Joplin Gardens

Inspectors wroteBased on record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when staff failed to follow the care plan regarding the use of a mechanical lift for a transfer resulting in one resident (Resident #1) suffering a fracture to the upper arm. A sample of six residents was reviewed for transfer safety. The facility census was 76. On 02/17/26, the Administrator and Director of Nursing (DON) were notified of the Past Non-Compliance that occurred on 02/16/26, at 10:30 A.M., which resulted in injury to Resident #1. On 02/17/26, the Administrator completed a root cause analysis and investigation into the incident and educated employees involved. [...]

Inspectors wroteThis citation is uncorrected. For prior example please see Event ID 1D8649-H1, exit date 12/12/25.1. Please refer to event 1D8649-H2, exit date 01/23/26, for details.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week. The facility census was 79. Review showed the facility did not provide a policy related to nursing schedules.1. Review of the Monthly Work Schedule, dated August 2025, showed no RN scheduled to work. Review of the Monthly Work Schedule, dated September 2025, showed no RN scheduled to work. Review of the facility provided time sheets showed no RN clocked in or out on 09/13/25, 09/20/25, 09/21/25, and 09/28/25. Review of the facility provided time sheets showed on 09/14/25 an RN clocked in at 7:00 A.M. and clocked out at 11:00 A.M. (4 hours). Review the facility provided time sheets showed on 09/27/25 the Director of Nursing (DON) clocked in at 10:00 A.M., clocked out at 2:00 P.M., and clocked in at 4:00 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #1, #2, #3, #4, #5, #6) . The facility census was 79. Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for six residents (Resident #1, #2, #3, #4, #5, and #6) . The facility census was 79. Review showed the facility did not provide a shower policy. 1. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to have sufficient nursing staff to meet the needs of the residents. The facility failed to provide showers per the preferences of three residents (Residents #1, #2, and #3), answer call lights in a timely manner for one resident (Resident #4) who experienced a fall, and repositioning and meal assistance/cueing for one resident (Resident #6). A sample of 12 residents was reviewed for staffing. The facility census was 84. Review showed the facility did not provide a shower policy.1. Review of the resident's census, dated 01/22/26, showed a total of 84 residents with 22 residents on 100-hall. Review of a listing provided by the Administrator and Director of Nursing (DON), on 01/22/26, showed eight of the 22 residents on the 100-hall required two-person assist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all dependent residents received services necessary to maintain good grooming and personal hygiene when the staff failed to provide assistance with bathing to three residents (Resident #1, #2, and #3) out of a sample of thirteen residents. The facility's census was 71. Review of the facility's policy titled Daily Care Needs, dated March 2015, showed the following: -The purpose of daily care needs is to refresh the resident and provide cleanliness, comfort, and neatness; -Before beginning care, staff should check the bathing schedule. Review of the facility's policy titled Bath (Shower), dated March 2015, showed the following: -It is the policy of the facility to provide a shower to maintain skin integrity, comfort, and cleanliness; [...]

Inspectors wroteBased upon record review and interviews, the facility failed to perform a complete admission assessment, including a skin assessment, and did not identify and provide timely treatment for a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one resident (Resident #1). The facility census was 71. Review of a facility policy titled admission Nurse's Note, dated March 2015, showed the following: -The purpose of the policy is to ensure information is documented for the resident upon admission; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain ceiling vents to ensure condensation and/or peeling paint did not drop from the vent onto the food preparation area. This had the potential to affect all 65 residents of the facility who received their meals from the facility kitchen. 1. During the initial tour of the kitchen on 08/20/24, at 9:00 A.M., with the Dietary Manager (DM), three ceiling vents were observed to have rust, dust, and peeling paint on and around the vents. One vent, located in front of the freezer, was observed to be falling from the ceiling. Another vent, located above the edge of the food preparation table, had condensation dripping from the edges of the vent, landing in front of the food preparation table. The drips were confirmed by the DM and [NAME] #1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin pens were dated when opened for seven of 13 residents (Residents #8, #53, #49, #33, #55, #34, and #11) who were administered insulin in the facility. The facility failed also failed to ensure five vials of influenza vaccines were not expired in two of two medication rooms. Review of an undated facility policy titled, Labeling Drugs and Medications, showed all drugs and biologicals must be properly labeled and legible at all times. Review of an undated facility policy titled, Medications, Storage of, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food at a palatable temperature on one of three halls (300 hall) when six on the hall (Residents #17, #18, #21, #29, #33, and #38) complained of cold food on the hall of 27 residents. Review of the facility's policy titled Food Temperatures, dated May 2015, showed the following guidance: -Temperatures of hot foods should be maintained at no less than 140.0 degrees Fahrenheit (F) during meal service; -Hot food should be at least 120 degrees F when served to the resident. 1. Review of Resident #21's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 05/07/24, showed the resident was moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for one resident of one resident (Resident #216) reviewed for EBP, out of a total sample of 22, who had had a peripherally inserted central catheter (PICC line - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) and received antibiotics. Review of the facility's policy titled, Enhanced Barrier Precautions, dated March 2024, showed the following: -The purpose of the policy is to prevent broader transmission of MDRO (multi-drug resistant organisms) and to help protect patients with chronic wounds and indwelling devices; -EBP (enhanced barrier precautions) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - mandated federal assessment completed by facility staff) assessment was accurate and complete for one resident (Resident #24) of 22 residents whose MDS were reviewed. Review of the Resident Assessment Instrument manual, version 1.19.1, dated October 2023, showed the following: -The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status; -In addition, an accurate assessment required collecting information from multiple sources, some of which are mandated by regulations. [...]

Inspectors wroteBased on interview and record review, the facility 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 of one resident (Resident #23) reviewed for insulin use out of a total sample of 22. 1. Review of Resident #23's Face Sheet,' located in the 'Face Sheet tab of the EMR, showed the following: -admission date of 07/05/24; -Diagnoses included diabetes and bilateral (both sides) shoulder fractures. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 07/11/24, showed the following: -Cognitively intact for daily decision-making' -Administered insulin on six out seven days during the observation period. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure an environment as free of hazards of possible when staff failed to transfer one resident (Resident #38), of 22 sample residents, with two staff members as care planned when using the mechanical lift (Hoyer Lift). 1. Review of Resident #38's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admission date of 07/20/19; -Diagnoses included of type II diabetes mellitus with diabetic neuropathy (causes weakness, numbness and pain, usually in the hands and feet), cerebral infarction (stroke), and acquired absence of left leg below the knee (BKA). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #8, Resident #47 and Resident #104). The facility census was 60. Record review of the facility's policy titled Do Not Resuscitate (DNR- do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) Guidelines, undated, showed the following: -The facility recognizes the right of any competent resident or person responsible for making health care decisions for the resident to request the cardiopulmonary resuscitation (CPR) be withheld in the event of cardiac or respiratory arrest; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to obtain physician's orders for side rail use; and failed to include the side rail on the care plan for three residents (Resident #7, Resident #43, and Resident #50). Staff failed to complete ongoing assessments to ensure the side rails are appropriate for use, failed to include the side rail on the care plan for four residents, and failed to obtain physician's orders for the use of side rails for one resident (Resident #12). The facility's census was 60. Record review of the facility's policy titled Side Rail Protocol, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all controlled drugs were reconciled periodically per standards of practice when off going and on coming nurses/certified medication technicians (CMTs) failed to count narcotics/controlled medications and failed to sign the controlled substance shift change record during shift change for two of two medication carts, two of two nurse treatment carts, and one of two refrigerator lock boxes located in the facility. The facility census was 60. Record review of the facility policy titled, Narcotic Count, undated, showed the following: -Purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate below five percent when staff made three errors out of 27 opportunities, resulting in an error rate of 11.11 percent, affecting three residents (Resident #6, #24, and #37). The facility census was 60. Record review of the facility provided information titled, Insulin By Kwikpen (or similar pen type device) showed the following: -Staff need to prime the pen before each use to assure the unit accuracy. Turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose in and count to five slowly. Staff should see insulin at the tip of the needle, if not re-prime. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure significant medication errors did not occur, when staff failed to properly administer insulin to two residents (Resident #6 and Resident #37) and failed to properly administer insulin and failed to administer an oral diabetes medication as ordered for multiple consecutive days to one resident (Resident #24). The facility census was 60. Record review of the facility provided information titled, Insulin By Kwikpen (or similar pen type device) showed the following: -Staff need to prime the pen before each use to assure the unit accuracy. Turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in until it stops, and 0 is seen in the dose window. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal (pneumonia) vaccine to one resident (Resident #7) and failed to offer the pneumococcal vaccine to two residents (Resident #35 and Resident #36). The facility census was 60. Record review of the facility policy titled, Immunization Recommendations for Residents of Long-Term Care Facilities, undated, showed the following: -Timing of Immunizations: -Pneumococcal: PCV20 (PREVNAR 20) and PPSV23 (Pneumococcal Polysaccharide vaccine); -Pneumococcal vaccination in persons ages 65 and older years, unless contraindicated will be administered according to the following guidelines when determining the vaccination status; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff utilized proper infection control practices, to promote healing and prevent infection, during wound care for one resident (Resident #14) with a Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon or muscle). The facility had a census of 60. Record review of the facility policy titled, Wound Care and Treatment, undated, showed the following: -It is the purpose of this facility to prevent and treat all wounds; -Clean technique is used. Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -If the resident is soiled, wound care must not be done until he/she is cleaned; -There must be a specific order for the treatment; -Handwashing must be done as outlined in the guidance; -Cut the tape with clean scissors; -Put gloves on; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #24) had a complete order for a catheter (a sterile tube inserted into the bladder to drain urine) with the size of catheter/balloon bulb included. The facility census was 60. Record review showed the facility did not provide a policy regarding catheter orders. Record review of the facility's Charting and Documentation Policy, undated, showed the following for catheter care documentation should include: -Type of procedure performed and who performed it; -Date and time the procedure was performed; -Type of and size of catheter used. 1. Record review of Resident #24's face sheet (admission data) showed the following: -admission date of 3/21/21 with a latest return of 2/25/22; [...]

Inspectors wroteBased on observation and interview the facility failed to ensure required postings including resident rights, abuse/neglect hotline, and Ombudsman contact information, was posted in a prominent location for residents, visitors, and staff. The facility census was 76. 1. Observation on 10/15/19 at 12:45 P.M., showed the facility posted Resident Right information, Ombudsman contact information, and the Department of Health and Senior Services (DHSS) Abuse and Neglect Hotline information in the kitchenette of the main lobby area, in the far right corner on a wall, facing away from the main entrance. The Resident Right poster consisted of fine print which may not be visible to all residents and visitors. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a switch in two common-use restrooms, located on the service hall, that would activate the resident call light system. This deficient practice had the potential to affect all residents and visitors who might need to use the toiletsand required staff assistance. The facility had a census of 76. 1. Observation on 10/15/19, beginning at 8:00 A.M., showed two unsecured common-use restroom doors, located in the service hall, in which residents could access. Both restrooms did not have an call light activation switch. During an interview on 10/15/19, at approximately 9:00 A.M., the maintenance supervisor said he did not know the restrooms in the service halls needed a call light activation switch.