Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspire Senior Living Joplin during CMS and state inspections, most recent first.
A resident with CHF, COPD, CKD, and diabetes had an order for daily weights and notification for significant weight gain, but staff missed multiple weights, failed to document or report several large gains, and did not care plan the CHF-related interventions. After the resident returned from the hospital on a fluid restriction, staff did not document intake, and the record later showed a regular diet with no fluid restriction. The resident developed worsening edema, abdominal distention, shortness of breath, orthopnea, tachypnea, severe hyponatremia, and hypervolemia, and interviews confirmed staff expected weights, fluid monitoring, and physician notification for these changes.
Staff failed to complete and document required two-step TB screening for multiple residents. Records showed missing or incomplete TB test entries, absent step-two documentation, and no TB results in the immunization tab for some residents. An LPN, RNs, the ADON, DON, and Administrator all described that residents should receive admission TB testing and that results should be recorded, but the charting showed the process was not consistently completed.
A resident with stroke, CHF, and bowel and bladder incontinence was left in the dining room with a soiled brief before mealtime after asking to be taken back to the room for a change. CNA F allegedly refused, told the resident to wait, and said the resident was trying to trick staff, while also telling the resident to eat and shut up. Another CNA later assisted the resident to the room for brief change, and multiple staff confirmed residents should be changed when soiled and not eat with a soiled brief.
A resident with COPD and diabetes mellitus was allowed to self-inject insulin after staff prepared the dose, but the record lacked a competency assessment and a physician order authorizing self-administration. The care plan did not include insulin self-administration, while progress notes showed staff observed the resident injecting insulin and continued to draw up the medication. Interviews with the resident and nursing leadership confirmed the resident was checking blood sugars and injecting insulin with staff assistance, despite the missing order and assessment.
CPR was started on a resident with a documented DNR order after the resident was found unresponsive in the dining room. The resident had COPD, CHF, and diabetes, and the DNR was listed in the care plan, physician orders, and an outside hospital DNR form, though the face sheet did not show code status. Staff later verified the DNR and stopped CPR, and interviews showed mixed understanding about whether CPR should begin before code status is confirmed.
An LPN reactivated Naltrexone for a resident with alcohol abuse without a physician order after it had been discontinued when hydrocodone-acetaminophen was started for pain. The MAR showed Naltrexone was then administered along with PRN hydrocodone-acetaminophen, even though the order note flagged a drug interaction and stated Naltrexone should be suspended with intermittent opioid treatment. Staff and the attending physician confirmed nurses should not write their own orders and that the restart was not authorized.
A facility failed to ensure ordered insulin was administered for two residents with DM. One resident with an insulin glargine order had multiple missed doses documented as refusal, no insulin required, or held without order parameters, and the chart often lacked BS readings and physician notification. Another resident with a Lantus order also had repeated missed doses, with staff documenting low or outside-parameter vitals, refusal, or no insulin required, while progress notes did not show physician notification. Interviews confirmed staff should follow physician orders and notify the physician when insulin is held or refused.
Four nurse aides continued working with residents beyond the required training period without current CNA certification. Interviews and record review showed the aides had been hired months earlier, had either not completed testing or had not yet started classes, and one aide was observed assisting a resident in a wheelchair. The DON and Administrator said they were unaware some aides had worked longer than four months and that the staff member responsible for tracking CNA certification had been fired, leaving no one tracking it.
Medication administration was not accurately controlled when a CMT left a resident’s pills on a bedside table unsupervised and later documented them as given, despite the resident saying the pills were left while he/she used the bathroom. In addition, six medication cups with pills were found in the locked med room/cart area for several residents, including some cups labeled with room numbers and some unlabeled, while the MARs showed the doses as administered with no refusal or omission documented. Interviews with the CMT, RN, DON, and residents confirmed that medication was being left in rooms or in the cart instead of being witnessed as taken.
A resident with dementia and a history of falls, who was on anticoagulant therapy, experienced a fall from bed resulting in a head injury. Nursing staff assessed the resident at the time but failed to document the incident, notify the physician, or communicate the need for post-fall monitoring to subsequent shifts. This led to a lack of required neurological checks and follow-up assessments, with staff on later shifts unaware of the fall or injury until days later.
A failure to document medication reconciliation during discharge resulted in a card of 30 Percocet 5-325 mg tablets being sent home with the wrong resident. The resident who received the medication did not have an order for it, while the intended recipient did not receive their prescribed medication. Staff interviews revealed lapses in the process for handling and documenting controlled substances, and the error was not reported promptly to facility leadership.
A resident who was cognitively intact and required moderate assistance kept personal funds in a lockbox provided by the facility. After withdrawing cash and securing it in the lockbox with staff assistance, the resident later discovered the lockbox had been forcibly opened and the money was missing, while debit cards remained. Staff interviews confirmed awareness of the resident's practice and facility policy prohibiting misappropriation, but the funds were still stolen, demonstrating a failure to protect the resident's property.
A deficiency was identified involving the wrongful use of residents' belongings or money, as noted in event ID XMKY12. Surveyors found instances where residents' personal property or finances were mishandled, indicating a failure in the facility's duty to protect these assets.
A resident with moderate cognitive impairment discovered their purse, containing cash, debit cards, and personal items, missing after lunch. Despite the facility's policy against misappropriation, the resident's belongings were not safeguarded, and an inventory sheet was not completed upon admission. Staff were aware of the resident's practice of keeping the purse in the room, but the facility's procedures to protect personal property were not enforced, resulting in the loss of the resident's belongings.
A resident returned from the hospital without discharge paperwork or medication orders, resulting in them not receiving any medication for a day. The admitting LPN did not contact the hospital or physician to obtain orders, and other staff were unaware of the missing orders. The DON and Administrator confirmed the admitting nurse's responsibility to ensure medication orders were in place.
Failure to Monitor CHF Weight Gain and Fluid Restriction
Penalty
Summary
The facility failed to provide care according to physician orders and standards of practice for a resident with CHF, COPD, CKD, and diabetes who had an order for daily morning weights and instructions to call the heart clinic for a 3-pound overnight gain or 5-pound weekly gain. The resident’s record showed multiple missed weights, including dates when no weight or refusal was documented, and several significant weight increases were recorded without documentation that the physician or heart clinic was notified. The care plan also did not include CHF, the diuretic therapy, or the ordered daily weights. The resident’s weight fluctuated repeatedly, including a 15-pound gain over two days early in the stay, a 4-pound gain in two days, a 3.8-pound gain in one day, a 3.6-pound gain, and a 12-pound gain in one night, yet the record did not show physician or heart clinic notification for these changes. During this period, staff also failed to document weights on several days. After the resident returned from the hospital on a 1500 mL fluid restriction, the April record showed the fluid restriction was documented on the MAR, but intake was not documented on the intake and output record, and the dietary profile later showed a regular diet with no fluid restriction. The resident was hospitalized after worsening swelling, weakness, shortness of breath, severe hyponatremia, hypervolemia, abdominal distention, lower extremity edema, and right shoulder effusion. After readmission, staff documented shortness of breath, orthopnea, tachypnea, abdominal distention, and additional large weight gains, including a 9.8-pound gain in two days and a 2.4-pound gain in one day, without documentation of physician notification. Interviews with nursing, dietary, and administrative staff confirmed that weights were expected to be obtained and documented, fluid restriction and intake were to be monitored, and the physician should have been notified for significant weight gains and shortness of breath.
Incomplete TB Screening and Documentation
Penalty
Summary
The facility failed to establish and maintain a complete infection control program when staff did not ensure all residents were screened for tuberculosis and did not complete the required two-step TB testing for three residents. The facility policy required TB screening for new residents and repeat screening for current residents in accordance with state requirements, and Missouri regulations required an initial Mantoux PPD two-step tuberculin test within one month prior to or one week after admission, with a second test given one to three weeks later if the first test was negative. Resident #1 was admitted with diagnoses including COPD, CHF, and diabetes mellitus. The resident’s record showed TB testing orders for step one and step two, along with orders to read both tests. The February 2026 record documented step one as completed, but step two was not documented as completed; one later entry for step two showed the resident sleeping. The April 2026 record documented step one as completed, but there was no documented step two result. The resident’s immunization record contained no TB screening or TB testing entries, and staff did not document TB results in the progress notes. Resident #3 was admitted with diagnoses including COPD and neck cancer. The record showed TB testing orders for step one and step two and orders to read both tests. The April 2026 MAR did not document the initial step one test as completed. In May 2026, step one was documented as completed, step two was documented as completed on 05/15/26, and both readings were documented as completed; however, the immunization record only showed an entry for a TB skin test administered with no results documented. Resident #4 was admitted with diagnoses including stroke and CHF. The record showed orders for both steps of the TB test and both readings, but the progress notes did not document TB screening or testing. The immunization record showed only one TB skin test entry with negative results, and there was no documented step two test. Staff interviews confirmed that residents should receive a two-step TB test on admission, that results should be documented in the immunization tab, and that some TB tests had not been completed.
Failure to Preserve Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when staff did not assist the resident to leave the dining room to have a soiled brief changed before mealtime. Resident #4 had diagnoses including stroke and CHF, was cognitively intact, and was dependent on staff for toileting, mobility, and showering, with bowel and bladder incontinence documented in the MDS and care plan. The care plan directed staff to assist with tasks, provide toileting support, and check and change the brief as needed. During observation and interview, the resident reported that after soiling the brief in the dining room, the resident asked CNA F to return to the room to be changed before eating, but CNA F told the resident to wait and did not want to take the resident back to the room. The resident stated CNA F accused the resident of trying to trick staff, told the resident to eat and shut up, and left the resident crying in the dining room because of embarrassment and the smell of the soiled brief. CNA D observed the resident with a large bowel movement, overheard the request to be changed, and then assisted the resident back to the room for brief change after CNA F left the resident at the table. Multiple staff members, including CNAs, CMT, LPNs, RNs, the ADON, DON, and Administrator, stated residents should be changed if soiled and should not eat with a soiled brief or be told to shut up.
Failure to Obtain Order and Assessment for Insulin Self-Administration
Penalty
Summary
The facility failed to ensure that a resident only self-administered medication after it had been determined to be clinically appropriate. Resident #2, who had diagnoses including COPD and diabetes mellitus, requested to self-administer insulin injections and was observed giving self-injections using proper technique. However, the resident’s record did not contain documentation of a self-administration assessment to determine competency, and there was no physician order authorizing self-administration of medication. The resident’s care plan, revised 01/28/26, addressed assistance with daily activities, fluctuating blood sugars, and medication administration per order, but did not include self-administration of insulin. Progress notes documented that the resident requested to self-administer insulin and that staff observed the resident injecting insulin, while staff continued to draw up the insulin as directed. A later note stated the resident was an insulin-dependent diabetic who requested to self-inject after the nurse set it up, with the nurse present to observe the injection, but the record still did not show physician notification or an order for self-administration. The physician’s order sheet contained an order for insulin glargine to be injected by staff, and the May 2026 MAR documented the insulin as administered by staff. During interviews, the resident stated he/she checked blood sugar and self-administered insulin after staff prepared the injection. Nursing staff gave mixed responses about whether a physician order was required and whether the resident was care planned for self-administration, while the DON and Administrator stated that a physician order was required and that self-administration should be included in the care plan.
CPR Initiated Before Confirming Resident DNR Status
Penalty
Summary
Facility staff failed to ensure a resident’s DNR order was honored when CPR was initiated on a resident who had a documented DNR. The resident had diagnoses including COPD, CHF, and diabetes mellitus. The resident’s care plan identified code status as DNR, the current physician order sheet included a DNR order, and an outside hospital DNR form was signed by the resident and a physician. The resident’s face sheet did not indicate code status. According to the progress note, the resident was found unresponsive in the dining room at approximately 8:45 A.M., and CPR had already been initiated before DNR status was verified. The resident was pronounced dead at approximately 8:51 A.M. Staff documented that CPR was stopped after the DNR was confirmed. Interviews showed that a CNA observed the resident become limp and appear not to be breathing, another CNA and a hospice nurse started CPR, and an LPN then entered and instructed them to stop CPR after checking the resident’s code status. Interviews with multiple CNAs, CMTs, LPNs, RNs, the SSD, ADON, DON, and Administrator showed staff knew code status could be found in the chart, care plan, or code book at the nurses’ station, and several stated CPR should not be given to a resident with a DNR order. However, staff also described that CPR may be started until code status is confirmed, and the resident’s DNR was not honored before CPR began.
Unauthorized Restart of Naltrexone
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when an LPN reinitiated Naltrexone for a resident with a history of alcohol abuse without a physician order. The resident was admitted with an order for Naltrexone 50 mg, 0.5 tablet by mouth in the morning, and that order was discontinued the next day when hydrocodone-acetaminophen 5-325 mg every 8 hours as needed was added for pain. The resident’s care plan did not address the history of alcohol abuse, Naltrexone use, or pain medication. Despite the discontinuation, the resident’s medication record later showed a new order for Naltrexone 50 mg, 0.5 tablet by mouth daily due to alcohol abuse. The order progress note documented a possible drug interaction between Naltrexone and hydrocodone-acetaminophen and stated that Naltrexone therapy should be suspended in patients receiving intermittent opioid treatment. The MAR showed Naltrexone was administered on two days, and hydrocodone-acetaminophen was also administered on the same day as the restarted Naltrexone. Staff interviews showed nurses understood that physician contact and physician orders were required for new medications, and multiple staff stated nurses should not write their own orders. The LPN who reactivated the medication said it was done because the resident needed it for alcohol abuse, but also acknowledged the physician had discontinued it on admission because of narcotic pain medication. The DON identified the restart as a medication error, and the attending physician stated the medication was not restarted by him, he was not notified, and the initiation and administration of Naltrexone in this situation was a medication error.
Failure to Administer Ordered Insulin and Notify Physician
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when insulin was not administered as ordered for two residents with diabetes mellitus. Resident #1 was admitted with diabetes mellitus and had a physician order for insulin glargine 10 units subcutaneously daily. Review of the March and April 2026 MARs showed multiple dates when the insulin was not given as ordered, with documentation such as “see progress note,” “resident refused,” “no insulin required,” or no administration recorded. In several instances, the MAR did not include a blood sugar reading, and the progress notes did not document a reason for holding the insulin or notification to the physician. Resident #1’s record also showed occasions when blood sugar values were documented, including 171 mg/dL, 177 mg/dL, 185 mg/dL, 162 mg/dL, 153 mg/dL, and 176 mg/dL, yet the insulin was still not administered and the chart stated “no insulin required.” The insulin order did not contain parameters to hold the medication. When the resident was documented as refusing insulin, the progress notes did not show physician notification. The resident’s record also showed a hospital stay during the review period, and after return the insulin dose was increased to 15 units daily, but the MAR continued to show insulin not administered with documentation that it was not required or held without supporting order parameters or physician notification. Resident #6 was admitted with diabetes mellitus and had a physician order for Lantus 48 units subcutaneously twice daily. Review of the May 2026 MAR showed repeated missed doses on both morning and evening administrations. Staff documented blood sugar values such as 76 mg/dL, 87 mg/dL, 85 mg/dL, 68 mg/dL, 95 mg/dL, 74 mg/dL, 63 mg/dL, 80 mg/dL, 133 mg/dL, 117 mg/dL, 129 mg/dL, 83 mg/dL, 118 mg/dL, 159 mg/dL, 72 mg/dL, 133 mg/dL, and 122 mg/dL, but often recorded that insulin was not given because vital signs were outside parameters, no insulin was required, or the resident refused. The order did not contain hold parameters until 05/27/26, when it was changed to hold for blood sugar less than 120 mg/dL. Even after that change, insulin was still not administered for blood sugar readings of 133 mg/dL and 122 mg/dL, and the progress notes did not document physician notification. Interviews with nursing and administrative staff confirmed that physician orders should be followed and that the physician should be notified when insulin is held or a resident refuses medication. Staff stated that a progress note should be made when insulin is held and that long-acting insulin should not be held without an order. The attending physician stated staff should not be holding long-acting insulin and should notify him/her if blood sugar was really low so he/she could decide whether it should be held.
Nurse Aides Worked Beyond Required Training and Certification Time Frame
Penalty
Summary
The facility failed to ensure nurse aides were certified within the required time frame when four nurse aides continued working with residents beyond four months without current CNA certification. Review of the facility policy stated that individuals hired as nurse aide trainees must complete an approved CNA training program and pass the state exam within the required timelines, and that trainees may not continue working in resident care if they fail to meet certification timelines or exam requirements. The facility census was 106. Record review and interviews showed NA A, NA B, NA C, and NA D were hired between August and September 2025 and were still working as nurse aides in February 2026 without current CNA certification. NA A said he/she had completed classes about two months earlier but had not tested; NA B said he/she finished classes about two months earlier and the test had been canceled and not rescheduled; NA C was observed assisting a resident in a wheelchair and said he/she had finished training but had not passed the test yet; and NA D said he/she had just started classes and had not tested. The DON and Administrator stated they were not aware some nurse aides had been working longer than four months, and both said the staff member responsible for tracking CNA certification had been fired about a month earlier, with no one tracking it since then.
Medication Left Unsupervised and Unadministered Cups Found in Cart
Penalty
Summary
The facility failed to ensure accurate dispensing and documentation of medication administration when staff left medication unsupervised in a resident’s room and when multiple medication cups containing pills were found left in the medication cart. The report states that the facility’s policies required medications to be stored securely, administered according to resident-centered medication pass procedures, and not retained in resident rooms unless self-administration had been ordered and assessed. No order for self-administration was found for the resident involved in the room observation. For one resident, who was cognitively intact and had diagnoses including type 2 diabetes mellitus, chronic foot ulcer, hypertension, chronic kidney disease with heart failure, lymphedema, depression, anxiety, and urinary retention, a medicine cup containing approximately 10 to 15 pills was observed on the bedside table in the middle of the room while no staff were present. The resident stated that the CMT often left medication on the bedside table and left because it took a long time to take the pills one at a time, and that the medication had been left there while the resident used the bathroom. The CMT acknowledged leaving the medication in the room, said the resident and staff both needed to use the bathroom, and stated awareness that medication was not supposed to be left in the room. The MAR showed the medications as administered at times that did not match the resident’s account of when the pills were actually taken. For four other residents, the surveyor found six medication cups with pills sitting in the locked medication room, with room numbers written on five cups and two cups unlabeled. The cups contained medications for residents with diagnoses including moderate cognitive impairment, severe cognitive impairment, anticoagulant therapy, seizure disorder, diabetes, heart failure, atrial fibrillation, and chronic kidney disease. The MARs for those residents showed the medications as administered, but there was no documentation that the medications had been refused or not given. One CMT said he/she did not remember leaving the cups and thought some residents may have refused, while RN and DON interviews indicated that medication should not be left in the cart and that refused medication should not remain there. Residents also reported that staff sometimes left medication on bedside tables and did not return to ensure it was taken.
Failure to Document and Communicate Fall with Injury
Penalty
Summary
Facility staff failed to follow standards of practice in the assessment, documentation, and communication of a resident's fall with injury. A resident with a history of dementia, atrial fibrillation, repeated falls, and on anticoagulant therapy experienced a fall from bed, hitting their head and sustaining a hematoma. Although the fall was witnessed and initially assessed by nursing staff, there was no documentation of the incident, assessment, or physician notification in the resident's medical record for several days following the event. Multiple staff members, including RNs and LPNs, were aware of the fall but each assumed that another staff member would complete the required documentation and follow-up. As a result, essential post-fall monitoring, including neurological checks and ongoing assessments, were not consistently performed or communicated to subsequent shifts. The lack of documentation and handoff led to staff on following shifts being unaware of the need for fall follow-up monitoring, and the physician was not promptly notified as required by facility policy. Interviews with staff and review of records confirmed that the facility's fall prevention policy, which requires immediate assessment, documentation, physician and family notification, and 72-hour follow-up monitoring after a fall, was not followed. The deficiency was further compounded by a recent transition to a new electronic documentation system, which some staff cited as a reason for confusion about where to document. The failure to document and communicate the fall and subsequent injury resulted in delayed recognition and management of the resident's condition.
Failure to Document Medication Reconciliation Leads to Controlled Substance Error at Discharge
Penalty
Summary
The facility failed to have an effective process in place to ensure the proper receipt and disposition of all controlled drugs, specifically during the discharge process. Staff did not document medication reconciliation upon discharge for one resident, which resulted in a card containing 30 Percocet (oxycodone-acetaminophen) 5-325 mg tablets, prescribed for a different resident, being sent home with the wrong individual. The resident who received the medication in error did not have an order for Percocet, while the resident for whom the medication was intended had already been discharged and did not receive it. Review of records showed that the medication reconciliation list was not completed for the discharged resident, and the narcotic record sheet for the intended recipient showed no tablets administered and no documentation of medication disposition. Staff interviews revealed inconsistencies and lapses in the process for handling and documenting controlled substances during discharge. The charge nurse did not verify each medication card against the medication list, and the process was rushed, leading to the error. Additionally, the nurse responsible did not follow the established procedure of confirming each medication one card at a time with the resident's orders and the reconciliation sheet. Further, the error was not reported promptly to the facility Administrator. The Director of Nursing was made aware of the missing narcotics on the day of the incident but failed to report the issue to the Administrator or regulatory authorities in a timely manner. This delay in reporting contributed to the prolonged period before the error was identified and addressed. The facility's policies required documentation and verification steps that were not followed, resulting in the mismanagement of controlled substances during the discharge process.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
A cognitively intact resident, who required moderate assistance for transfers and mobility, experienced the misappropriation of personal funds while residing in the facility. The resident chose to keep personal cash and financial cards in a lockbox provided by the facility and stored in the resident's dresser. The lockbox was installed by the Maintenance Supervisor and was intended to secure the resident's valuables. The resident withdrew $200 from the bank, spent $15, and placed the remaining $185 in the lockbox with the assistance of the Housekeeping Supervisor. The key to the lockbox was hidden in the room, and only a few staff members were aware of the money's presence. On a later date, when the resident requested assistance to access the lockbox to pay a bill, it was discovered that the lock had been broken and the envelope containing $185 was missing. The debit and credit cards remained in the lockbox, but the resident and staff were concerned about potential compromise, leading to the cancellation and replacement of the cards. The resident reported not having left the facility or having unsupervised visitors during the relevant period. The family member who visited last confirmed the lockbox was intact during their visit. The incident was reported to the facility administration and local law enforcement, and an internal investigation was initiated. Interviews with staff, including the Housekeeping Supervisor, Business Office Manager, Maintenance Supervisor, and others, confirmed that staff were aware of the resident's practice of keeping money in the lockbox and that it was not appropriate for staff to take resident belongings. The facility's policy prohibits misappropriation of resident property, and staff are expected to report missing or stolen items. Despite these policies, the lockbox was forcibly opened, and the resident's money was stolen, indicating a failure to protect the resident from the wrongful use of their belongings.
Failure to Protect Residents' Belongings
Penalty
Summary
The deficiency involves the failure to protect each resident from the wrongful use of their belongings or money. This was identified during an event with the ID XMKY12, which concluded on 11/21/24. The report references two specific cases, MO00245443 and MO00244807, indicating that surveyors found instances where residents' personal belongings or financial resources were misused or mishandled. The details of these cases suggest a breach in the facility's responsibility to safeguard residents' property, leading to the noted deficiency.
Misappropriation of Resident's Belongings
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal property, including a purse, wallet, debit cards, ID cards, and money. The resident, who had moderate cognitive impairment and required assistance for transfers and mobility, discovered the items missing after lunch when attempting to make a payment to the facility. The resident's purse, described as a black clutch with two zippers, contained $140 in cash, debit cards, a checkbook, and other personal items. Despite efforts by staff to locate the purse, it was not found. The facility's policy prohibits the misappropriation of resident property, yet the resident's belongings were not adequately safeguarded. The resident reported the missing items to the housekeeping supervisor, who assisted in searching the room. The administrator and other staff members were notified, and a grievance was filed. The police were also contacted, and an investigation was initiated. However, there were no security cameras in the facility, and no leads or suspects were identified. Interviews with staff revealed that an inventory sheet was not completed for the resident upon admission, and staff were aware that the resident kept the purse in the room. The facility's policy requires that residents be encouraged to lock up valuable items or have them taken home, but this was not enforced. The deficiency highlights a failure in the facility's procedures to protect residents' personal property, leading to the loss of the resident's belongings.
Failure to Administer Medications Upon Resident's Readmission
Penalty
Summary
The facility failed to provide care per standards of practice when staff did not update orders and continue medications for a resident upon their return from the hospital. The resident, who had been hospitalized for several days, returned to the facility without any discharge paperwork or medication orders. As a result, the resident did not receive any medication for one day, despite having a complex medical history that included Parkinson's disease, dyskinesia, metabolic encephalopathy, malnutrition, and dementia. Upon the resident's return, the admitting LPN did not receive a report from the hospital and did not attempt to contact the hospital or the physician to obtain the necessary orders. The LPN was unaware of the facility's policy for admitting residents without orders and did not take steps to ensure the resident received their medications. The resident's medication administration record showed no documentation of medication administration for the days following their readmission. Interviews with facility staff revealed a lack of communication and understanding of responsibilities regarding the admission process. The admitting nurse did not enter medication orders or contact the necessary parties to obtain them. Other staff members, including another LPN and a CMT, were also unaware of the missing orders and did not take action to rectify the situation. The DON and Administrator confirmed that the admitting nurse was responsible for ensuring medication orders were in place and that it was inappropriate for a resident to go without medication for a day.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Joplin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Joplin Gardens | 1 mi | ★★★★★ | 6 | 0 |
| Communities Of Wildwood Ranch | 2.6 mi | ★★★★★ | 0 | 0 |
| Westgate | 2.6 mi | ★★★★★ | 3 | 1 |
| Nhc Healthcare, Joplin | 3.1 mi | ★★★★★ | 0 | 0 |
| Galena Nursing & Rehab Center | 4.9 mi | ★★★★★ | 16 | 1 |
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