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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Joplin Gardens during CMS and state inspections, most recent first.
A resident with a history of stroke, significant mobility limitations, and moderately impaired cognition had a care plan requiring a Hoyer lift with two staff for all transfers. A CNA, seeing the resident in a wheelchair without a sling and not checking the care plan or consulting nursing staff, assumed the resident could be transferred with a one-person gait belt assist. During the attempted transfer from wheelchair to bed, the resident began sliding off the bed, the CNA grabbed the resident under the arms, heard a crack, and then called for a nurse to help return the resident to bed. The resident later reported shoulder pain and decreased mobility, and imaging revealed a possible humerus fracture, after which the resident returned from the ED with the arm in a sling and ongoing pain during care.
The facility failed to honor a resident’s right to self-determination by not adequately promoting and facilitating resident choice, resulting in a repeated citation related to resident rights. The deficiency is linked to a prior uncorrected event and a subsequent complaint investigation, though no further clinical or resident-specific details are provided in the report excerpt.
The facility did not ensure that an RN was on duty for at least eight consecutive hours each day, as required. Staff schedules and time sheets showed multiple days without RN coverage, and interviews with staff and administration confirmed ongoing lapses, particularly on weekends. The DON and Administrator acknowledged the deficiency and the lack of a policy for nursing schedules.
The facility did not consistently honor resident shower preferences or provide showers according to the stated schedule, resulting in several residents—many with significant physical impairments—going extended periods without showers or adequate hygiene. Documentation was incomplete, care plans often lacked individualized shower preferences, and staff cited insufficient staffing as a barrier to meeting resident needs.
Insufficient staffing led to missed showers, delayed call light response, and delayed resident care. Residents with significant ADL needs, including one with stroke-related weakness, one with diabetes and amputation, and one requiring a mechanical lift, reported showers were often not completed as scheduled because staff were too limited and busy with other duties. A resident who required two-person transfers fell after waiting for help from the toilet, and another resident needing feeding assistance was observed with an untouched meal tray while staff provided only limited help. Staff interviews confirmed that showers, repositioning, and other care tasks were difficult to complete with the number of CNA, CMT, and nurse staff assigned.
The facility failed to provide adequate bathing assistance to three residents, leading to deficiencies in personal hygiene care. A resident with paraplegia reported only receiving three showers over three months, despite needing substantial assistance. Another resident with moderate cognitive impairment had inconsistent shower documentation, and a third resident reported receiving showers only once every two weeks. Staff acknowledged the expectation of two showers per week, but this was not consistently met.
A resident with a stage 3 pressure ulcer was admitted to the facility, but a complete skin assessment was not conducted within the required timeframe. Despite the resident's risk factors, staff failed to document attempts to assess the skin until three days post-admission, when the ulcer was finally identified and treated. Interviews revealed that the admission nurse was responsible for timely assessments, which were not completed as per facility policy.
The facility failed to maintain kitchen ceiling vents, with rust, dust, and peeling paint observed. One vent was falling, and another had condensation dripping near the food prep area, risking contamination. The Maintenance Director was aware but had not fixed the issues, and the Administrator confirmed no monitoring policy existed.
The facility failed to properly label and store medications, with insulin pens for several residents found opened and undated, and expired influenza vaccines not removed from medication rooms. LPNs confirmed these deficiencies, and the DON acknowledged the responsibility of nurses to date insulin pens when opened.
The facility failed to maintain food at a palatable temperature for residents on the 300 hall, with several residents reporting cold meals. Observations confirmed food temperatures below required levels, and the Dietary Manager acknowledged a malfunctioning steamer bay and a lapse in monitoring food temperatures prior to service.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a PICC line receiving antibiotics. Despite a policy to prevent MDRO transmission, an LPN was observed not using PPE during IV care, and staff reported not receiving EBP training. The resident confirmed the lack of PPE use during high-contact care, and the Infection Preventionist noted PPE was not readily accessible. The DON acknowledged previous training, but staff remained unaware of EBP requirements.
A facility failed to ensure the accuracy and completeness of the MDS assessment for a resident, missing critical sections on Cognitive Patterns, Mood, and Behaviors. The Social Services Director, responsible for coding these sections, was unsure why they were not completed, and the MDS Coordinator, who signed off on the assessment, could not explain the omissions.
A facility failed to document and follow physician's orders for a diabetic resident, leading to a lack of proper blood sugar monitoring and insulin administration. An LPN did not document a required blood sugar check or communicate with other staff, resulting in a lapse in care. The DON confirmed that proper documentation and communication were not followed.
A resident with diabetes and a history of stroke was injured during a transfer when a CNA used a Hoyer lift alone, contrary to the care plan requiring two staff members. The resident's toenail was injured, necessitating medical attention. Interviews confirmed the CNA acted alone, breaching protocol.
Failure to Follow Transfer Care Plan Resulting in Arm Fracture
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident free from accident hazards and to provide adequate supervision and assistance during transfers, specifically by not following the resident’s care plan requiring a mechanical lift. The resident had a history of stroke with right-sided weakness/paralysis, speech difficulty, obesity, cognitive communication deficit, arthritis pain, generalized muscle weakness, difficulty walking, and restlessness and agitation. A quarterly MDS documented moderately impaired cognition, functional limitations in one upper extremity and both lower extremities, and dependence on assistance for transfers. The resident’s care plan, last reviewed in January, directed staff to use a Hoyer lift with two staff for transfers in and out of bed and wheelchair, to follow protocol and policy when using the lift, and to use two-person assist with repositioning. On the morning of the incident, the resident was in a wheelchair without a Hoyer sling under them. A CNA later received a request from a family member to put the resident back to bed. The CNA, seeing no sling, assumed the resident might now be a one-person assist for transfers and did not review the care plan or ask other staff about the resident’s transfer status. The CNA applied a gait belt and attempted to transfer the resident from the wheelchair to the bed alone, contrary to the care plan that required a Hoyer lift with two staff. As the resident sat on the edge of the bed, they began to slide down, and the CNA grabbed the resident from the front, under the arms, to prevent them from sliding to the floor. During this maneuver, the CNA reported hearing a crack while holding the resident, and then called for the nurse, who assisted in getting the resident back into bed. Initial nursing assessment noted no head injury and only mild redness to the mid-back without skin tears or bruising, and the resident complained of generalized pain for which PRN Tramadol was given. Later, the resident complained of pain and decreased mobility in the left shoulder, leading to an x-ray of the left humerus that showed a possible fracture. The resident was sent to the hospital for evaluation and returned with the left arm in a sling, continuing to show signs and symptoms of pain during care. Interviews with multiple staff confirmed that the resident should have been transferred with a Hoyer lift and two staff, and that staff were expected to follow the care plan or consult a nurse if unsure of a resident’s transfer status.
Failure to Honor Resident Right to Self-Determination and Choice
Penalty
Summary
The deficiency involves the facility’s failure to honor the resident’s right to self-determination and to promote and facilitate resident choice. Surveyors cited that the facility did not adequately support resident choice as required, resulting in a violation of the resident’s rights. The report references a prior, uncorrected citation for the same issue under Event ID 1D8649-H1 with an earlier exit date, and indicates that details of the current deficiency are documented under Event ID 1D8649-H2 associated with a specific complaint number. No additional clinical or resident-specific details are provided in this excerpt.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days per week, as required. Review of monthly work schedules for August and September 2025 showed no RN was scheduled to work, and time sheets confirmed that on several specific dates, no RN clocked in or out. On one date, an RN worked only four hours, and on another, the Director of Nursing (DON) worked eight non-consecutive hours. The facility did not have a policy related to nursing schedules available for review. Interviews with staff, including LPNs, a Certified Medication Tech, the DON, and the Administrator, confirmed that there was not consistent RN coverage, especially on weekends. The DON stated that four RNs were employed, but acknowledged that there was not always an RN on shift. The Administrator also confirmed lapses in RN coverage and awareness of the state requirement for eight hours of RN coverage per day. The MDS Coordinator occasionally worked on weekends, but overall, RN coverage was inconsistent and did not meet regulatory requirements.
Failure to Honor Resident Shower Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring reasonable shower preferences for six residents. Multiple residents, all of whom were cognitively intact and had varying degrees of physical impairment, reported not receiving showers according to their preferences or the facility's stated schedule. Documentation was inconsistent or missing, with shower sheets unavailable for certain months and staff failing to record refusals or re-approach attempts. Residents expressed uncertainty about when they last received a shower and indicated a desire for more frequent showers, typically at least twice per week, which was not consistently provided. Care plans for several residents did not include individualized shower schedules or preferences, and in some cases, staff did not follow the preferences that were documented. For example, one resident preferred showers only from male staff, but there was no evidence that this preference was consistently accommodated. Another resident preferred showers on specific days or with certain staff, but reported that staffing shortages prevented these preferences from being met. Several residents went extended periods—sometimes weeks—without a shower, and some received only bed baths or brief changes, which they felt were inadequate for personal hygiene. Interviews with staff, including CNAs, CMTs, LPNs, and the DON, revealed that staffing shortages and the lack of a dedicated bath aide contributed to the inability to provide showers as scheduled. Staff acknowledged that residents were not consistently receiving two showers per week and that documentation of showers and refusals was incomplete. The facility did not have a shower policy available for review, and the process for offering and documenting showers was inconsistently followed, leading to unmet resident preferences and needs.
Insufficient staffing led to missed showers, delayed call light response, and delayed resident care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, and surveyors observed multiple care failures tied to staffing shortages. The report states that residents did not receive showers according to their preferences, call lights were not answered in a timely manner for a resident who later fell while trying to transfer from the toilet, and one resident did not receive timely repositioning and meal assistance/cueing. The facility census was 84, and staffing sheets showed limited numbers of nurses, CMTs, CNAs, and NAs assigned to the halls during the reviewed dates. The facility also did not have a shower policy. On the 100-hall, 22 residents were present and 8 required two-person assist. On the 200-hall, 31 residents were present and 12 required two-person assist. On the 300-hall, 31 residents were present and 11 required two-person assist. Staffing records showed that some shifts had only one nurse and one CNA on a hall, while other shifts had a nurse, CMT, and CNA, with occasional float staff. Shower logs showed residents were scheduled for twice-weekly showers with make-up days, but interviews with residents and staff described that showers often were not completed because there were too many other duties and not enough staff available on the halls. Resident #1, who had stroke-related weakness, paralysis, glaucoma, depression, and swallowing/speech difficulty, preferred morning showers and required substantial assistance with bathing and toileting hygiene. Shower documentation showed gaps of five, six, seven, and ten days between showers, and the resident and family member said there were not enough staff to keep the shower schedule. Resident #2, who had diabetes with severe nerve damage, a left below-the-knee amputation, obesity, depression, insomnia, and an open foot wound, preferred late-night showers and male staff. Shower records showed long intervals between showers, including 11 days between documented showers, and the resident said showers were only occurring about weekly to every week and a half. Resident #3, who had cerebral palsy, post-polio syndrome, poor vision, chronic pain, anxiety, and insomnia, required a mechanical lift and extensive assistance for bathing and transfers; staff and the resident said showers were not consistently completed because of limited staffing and competing duties. Resident #4, who had a right above-the-knee amputation, diabetes, obesity, depression, anxiety, urinary incontinence/retention, and a history of UTI, required two staff for transfers. The resident had a documented fall while trying to transfer from the toilet after waiting for help, and the resident and roommate reported long waits for call light response, with the roommate sometimes going into the hall to find staff. Resident #6, who had dementia, depression, malnutrition, osteoarthritis, chronic pain, and pressure ulcers, had an order for staff assistance with eating and needed cueing and encouragement. During observation, the resident’s lunch tray remained largely untouched while the resident sat in bed holding a spoon, and staff only provided limited feeding assistance before leaving the room. Staff interviews repeatedly described difficulty completing showers, repositioning, toileting, feeding, and call light response because of limited staffing and multiple competing resident care demands.
Inadequate Bathing Assistance for Residents
Penalty
Summary
The facility failed to ensure that all dependent residents received necessary services to maintain good grooming and personal hygiene, specifically in providing assistance with bathing. Three residents out of a sample of thirteen did not receive adequate bathing assistance. Resident #1, who was cognitively intact and required substantial assistance for showering, reported having only three showers over a three-month period, despite expressing a preference for two showers weekly. The resident's care plan indicated a need for staff assistance with showering, yet the documentation showed infrequent showers. Resident #2, with moderate cognitive impairment and dependent on staff for showers, did not have any showers documented in October 2024. In November 2024, the resident received four showers, with one refusal noted, but no showers were documented for December 2024 due to hospitalization. The care plan required staff assistance with activities of daily living, including showers, but the documentation was inconsistent with the resident's needs. Resident #3, who had moderate cognitive impairment and required moderate staff assistance with showers, reported receiving showers only once every two weeks, contrary to the care plan that indicated a need for weekly showers. The facility's staff, including a Nurse Assistant, Certified Medication Technician, and Licensed Practical Nurse, acknowledged that residents should receive two showers per week, but admitted that this was not always achieved. The Director of Nursing was working on a new process to improve shower documentation, but the deficiency in providing adequate bathing assistance remained evident.
Failure to Conduct Timely Skin Assessment for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to perform a complete admission assessment, including a skin assessment, for a resident who was admitted with a stage 3 pressure ulcer. The resident, who had a history of pressure sores and other risk factors for skin breakdown, was admitted with paraplegia and diabetes mellitus. Despite these conditions, the initial skin assessment was not conducted within the required timeframe, and the resident's pressure ulcer was not identified or treated promptly. Upon admission, the nurse documented an inability to perform a skin assessment because the resident was in a power chair and arranging a new room. Over the next few days, staff did not document any attempts to assess the resident's skin. It was not until three days after admission that staff observed a brown adhesive dressing on the resident's coccyx and identified an open area, prompting the ordering of an air mattress and notification of the wound care nurse. Interviews with facility staff, including LPNs and the Director of Nursing, revealed that the admission nurse was responsible for completing skin assessments within two hours of admission. However, this did not occur, and the resident went three days without a proper skin assessment. The facility's policy and staff interviews emphasized the importance of timely skin assessments to assume responsibility for any wounds, but this protocol was not followed in this case.
Ceiling Vent Maintenance Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain ceiling vents in the kitchen, which had the potential to affect all 65 residents who received meals from the facility. During an initial tour of the kitchen, three ceiling vents were observed to have rust, dust, and peeling paint. One vent was falling from the ceiling, and another vent had condensation dripping from its edges, landing near the food preparation table. These conditions were confirmed by the Dietary Manager and another staff member, who acknowledged the potential for condensation and peeling paint to contaminate food. The Maintenance Director admitted awareness of the vent conditions but had not addressed the issues. Additionally, the Administrator confirmed the absence of a policy for monitoring the kitchen ceiling vents.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, specifically insulin pens and influenza vaccines, as observed during a survey. Insulin pens for seven residents were found opened and undated, which is against the facility's policy that requires all medications to be properly labeled with open dates. This issue was confirmed by LPNs during observations of medication carts, where multiple insulin pens for different residents were found without open dates. The Director of Nursing acknowledged that it was the nurses' responsibility to ensure insulin pens were dated when opened. Additionally, the facility did not remove expired influenza vaccine vials from two medication rooms. During observations, LPNs confirmed the presence of expired vaccine vials, which should have been disposed of according to the facility's policy. The Administrator stated that the Assistant Director of Nursing, the Director of Nursing, and unit nurses were responsible for ensuring expired medications were properly disposed of, indicating a lapse in adherence to the facility's medication storage policy.
Failure to Maintain Palatable Food Temperatures
Penalty
Summary
The facility failed to maintain food at a palatable temperature for residents on the 300 hall, as evidenced by complaints from six residents about receiving cold food. The facility's policy requires hot foods to be maintained at no less than 140 degrees Fahrenheit during meal service and at least 120 degrees Fahrenheit when served to residents. However, during interviews, residents reported that their meals were often cold, despite being served in close proximity to the kitchen. Observations and test tray evaluations confirmed that food temperatures were below the required levels, with a fried fish fillet measuring 103 degrees Fahrenheit and onion rings at 127 degrees Fahrenheit. The Dietary Manager (DM) acknowledged that the steamer bay, which had been recently repaired, was not functioning properly, registering a temperature of 117 degrees Fahrenheit. The DM admitted to not checking the temperature logs prior to meal service on the 300 hall and was unaware of the malfunction. Despite appropriate temperatures being recorded in the kitchen, the issue persisted at the point of service, indicating a lapse in monitoring and ensuring food safety standards were met during meal distribution.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a peripherally inserted central catheter (PICC line) who was receiving antibiotics. The facility's policy on EBP, dated March 2024, aimed to prevent the transmission of multi-drug resistant organisms (MDRO) and protect patients with chronic wounds and indwelling devices. However, during an observation, a Licensed Practical Nurse (LPN) was seen disconnecting intravenous antibiotics from the resident's PICC line without wearing a gown or gloves, which are required for high-contact care. The LPN admitted to not receiving any training or in-services on EBP and noted the lack of readily accessible personal protective equipment (PPE) for administering IV antibiotics. Interviews with the resident and staff revealed a lack of adherence to EBP protocols. The resident reported that nursing staff had not been using gowns or gloves during IV antibiotic administration or high-contact care such as showering. A Certified Nurse Aide (CNA) also confirmed not receiving any training on EBP. The Infection Preventionist mentioned that a dot on the resident's name plate indicated the need for EBP, but PPE was stored in a location not immediately accessible. The Director of Nursing (DON) and the Regional Quality Assurance (QA) nurse were informed of the deficiency, and the DON stated that training had been conducted twice, yet staff remained unaware of the EBP requirements.
Incomplete MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Minimum Data Set (MDS) assessment for a resident, identified as Resident #24, among 22 residents whose MDS were reviewed. The MDS is a federally mandated assessment tool that must accurately reflect a resident's status, as per federal regulations. The assessment for Resident #24, with an Assessment Reference Date of 05/21/24, was incomplete as staff did not assess the resident in critical care areas, including Cognitive Patterns, Mood, and Behaviors. This oversight was identified during a review of the resident's quarterly MDS located in the electronic medical record. Interviews conducted with facility staff revealed a lack of clarity and accountability regarding the omission. The Social Services Director, responsible for coding the omitted sections, expressed uncertainty about why these areas were not coded, suggesting a possible absence during that week. Additionally, the MDS Coordinator, who signed off on the assessment as complete, was unable to provide an explanation for the missing sections. This indicates a breakdown in the assessment process, leading to the deficiency in accurately capturing the resident's status.
Failure to Document and Follow Physician's Orders for Diabetic Resident
Penalty
Summary
The facility failed to provide care according to standards of practice by not documenting and following physician's orders for a resident with diabetes and bilateral shoulder fractures. The resident was cognitively intact and required insulin administration. The physician's orders required blood sugar checks before meals, but there was a failure to document a blood sugar check at 4:00 PM as ordered. Additionally, there was no documentation of insulin administration or communication with other nursing staff regarding the resident's care. An LPN documented a high blood sugar reading and received orders to administer insulin and recheck the blood sugar level, but failed to document the follow-up actions. The LPN later remembered the oversight and instructed another LPN to check the blood sugar and notify the physician if it was over 300 mg/dL. The Director of Nursing confirmed that physician orders, blood sugar checks, and staff communication should have been documented in the EMR and reported at shift change.
Failure to Follow Care Plan for Resident Transfer
Penalty
Summary
The facility failed to ensure a safe environment free from hazards by not adhering to the care plan for a resident requiring assistance from two staff members during transfers using a mechanical lift. The incident involved a resident with a history of type II diabetes mellitus with diabetic neuropathy, cerebral infarction, and an acquired absence of the left leg below the knee. The resident's care plan specified the need for two or more people for mobility and transfers using a Hoyer lift. However, during a transfer, a CNA attempted to move the resident alone, resulting in the resident's right great toenail being injured when it was bumped against a doorframe. The incident report and progress notes confirmed that the CNA was alone during the transfer, contrary to the care plan requirements. The resident, who was cognitively intact, reported the incident and the subsequent injury to the toenail, which required medical attention due to the resident's diabetic condition. Interviews with the CNA and the Director of Nurses confirmed the breach in protocol, as the Hoyer lift should have been operated by two staff members. The lack of a second staff member during the transfer was not documented in the incident report or progress notes.
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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) |
|---|---|---|---|---|
| Aspire Senior Living Joplin | 1 mi | ★★★★★ | 6 | 0 |
| Nhc Healthcare, Joplin | 2.2 mi | ★★★★★ | 0 | 0 |
| Communities Of Wildwood Ranch | 3.6 mi | ★★★★★ | 0 | 0 |
| Westgate | 3.6 mi | ★★★★★ | 1 | 0 |
| Galena Nursing & Rehab Center | 5.8 mi | ★★★★★ | 3 | 1 |
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