediate) lab results resulting in delayed culture follow-up and treatment for one resident with a urinary tract infection.
Report Facts
residents affected: 1
Inspection Report — Dec 15, 2022
Complaint Investigation
Date: Dec 15, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; complaint investigation with complaint number MO00210652.
Complaint Details
Complaint number MO00210652; substantiation not indicated in the document.
Findings
Two deficiencies were cited: one federal deficiency for failures in grievance documentation and follow-up, and one Missouri state citation for failures related to residents' exercise of rights/voice regarding grievances.
Deficiencies (1)
F585 Grievances: Based on observations, interviews, and record reviews, the facility failed to document thorough grievance investigations, did not consistently log or address resident complaints, and failed to identify or inform residents of the grievance officer.
Inspection Report — Sep 13, 2022
Routine
Date: Sep 13, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eight federal health deficiencies and four Missouri state licensure deficiencies were cited, addressing inconsistent code status documentation, pressure ulcer/wound care and infection control, catheter orders and care, bed rail/enabler assessments and documentation, pharmacy controlled substance reconciliation, medication administration errors (including insulin priming/administration), and lack of pneumococcal vaccine documentation.
Deficiencies (8)
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to ensure residents' code status (DNR/full code) was clearly and consistently documented across the medical record, door tags and folders for multiple residents.
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: The facility failed to ensure proper infection control and wound care practices during treatment of a resident's Stage 4 pressure ulcer, including observed failures in hand hygiene and technique by nursing staff.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure catheter orders were complete and included catheter/balloon size and related details for a resident with an indwelling catheter.
F700 Bedrails: The facility failed to document resident assessments, risks/benefits, informed consent, physician orders, and care plan inclusion for use of side rails/enablers for multiple residents.
F755 Pharmacy Srvs/Procedures/Pharmacist/Records: The facility failed to ensure controlled drugs were reconciled per policy and practice, with numerous missing initial/signatures on narcotic counts for medication carts and locked storage.
F759 Free of Medication Error Rts 5 Prcnt or More: The facility had a medication error rate above five percent (three errors out of 27 opportunities, 11.11 percent), affecting three residents and showing failures in safe medication administration practices (including insulin pen priming).
F760 Residents are Free of Significant Med Errors: The facility failed to ensure significant medication errors did not occur, including improper insulin administration and missed oral diabetes medication for residents.
F883 Influenza and Pneumococcal Immunizations: The facility failed to document administration or appropriate consent/declination for pneumococcal vaccine for multiple residents.
Report Facts
residents affected: 3
Inspection Report — Sep 13, 2022
Life Safety
Date: Sep 13, 2022
Visit Reason
Federal Life Safety (CMS-2567) and Missouri State licensure (State Form); life safety survey (K-tag deficiencies cited).
Findings
Six deficiencies were cited: three federal life safety deficiencies involving fire drills, electrical panel clearance, and improper use of power/extension cords, and three Missouri state deficiencies referencing the same fire drill, electrical wiring, and extension cord issues.
Deficiencies (3)
K712 Fire Drills: Facility failed to complete required fire drills at expected and unexpected times under varying conditions and failed to document/sound alarms for some drills, with missing quarterly/shift drills.
K911 Electrical Systems - Other: Facility failed to maintain required three-foot clearance around electrical panels, with stored items placed in front of and against panels.
K920 Electrical Equipment - Power Cords and Extension Cords: Facility allowed improper use of power taps, outlet extenders and extension cords in resident rooms and other areas, with observed extension cords and outlet extenders in multiple resident rooms.
Inspection Report — Jun 1, 2021
Complaint Investigation
Date: Jun 1, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) for Joplin Gardens; complaint investigation (MO00185962) is cited in the file.
Complaint Details
MO00185962; substantiation not stated.
Findings
Two deficiencies were cited: one federal deficiency for failure to promptly report alleged abuse involving multiple residents, and one Missouri state deficiency for failure to develop/implement abuse/neglect policies (state item refers to the federal finding).
Deficiencies (1)
F609 Reporting of Alleged Violations: The facility failed to promptly report allegations of abuse involving four residents and one staff member to facility management and to the State Survey Agency as required.
Report Facts
residents affected: 4
staff affected: 1
Inspection Report — Feb 18, 2021
Routine
Date: Feb 18, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri State licensure survey (State Form); the file documents a COVID-19 focused Emergency Preparedness survey completed 02/18/2021.
Findings
Two deficiencies were cited: one federal health deficiency for inadequate food temperature monitoring and hot foods served at unsafe or unappetizing temperatures, and one Missouri state licensure deficiency under 19 CSR 30-85.052(5) referencing the federal finding.
Deficiencies (1)
F804 Nutritive Value/Appear, Palatable/Prefer Temp: Based on observation, interview, and record review, staff failed to ensure hot foods were served at appetizing/safe temperatures; documented food temperatures were low (examples included 55-100°F), staff did not consistently take food temperatures, and hot food on the steam table was not adequately covered or monitored.
Inspection Report — Jan 5, 2021
Complaint Investigation
Date: Jan 5, 2021
Visit Reason
CMS-2567 health and Emergency Preparedness forms; the survey is a COVID-19 Focused Emergency Preparedness and Infection Control complaint investigation.
Findings
No deficiencies were cited on this COVID-19 Focused Emergency Preparedness and Infection Control complaint investigation; the facility was found to be in compliance with the applicable CMS/CDC requirements.
Inspection Report — Dec 4, 2020
Complaint Investigation
Date: Dec 4, 2020
Visit Reason
Federal CMS-2567 health and emergency preparedness survey; the Initial Comments state a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey and indicate this was a complaint investigation.
Complaint Details
No complaint number stated; the complaint investigation noted no deficiencies were cited.
Findings
No deficiencies were cited; the survey consisted of COVID-19 focused emergency preparedness and infection control initial comments stating the facility was found in compliance.
Inspection Report — Nov 15, 2020
Routine
Date: Nov 15, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure form; the survey is a COVID-19 Focused Emergency Preparedness (infection control) survey as stated in the Initial Comments.
Findings
Two deficiencies were cited: one federal infection prevention and control deficiency and one Missouri communicable disease rule referencing the federal finding. The findings relate to failures in infection prevention during the COVID-19 pandemic, including symptomatic staff allowed to work and inadequate screening/communication.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program during the COVID-19 pandemic when staff with symptoms were allowed to work and screening/communication procedures were not consistently followed.
Report Facts
residents observed on COVID unit: 2
Inspection Report — Sep 25, 2020
Complaint Investigation
Date: Sep 25, 2020
Visit Reason
Federal CMS-2567 health survey (CMS-2567); COVID-19 Focused Emergency Preparedness and COVID-19 Focused Infection Control Survey. The form notes this was a complaint investigation.
Findings
No deficiencies were cited on this complaint investigation; the facility was found to be in compliance with the applicable COVID-19 focused emergency preparedness and infection control requirements.
Inspection Report — Aug 7, 2020
Routine
Date: Aug 7, 2020
Visit Reason
Federal CMS-2567 infection control and emergency preparedness surveys; the surveys are stated as COVID-19 focused infection control and emergency preparedness.
Findings
Zero deficiencies were cited. The COVID-19 focused infection control and emergency preparedness surveys found the facility in compliance with the applicable CMS/CDC practices.
Inspection Report — Jul 9, 2020
Complaint Investigation
Date: Jul 9, 2020
Visit Reason
CMS-2567 federal health and emergency preparedness (COVID-19 focused) survey; the file states a complaint investigation.
Findings
No deficiencies were cited; the facility was found to be in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report — Jun 10, 2020
Routine
Date: Jun 10, 2020
Visit Reason
Federal CMS-2567 (health and emergency preparedness sections); the form states a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey were conducted.
Findings
No deficiencies were cited. The survey addressed COVID-19-focused emergency preparedness and infection control and found the facility in compliance with CMS and CDC recommended practices.
Inspection Report — Oct 18, 2019
Routine
Date: Oct 18, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies were cited: two federal deficiencies addressing required postings and the resident call system, and two Missouri state deficiencies addressing nurses' call system requirements (referencing the federal finding) and tuberculosis testing for staff.
Deficiencies (2)
F575 Required Postings: The facility failed to ensure required postings (resident rights, abuse/neglect hotline, and ombudsman contact information) were posted in a prominent location accessible to residents, visitors, and staff.
F919 Resident Call System: The facility failed to provide call light activation switches in two common-use restrooms and the restrooms were unsecured, meaning residents could not reliably activate the resident call light system.
Report Facts
staff sampled: 12
Inspection Report — Oct 18, 2019
Life Safety
Date: Oct 18, 2019
Visit Reason
Federal CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not otherwise stated in the forms.
Findings
Four deficiencies were cited: two Life Safety Code deficiencies concerning self-closing doors and exit signage, and two Missouri state licensure deficiencies regarding hazardous area separation and exit sign placement/letter size.
Deficiencies (2)
K223 Doors with Self-Closing Devices: Observation showed two kitchen/service doors leading into the main kitchen/service hall did not shut completely without staff assistance and allowed passage of smoke into the exit corridor.
K293 Exit Signage: Observation and interview showed the facility failed to provide non-egress signage on doors not used as an exit during an emergency.
Inspection Report — Dec 13, 2018
Routine
Date: Dec 13, 2018
Visit Reason
CMS-2567 federal health survey and Missouri State Form (state licensure) are included in the file; the survey type is not stated in the documents.
Findings
There are 3 federal health deficiencies concerning nurse aide registry/background checks, notice requirements for transfers/discharges, and residents' code status/CPR documentation, and 1 Missouri state licensure deficiency referencing nursing care per resident condition.
Deficiencies (3)
F606 Not Employ/Engage Staff w/ Adverse Actions: Based on interview and record review, the facility failed to check the nurse aide (NA) registry to ensure all new staff did not have a Federal Indicator, and staff had not completed the NA registry check for three out of ten sampled employees.
F623 Notice Requirements Before Transfer/Discharge: Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of transfers or discharges and failed to provide the ombudsman with a copy of the notification for three residents out of 18 sampled residents.
F678 Cardio-Pulmonary Resuscitation (CPR): Based on observation, record review, and interview, the facility failed to ensure residents' code status information was accessible and consistent between the electronic health record and paper medical records for two residents out of a sample of 18 residents.
Report Facts
employees sampled: 10
residents sampled (transfer/discharge): 18
residents sampled (CPR/code status): 18
Inspection Report — Dec 13, 2018
Life Safety
Date: Dec 13, 2018
Visit Reason
CMS-2567 Life Safety survey and Missouri Department of Health and Senior Services State Form; the survey is an annual recertification as stated on the form.
Findings
There are 2 deficiencies: one life safety deficiency for electrical equipment/outlets with cords/devices under pressure from furniture and no maintenance program to check outlets, and one state licensure deficiency regarding electrical wiring/equipment (Class II*) referencing the same electrical issue.
Deficiencies (1)
K 919 Electrical Equipment - Other: The facility allowed electrical outlets in resident rooms to remain with pressure on plugs created by furniture; multiple resident rooms were observed with devices or cords plugged into outlets under pressure and the maintenance supervisor reported no program to check the outlets.
Inspection Report — Apr 24, 2018
Complaint Investigation
Date: Apr 24, 2018
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form licensure survey; file cites complaint MO00141033.
Complaint Details
MO00141033; substantiation not stated in the document.
Findings
Four deficiencies were cited: two federal deficiencies (SS=D) for failures in post-fall neurological monitoring and in monitoring anticoagulant/medication interactions, and two Missouri State Form Class II deficiencies referencing those federal findings.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure post-fall nursing monitoring, including neurological checks and the use of neurologic flow sheets and 72-hour follow-up, were completed for residents after unwitnessed falls or head injuries.
F757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to monitor medication interactions and anticoagulant therapy for a resident on Coumadin who was placed on an antibiotic, lacking appropriate lab monitoring/orders and follow-up.
Report Facts
residents referenced for post-fall monitoring issues: 4
residents affected by medication monitoring failure: 1
Inspection Report — Jan 4, 2018
Routine
Date: Jan 4, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failing to report and investigate alleged misappropriation of a resident's property, and one Missouri state licensure deficiency requiring development/implementation of policies that references the federal finding.
Deficiencies (1)
F609 Reporting of Alleged Violations: Based on record review and interview, the facility failed to report misappropriation of property to the state agency and perform a proper and thorough investigation for one resident after the resident reported his/her wallet missing which contained one hundred dollars.
Report Facts
amount of money reported missing from resident's property: 100
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