Inspection Reports for
Joplin Gardens
2810 S Jackson Ave, Joplin, MO 64804, United States, MO, 64804
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
86% occupied
Based on a December 2025 inspection.
Occupancy rate 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
Annual Inspection
Census: 71
Deficiencies: 5
Date: Jan 23, 2025
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations regarding resident care and facility operations at Joplin Gardens.
Findings
The facility failed to ensure dependent residents received necessary assistance with grooming, hygiene, and showers. Additionally, the facility did not perform complete admission assessments including skin assessments and timely treatment for pressure ulcers for one resident.
Deficiencies (5)
F677 ADL Care Provided for Dependent Residents. The facility failed to ensure all dependent residents received necessary grooming and personal hygiene assistance, including showers, as evidenced by observations and interviews with three residents.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to perform a complete admission assessment including skin assessment and did not provide timely treatment for a pressure ulcer for one resident.
A4076 Clean, Dry, Odor Free. Residents were not consistently clean, dry, and free of offensive odors as required by regulation.
A4077 Residents Groomed/Dressed Appropriately. Residents were not consistently well-groomed and dressed appropriately considering their preferences and medical conditions.
A4083 Pressure Sore Prevention/Treatment. The facility failed to keep residents free from avoidable pressure sores and provide adequate treatment for existing sores.
Report Facts
Facility census: 71
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in interviews regarding shower policies and skin assessment procedures |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Interviewed about shower frequency and skin assessments |
| Licensed Practical Nurse E | Licensed Practical Nurse (LPN) | Interviewed regarding wound care nursing responsibilities |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Interviewed about admission skin assessment responsibilities |
| Administrator | Administrator | Interviewed about shower policies and skin assessment follow-up |
| Certified Medication Technician B | Certified Medication Technician (CMT) | Interviewed about shower provision |
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
Recertification
Census: 65
Deficiencies: 7
Date: Aug 23, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services.
Complaint Details
The survey included a complaint investigation component as noted in the initial comments and deficiencies related to complaint issues were cited.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to accuracy of assessments, quality of care, free of accident hazards, labeling and storage of drugs and biologicals, nutritive value and food safety, and infection prevention and control.
Deficiencies (7)
F641 Accuracy of Assessments. The facility failed to ensure the Minimum Data Set assessment was accurate and complete for one resident out of 22 reviewed.
F684 Quality of Care. The facility failed to document and follow physician's orders related to blood sugar tests for one resident out of 22 reviewed for insulin use.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to ensure an environment free of hazards when transferring one resident with mechanical lift requiring two staff members.
F761 Label/Store Drugs and Biologicals. The facility failed to ensure insulin pens were dated when opened and refrigerated medications were not expired for multiple residents.
F804 Nutritive Value/Appear, Palatable/Prefer Temp. The facility failed to maintain food at a palatable temperature and served cold food to residents on one hall.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to maintain ceiling vents free of rust, peeling paint, and condensation in the kitchen.
F880 Infection Prevention & Control. The facility failed to implement an effective infection prevention and control program including enhanced barrier precautions for one resident out of 22 reviewed.
Report Facts
Survey Census: 65
Sample Size: 22
Deficiencies cited: 7
Inspection Report
Life Safety
Census: 66
Capacity: 66
Deficiencies: 7
Date: Aug 22, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid requirements and the 2012 edition of the NFPA 101 Life Safety Code for Existing Health Care Occupancy.
Findings
The facility was found to be noncompliant with several life safety code requirements including egress door locking arrangements, delayed egress door signage, kitchen hood system maintenance, fire alarm system installation, fire extinguisher marking, natural gas fireplace safety, and fire drill documentation.
Deficiencies (7)
K 222 Egress Doors: Doors in a required means of egress were equipped with delayed egress locking devices but failed to have proper signage and rapid removal provisions. The signage was severely faded and unreadable on multiple doors.
K 324 Cooking Facilities: The facility failed to ensure the kitchen hood system was checked monthly as required. No documented evidence of monthly checks was found and the kitchen hood pull station tag was blank.
K 341 Fire Alarm System - Installation: The fire alarm system was installed but the facility failed to ensure two exit doors had manual pull stations and smoke detectors were properly installed and maintained, potentially affecting 20 residents.
K 355 Portable Fire Extinguishers: Fire extinguishers lacked conspicuous markings in multiple locations throughout the facility, including near nursing offices and resident rooms, affecting all 66 residents.
K 522 HVAC - Any Heating Device: The facility failed to ensure three natural gas fueled fireplaces were installed and used in accordance with NFPA 101 regulations, potentially affecting all 66 residents.
K 712 Fire Drills: Fire drills were not conducted in accordance with NFPA 101 requirements. Documentation showed missing records for several quarters and incomplete fire drill records.
K 918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain essential electrical systems including generator inspections and monthly load testing, with missing documentation for multiple months, potentially affecting 66 residents.
Report Facts
Beds: 66
Deficiencies cited: 7
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 2
Date: Jan 24, 2023
Visit Reason
The inspection was conducted to investigate compliance with professional standards related to comprehensive care plans and treatment of infections, specifically following up on a deficiency related to monitoring and follow-up on STAT lab results for a resident infection.
Findings
The facility failed to meet professional standards by not properly monitoring and following up on STAT lab results, resulting in delayed treatment for a resident's infection. The deficiency involved incomplete documentation and delayed communication regarding lab results and antibiotic orders.
Deficiencies (2)
CFR 483.21(b)(3)(i) Comprehensive Care Plans: The facility failed to monitor and follow up on STAT lab results promptly, resulting in delayed treatment for a resident's infection.
19 CSR 30-85.042(66) Nursing Care per Resident Condition: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice as evidenced by the deficiency in F658.
Report Facts
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Notified on resident symptoms and STAT orders |
| LPN B | Licensed Practical Nurse | Reported UA results and lab communication |
| LPN C | Licensed Practical Nurse | Reported new orders for resident treatment |
| LPN E | Licensed Practical Nurse | Described lab order and follow-up procedures |
| RN G | Registered Nurse | Described notification and follow-up on UA results |
| RN F | Registered Nurse | Reported family concerns and lab follow-up |
| Director of Nursing | Director of Nursing | Described expectations for lab follow-up and physician orders |
| Certified Nurse Aide D | Certified Nurse Aide | Reported resident symptom observations |
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 2
Date: Dec 15, 2022
Visit Reason
The inspection was conducted to investigate grievances and complaints related to resident rights and voice grievances at Joplin Gardens.
Findings
The facility failed to document a thorough investigation of grievances, failed to identify the grievance officer, failed to ensure residents' right to file grievances anonymously, and failed to educate residents and staff on grievance procedures. Several residents reported unresolved grievances and concerns about staff behavior and missing personal items.
Deficiencies (2)
F585 Grievances. The facility failed to document thorough grievance investigations, identify the grievance officer, ensure residents' right to file grievances anonymously, and educate residents and staff on grievance procedures.
A8020 Exercise Rights/Voice Grievances. The facility did not meet the regulation requiring residents be encouraged and assisted to exercise their rights and voice grievances, resulting in a Class II violation.
Report Facts
Facility census: 57
Inspection Report
Life Safety
Census: 60
Capacity: 92
Deficiencies: 6
Date: Sep 13, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to complete fire drills at expected and unexpected times quarterly and did not maintain proper clearance around electrical panels. The improper use of power strips and extension cords was also noted, posing potential fire and electrical hazards.
Deficiencies (6)
K712 Fire Drills: The facility failed to complete fire drills at expected and unexpected times quarterly and failed to sound the fire alarm during daytime drills.
K911 Electrical Systems - Other: The facility failed to maintain a three-foot clearance around electrical panels due to storage of items in front of and around the panels.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed improper use of power taps, outlet extenders, and extension cords in resident rooms, risking fire or electrical injury.
A2061 Fire Drill Requirements, Evacuation: The facility did not meet the requirement of conducting a minimum of twelve fire drills annually with at least one every three months on each shift.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards.
A3037 Extension Cords/Duplex Receptacles: Extension cords were used improperly, not meeting UL approval or safety standards.
Report Facts
Facility capacity: 92
Census: 60
Minimum fire drills required: 12
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
Complaint Investigation
Census: 70
Deficiencies: 2
Date: Jun 1, 2021
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving four residents and one staff member at Joplin Gardens.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews showing failure to report abuse allegations timely and properly.
Findings
The facility failed to report allegations of abuse involving four residents and one staff member immediately and within the required timeframes. The investigation included interviews, record reviews, and confirmed that the facility did not meet reporting requirements.
Deficiencies (2)
F609: The facility failed to report allegations of abuse involving four residents and one staff member immediately and within two hours to the State Survey Agency as required by regulation.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds as required.
Report Facts
Facility census: 70
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 2
Date: Feb 18, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with food temperature and safety regulations.
Findings
The facility failed to ensure hot foods were served at safe and appetizing temperatures, with documented food temperatures below required levels and inadequate temperature monitoring practices.
Deficiencies (2)
F804 Food and drink: The facility failed to ensure hot foods were served at appetizing temperatures, with documented food temperatures as low as 55 degrees Fahrenheit and inadequate temperature monitoring during meal service.
A5005 Hot Food Hot, Cold Food Cold: The facility did not assure that hot food is served hot and cold food is served cold, as evidenced by the findings under F804.
Report Facts
Facility census: 62
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Census: 66
Deficiencies: 2
Date: Nov 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with infection prevention and control regulations related to COVID-19.
Findings
The facility failed to maintain an infection control program during the COVID-19 pandemic by not implementing CDC guidance and facility policies to prevent the spread of COVID-19, including allowing symptomatic staff to work.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain an infection control program during COVID-19 by allowing two staff members with COVID-19 symptoms to work their scheduled shifts.
A4085 Infection Control/Communicable Disease: The facility did not meet infection control requirements to prevent the spread of communicable diseases and failed to report a resident diagnosed with a communicable disease within seven days.
Report Facts
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in infection control deficiency for working while symptomatic with COVID-19 symptoms |
| ADON | Assistant Director of Nursing | Involved in communication and oversight related to symptomatic staff and infection control |
| CNA C | Certified Nurse Assistant | Named in infection control deficiency for working while symptomatic with COVID-19 symptoms |
| DON | Director of Nursing | Interviewed regarding employee screening and infection control procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 3
Date: Oct 18, 2019
Visit Reason
The document is a plan of correction submitted by Joplin Gardens following a survey conducted on 2019-10-18. It addresses deficiencies found during the inspection related to required postings, resident call system, and tuberculosis testing for staff.
Findings
Deficiencies included failure to post required resident rights and ombudsman information in an accessible location, lack of call light activation switches in common-use restrooms, and incomplete tuberculosis testing documentation for staff. The facility census was 76 at the time of inspection.
Deficiencies (3)
F575 Required Postings: The facility failed to post required resident rights, abuse/neglect hotline, and ombudsman contact information in a form accessible and understandable to residents and visitors. The Resident Rights poster was posted in fine print in a location not easily visible to all residents.
F919 Resident Call System: The facility did not provide call light activation switches in two common-use restrooms accessible to residents. Both restrooms lacked call light activation switches, potentially affecting all residents and visitors needing staff assistance.
A4029 Communicable Disease-Employees: The facility failed to complete required two-step tuberculosis testing for three staff members within the required timeframes and did not document test results properly.
Report Facts
Facility census: 76
Staff sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Personnel record reviewed for tuberculosis testing compliance |
| LPN B | Licensed Practical Nurse | Personnel record reviewed for tuberculosis testing compliance |
| Dietary Cook C | Dietary Cook | Personnel record reviewed for tuberculosis testing compliance |
Inspection Report
Life Safety
Census: 76
Capacity: 92
Deficiencies: 4
Date: Oct 16, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and emergency preparedness at the facility.
Findings
The facility failed to meet several Life Safety Code requirements, including doors with self-closing devices that did not close properly and lack of proper exit signage. These deficiencies had the potential to affect residents, staff, and visitors during an emergency.
Deficiencies (4)
K223: Doors with self-closing devices did not shut completely without staff assistance, allowing smoke to pass from the kitchen to the exit corridor. This posed a risk to residents, staff, and visitors using the service hall.
K293: The facility failed to provide non-egress signage on all doors not used as exits during an emergency, including a door to the courtyard lacking proper 'This is not an exit' signage.
A2008: Hazardous areas were not separated by at least one-hour fire-resistant construction as required, with doors not self-closing or automatic closing.
A2048: The facility did not place additional exit signs in corridors and passageways with letters at least six inches high and three-fourths inch wide as required.
Report Facts
Facility capacity: 92
Resident census: 76
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 |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 4
Date: Dec 13, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and to identify deficiencies in the facility's operations and care practices.
Findings
The facility was found deficient in multiple areas including failure to check the nurse aide registry for new staff, inadequate notice requirements before resident transfers or discharges, and failure to ensure staff knowledge and documentation of residents' code status for emergencies. Several residents' medical records lacked proper documentation and notification to responsible parties.
Deficiencies (4)
F606: The facility failed to check the nurse aide registry to ensure new staff did not have a Federal Indicator for abuse, neglect, or misappropriation of resident property.
F623: The facility failed to notify residents and their representatives in writing of transfers or discharges, including reasons and ombudsman notification, for three residents out of 18 sampled.
F678: The facility failed to ensure staff provided basic life support including CPR and failed to maintain consistent documentation of residents' code status across medical records and electronic health records for two residents.
A4074: The facility did not meet nursing care per resident condition requirements as referenced in F678.
Report Facts
Facility census: 72
Sampled residents: 18
Residents with transfer notification deficiencies: 3
Residents with CPR/code status deficiencies: 2
Inspection Report
Annual Inspection
Census: 72
Capacity: 92
Deficiencies: 2
Date: Dec 13, 2018
Visit Reason
This annual recertification survey was conducted to assess compliance with the Life Safety Code and related regulations.
Findings
The facility failed to maintain the electrical system in a safe manner by allowing electrical outlets in resident rooms to remain under pressure from furniture, posing a fire hazard. Several resident rooms had outlets with plugs under pressure, and the maintenance supervisor lacked a program to check and prevent this issue.
Deficiencies (2)
K919 Electrical Equipment - Other: The facility failed to maintain the electrical system safely by allowing electrical outlets in resident rooms to remain under pressure from furniture, creating a fire risk.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards, referencing deficiency K919.
Report Facts
Facility capacity: 92
Census: 72
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 4
Date: Apr 24, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to resident safety, medication management, and care practices at Joplin Gardens nursing facility.
Findings
The facility failed to ensure a safe environment free of accident hazards, specifically inadequate post-fall nursing monitoring and documentation. Additionally, the facility failed to monitor medication interactions and provide adequate neurologic assessments following resident falls.
Deficiencies (4)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to document post-fall nursing monitoring, including neurological checks, on four residents who sustained unwitnessed falls or head injuries. The facility did not complete required neurologic flow sheets or follow-up assessments after falls.
F757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to monitor medication interactions for one resident on antibiotic and blood thinning medication, resulting in inadequate documentation and oversight of the resident's condition and lab results.
A4054 Safe/Effective Medication System: There shall be a safe and effective system of medication distribution, administration, control and use. This regulation is not met as evidenced by deficiencies in medication monitoring and documentation.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation is not met as evidenced by failures in post-fall care and medication monitoring.
Report Facts
Census: 66
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Date: Jan 4, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving misappropriation of resident property.
Complaint Details
The complaint involved allegations of misappropriation of resident property. The investigation found the facility failed to report and investigate the incident properly, and the complaint was substantiated.
Findings
The facility failed to report misappropriation of property for one resident and did not conduct a thorough investigation or notify the state agency as required. The resident reported missing money and a wallet, but the facility did not notify police or replace missing items promptly.
Deficiencies (2)
F609: The facility failed to report alleged violations involving misappropriation of resident property within required timeframes and did not perform a proper investigation for one resident who reported missing money and a wallet.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, and failed to require reporting to the department for suspected abuse or neglect.
Report Facts
Resident census: 71
Dates of missing wallet reports: 3
Plan of correction completion date: Feb 18, 2018
Report
Sep 13, 2022
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