Inspection Reports for Kirksville Manor Care Center
1705 E La Harpe St, Kirksville, MO 63501, United States, MO, 63501
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
48 residents
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with sanitation and food safety standards in the facility's kitchen and dining areas.
Findings
The facility failed to ensure sanitary practices in the kitchen, with multiple areas observed to be unclean including walls, floors, sinks, and storage areas. Interviews with staff confirmed responsibilities for cleaning, but observations showed lapses in maintaining cleanliness and proper sanitizing procedures.
Deficiencies (1)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Report Facts
Census: 48
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen cleaning responsibilities and sanitation expectations |
| Cook A | Interviewed about cleaning duties and wiping down tables | |
| Administrator | Administrator | Interviewed about expectations for kitchen and dishwashing sanitation |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Jun 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of staff to resident abuse involving Certified Nurse Assistant (CNA) A and Resident #1.
Complaint Details
Complaint 1716802 involved an allegation that CNA A slapped Resident #1 and referred to the resident as a pedophile. The allegation was inconclusive due to lack of evidence to substantiate the abuse, though verbal abuse was acknowledged as calling a resident names.
Findings
The facility failed to protect one resident from physical and verbal abuse when CNA A slapped the resident and referred to the resident as a pedophile. The facility suspended CNA A, conducted an investigation, educated staff on abuse policies, and corrected the deficiency on 6/21/25. The abuse allegation was inconclusive due to lack of substantiation.
Deficiencies (1)
Failed to protect resident from physical and verbal abuse by staff.
Report Facts
Facility census: 48
Dates of events: Jun 13, 2025
Dates of events: Jun 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Named in physical and verbal abuse allegation involving Resident #1 |
| CNA B | Certified Nurse Assistant | Witnessed CNA A's actions and reported abuse allegation |
| NA F | Nurse Aide | Reported witnessing CNA B's report of abuse |
| LPN C | Licensed Practical Nurse | Received reports of abuse and confirmed witness statements |
| CNA E | Certified Nurse Assistant | Reported CNA A's verbal abuse and behavior toward Resident #1 |
| CNA H | Certified Nurse Assistant | Reported CNA A's hostile and aggressive behavior toward Resident #1 |
| Director of Nursing | Director of Nursing | Provided interview stating abuse allegation was inconclusive |
| Administrator | Administrator | Provided interview regarding investigation and findings |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 5
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, dignity, safety, and staffing.
Findings
The facility was found deficient in maintaining resident dignity and grooming, providing assistance with activities of daily living, timely and appropriate care following a fall with injury, fall prevention care planning, and adequate nursing staffing to meet residents' needs. Several residents experienced minimal to actual harm due to these deficiencies.
Deficiencies (5)
Failed to maintain resident dignity and self determination by not providing grooming assistance including basic haircuts for four residents.
Failed to provide assistance with activities of daily living including checking for incontinence, grooming, and routine showers for three residents.
Failed to provide appropriate treatment and care following a fall with injury for one resident, including failure to notify physician and delayed evaluation.
Failed to develop a care plan with interventions to prevent falls and failed to communicate fall information properly, resulting in actual harm to one resident.
Failed to provide sufficient nursing staff to meet residents' needs including incontinence care, personal hygiene, call light response, and meal assistance for five residents.
Report Facts
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 5
Facility census: 51
Inspection Report
Routine
Census: 49
Deficiencies: 7
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to assess compliance with resident dignity, activities of daily living assistance, fall prevention, staffing adequacy, infection control, and overall care quality at Kirksville Manor Care Center.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate assistance with activities of daily living, failure to provide appropriate post-fall care and communication, insufficient nursing staff to meet resident needs, and failure to maintain proper infection control signage during a COVID-19 outbreak.
Deficiencies (7)
Failed to treat four residents with dignity and respect; staff spoke disrespectfully and did not promptly respond to an incontinent resident.
Failed to provide assistance with activities of daily living for four residents; including failure to ensure glasses were worn, hair dried, and timely repositioning and incontinence care.
Failed to provide appropriate treatment and care following a fall with injury for one resident; delayed notification and evaluation led to multiple rib fractures and a scapular fracture.
Failed to develop a care plan with interventions to prevent falls for one resident at risk for falls; failed to communicate fall to oncoming shift and on-call physician.
Failed to provide sufficient nursing staff to meet residents' needs for five sampled residents; inadequate staffing led to delayed incontinence care, missed showers, delayed call light response, and missed meals.
Failed to conduct and document a facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies; inaccurate documentation of resident needs and staffing requirements.
Failed to ensure proper signage on the entrance of the building notifying visitors of COVID-19 outbreak and failed to post transmission based precaution signage outside of one COVID-19 positive resident's room.
Report Facts
Facility census: 49
Residents requiring two person or mechanical lift transfers: 27
Fall risk score: 17
Residents independent with toileting: 47
Licensed Practical Nurses providing direct care: 6
Nurse Aides providing direct care: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Notified on-call physician of resident fall; failed to notify administrative staff and provide thorough post-fall assessment |
| LPN C | Licensed Practical Nurse | Unaware of resident fall; called hospital for x-rays after family reported pain; notified family of hospital order |
| CNA E | Certified Nurse Assistant | Found resident on floor after fall; reported fall to RN A; described staff rudeness and failure to respond to call lights |
| CNA F | Certified Nurse Assistant | Reported resident tearful and in pain post-fall to charge nurse |
| DON | Director of Nursing | Interviewed regarding fall care expectations, staffing, and facility assessment |
| Administrator | Facility Administrator | Interviewed regarding facility assessment, staffing, and COVID-19 signage expectations |
| LPN M | Licensed Practical Nurse | Reported facility short staffed and unable to meet resident needs |
| CNA J | Certified Nurse Assistant | Reported difficulty providing timely care due to staffing shortages |
| CNA K | Certified Nurse Assistant | Reported difficulty providing timely care due to staffing shortages |
| CNA H | Certified Nurse Assistant | Reported difficulty providing timely care due to staffing shortages |
| LPN B | Licensed Practical Nurse | Unaware of resident fall during shift |
| PTA O | Physical Therapy Assistant | Reported resident was weak and unsafe to sit in wheelchair unsupervised |
| CMT L | Certified Medication Technician | Reported staffing shortages impacting resident care |
| Infection Control Nurse | Reported lack of COVID-19 signage in facility and outside resident room | |
| Physician Q | On-call Physician | Notified of resident fall but not informed of blood thinner use or ongoing pain |
Inspection Report
Routine
Census: 56
Deficiencies: 12
Date: Feb 16, 2024
Visit Reason
The inspection was a routine survey of Kirksville Manor Care Center to assess compliance with regulatory requirements related to resident dignity, beneficiary notices, grievance processes, resident assessments, care planning, fall prevention, respiratory care, nutrition, behavioral health care, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during care, failure to provide timely beneficiary notices, inadequate grievance process, untimely and inaccurate resident assessments, incomplete and inadequate care plans, failure to implement fall prevention interventions timely, improper storage of oxygen equipment, failure to follow menu portion sizes, failure to provide necessary behavioral health care including failure to respond to suicidal ideation, and failure to implement proper hand hygiene and infection control practices.
Deficiencies (12)
Failure to ensure dignity was provided during care when staff failed to cover Resident #53 during catheter care for 18 minutes.
Failure to provide written beneficiary notices at least two days before the end of covered Medicare services for 3 residents.
Failure to make efforts to resolve grievances for 2 residents and failure to ensure information on how to file a grievance was available.
Failure to complete a comprehensive admission Minimum Data Set (MDS) in the required timeframe for 1 resident.
Failure to complete a quarterly Minimum Data Set (MDS) in the required timeframe for 1 resident.
Failure to provide an accurate MDS to assess relevant care areas for 1 resident; dialysis was not documented.
Failure to develop and implement a comprehensive person-centered care plan for 4 residents including lack of specific behavior care plans, dialysis care plan, catheter care plan, and activity care plan.
Failure to ensure interventions were developed and implemented to prevent falls for Resident #53 until after multiple falls had occurred.
Failure to ensure oxygen tubing and nasal cannulas were stored in accordance with facility policy when not in use for 3 residents.
Failure to follow the prepared menu and serve correct portion sizes for meat, dessert, pureed entree, pureed vegetables, and pureed beans during the evening meal.
Failure to ensure staff implemented proper hand hygiene practices while providing care to Resident #19, including failure to wash hands and change gloves after incontinence care and before touching other items.
Failure to ensure one resident (Resident #53) received necessary behavioral health care services including failure to report suicidal ideation, provide psychiatric services, and update care plans accordingly.
Report Facts
Facility census: 56
Number of residents reviewed for MDS assessments: 21
Number of residents reviewed for respiratory care: 5
Number of residents reviewed for behavioral health care: 3
Number of residents reviewed for infection control: 5
Number of residents reviewed for nutrition: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in dignity deficiency for failing to cover resident during catheter care |
| LPN #2 | Licensed Practical Nurse | Named in dignity deficiency and fall prevention interviews |
| WCN/IP | Wound Care Nurse/Infection Preventionist | Named in dignity and infection control deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple interviews related to dignity, beneficiary notices, grievance process, MDS, care planning, fall prevention, respiratory care, behavioral health, infection control |
| Administrator | Administrator | Named in multiple interviews related to dignity, beneficiary notices, grievance process, MDS, care planning, fall prevention, respiratory care, nutrition, behavioral health, infection control |
| SSD | Social Services Director | Named in grievance and behavioral health deficiencies |
| MDS Coordinator | MDS Coordinator | Named in MDS and care planning deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in grievance and infection control deficiencies |
| LPN #4 | Licensed Practical Nurse | Named in grievance and infection control deficiencies |
| RN #17 | Registered Nurse | Named in care planning and fall prevention deficiencies |
| CNA #16 | Certified Nursing Assistant | Named in care planning deficiency |
| DA #6 | Dietary Aide | Named in nutrition deficiency |
| DM | Dietary Manager | Named in nutrition deficiency |
| RD | Registered Dietitian | Named in nutrition deficiency |
| CNA #21 | Certified Nursing Assistant | Named in infection control deficiency |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: Dec 20, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to accurately assess and timely report changes in condition for Resident #2 and failure to consistently evaluate, implement, and modify interventions to reduce fall risk for Resident #20.
Complaint Details
The complaint investigation focused on Resident #2's failure to timely report changes in condition and Resident #20's fall risk management and unsafe transport. Resident #2 developed severe knee complications after admission that were not timely reported to the physician. Resident #20 experienced multiple falls, was not secured safely during transport, and sustained multiple bruises and skin tears.
Findings
The facility failed to timely notify the physician of Resident #2's worsening knee condition, resulting in actual harm and hospitalization. For Resident #20, the facility failed to prevent falls, secure the resident safely during transport, and conduct proper post-fall evaluations, resulting in multiple injuries and actual harm.
Deficiencies (2)
Failure to accurately assess and timely report changes in condition to the resident's physician for Resident #2, resulting in actual harm.
Failure to consistently evaluate, implement, and modify interventions to reduce fall risk and failure to safely secure Resident #20 during transport, resulting in actual harm.
Report Facts
Facility census: 63
Blister size: 12
Pain rating: 10
Fall date: 2024
Bruise size: 2.5
Skin tear size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician C | Physician | Physician involved in Resident #2's care and orders |
| LPN A | Licensed Practical Nurse | Documented Resident #2's condition and communicated with physician |
| LPN B | Licensed Practical Nurse | Documented Resident #2's skin condition and pain |
| LPN D | Licensed Practical Nurse/Wound Nurse | Completed skin assessment for Resident #2 |
| Director of Nursing | Director of Nursing | Oversaw Resident #2's care and provided interview statements |
| Transportation Staff #34 | Transportation Staff | Transported Resident #20 from hospital; reported resident slid out of wheelchair |
| Certified Medication Technician #35 | Certified Medication Technician | Assisted in transporting Resident #20 from hospital |
| LPN #14 | Licensed Practical Nurse | Responded to Resident #20's fall in facility vehicle |
| Nurse Aide #11 | Nurse Aide | Provided interview regarding Resident #20's fall risk and bruising |
| Administrator | Facility Administrator | Provided statements on staff expectations for follow-up and transport safety |
Inspection Report
Routine
Census: 58
Deficiencies: 1
Date: Oct 4, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding residents' dignity, privacy, and preferences, specifically focusing on whether residents were treated in a manner that promoted their quality of life and respected their individual choices.
Findings
The facility failed to consistently honor residents' preferences regarding wearing pants or briefs in bed, resulting in some residents being exposed to passersby. Observations and interviews revealed that some cognitively impaired residents were left uncovered or exposed, and staff practices did not always align with residents' wishes or care plans. The facility policy supports dignity and respect, but implementation was lacking.
Deficiencies (1)
Failed to treat residents in a manner that promoted dignity and respected their preferences regarding clothing in bed, resulting in exposure of residents' lower bodies to passersby.
Report Facts
Residents affected: 4
Residents sampled: 6
Deficiency citations: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide C | Certified Nurse Aide (CNA) | Stated that incontinent residents can't wear briefs in bed due to risk of skin breakdown. |
| Certified Medication Technician D | Certified Medication Technician (CMT) | Reported attending a meeting where staff were instructed that residents can't wear briefs in bed due to risk of infection. |
| Licensed Practical Nurse E | Licensed Practical Nurse (LPN) | Said residents should have the choice to wear briefs and/or pants in bed. |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated staff should follow resident preferences regarding briefs or pants in bed and noted specific resident preferences and care plan requirements. |
Inspection Report
Routine
Census: 68
Deficiencies: 15
Date: Mar 3, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, infection control, and safety measures such as bed rail use.
Findings
The facility was found deficient in multiple areas including failure to provide effective call light accommodations, failure to notify residents and representatives of hospital transfers, incomplete baseline and comprehensive care plans, failure to follow physician orders for hip fracture care and tube feeding, improper use and assessment of bed rails, medication errors related to insulin pen administration, expired and unlabeled medications, failure to monitor antibiotic use, and inadequate food service practices.
Deficiencies (15)
Failed to provide effective call light accommodations for two residents with cognitive and physical impairments.
Failed to notify residents and responsible parties in writing of hospital transfers including appeal rights and ombudsman notification.
Failed to develop and implement baseline care plans within 48 hours of admission that addressed resident needs and provide copies to residents or representatives.
Failed to develop and implement comprehensive person-centered care plans with measurable goals and interventions for multiple residents.
Failed to follow physician orders for use of abductor pillow and knee immobilizer for a resident with hip fracture.
Failed to follow physician orders for tube feeding administration including holding feedings for high residuals and accurate documentation of amounts administered.
Failed to assess residents for bed rail entrapment risk, obtain informed consent, document alternatives tried, and ensure proper installation and maintenance of bed rails for 17 residents.
Failed to limit PRN psychotropic medication orders to 14 days or obtain documented clinical rationale and duration for extended use; failed to ensure appropriate diagnoses for antipsychotic and hypnotic medications.
Failed to remove expired medications, label insulin pens with resident name and open date, and label over-the-counter medications with open dates.
Failed to monitor antibiotic use and maintain complete antibiotic surveillance tracking including infection details, antibiotic start and stop dates, and outcomes.
Failed to regularly inspect bed frames, mattresses, and bed rails to identify and correct potential entrapment hazards for eight residents.
Failed to ensure a registered nurse worked a minimum of 35 hours per week as the director of nursing.
Failed to serve the correct amount of mechanical soft diet meat as directed by the dietician's menu spreadsheet.
Failed to ensure food items were discarded when expired, ovens were clean, staff did not touch food with contaminated gloves, and serving trays and plate covers were dry prior to meal service.
Failed to ensure insulin pens were primed according to manufacturer instructions prior to administration resulting in administration of less than ordered dose.
Report Facts
Certified census: 68
Residents with bed rails: 40
DON hours: 30.28
DON hours: 37.17
DON hours: 14.1
Medication administration volume: 1278
Medication administration volume: 1246
Medication administration volume: 786
Medication administration volume: 803
Medication administration volume: 650
Bed rail gap measurement: 4
Bed rail gap measurement: 4.25
Bed rail gap measurement: 4.5
Bed rail gap measurement: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding call light accommodations, baseline care plans, antibiotic stewardship, insulin pen administration, and bed rail use |
| Restorative Aide U | Restorative Aide | Interviewed regarding assessment of residents for call light use |
| Licensed Practical Nurse N | Licensed Practical Nurse | Interviewed regarding baseline care plan completion and transfer/discharge notices |
| Registered Nurse I | Registered Nurse | Interviewed regarding transfer/discharge notices and bed rail use |
| Certified Medication Technician E | Certified Medication Technician | Observed administering insulin pens without priming and interviewed regarding insulin pen administration |
| Certified Nurse Assistant I | Certified Nurse Assistant | Interviewed regarding care plan knowledge and hip fracture precautions |
| Certified Medication Technician R | Certified Medication Technician | Interviewed regarding medication cart management and expired medications |
| Licensed Practical Nurse S | Licensed Practical Nurse | Interviewed regarding medication expiration checks |
| Registered Nurse A | Registered Nurse Care Plan Coordinator | Interviewed regarding care plan completion and antibiotic administration |
| Licensed Practical Nurse O | Licensed Practical Nurse Infection Preventionist | Interviewed regarding antibiotic stewardship tracking and infection control |
| Maintenance Director | Maintenance Director | Interviewed regarding bed rail maintenance and measurements |
| Certified Nurse Assistant H | Certified Nurse Assistant | Interviewed regarding knowledge of entrapment risk and bed rail reporting |
| Certified Occupational Therapy Assistant | Certified Occupational Therapy Assistant | Interviewed regarding entrapment risk assessment and bed rail monitoring |
| Dietary Aide F | Dietary Aide | Observed serving meals and interviewed regarding serving sizes and food handling |
| Administrator | Administrator | Interviewed regarding DON hours, food service expectations, and expired food management |
Inspection Report
Routine
Census: 76
Deficiencies: 4
Date: Jan 31, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, catheter care, psychotropic medication management, and food safety standards.
Findings
The facility failed to complete significant change in status assessments for residents with declines in condition, maintain urinary catheter care standards, monitor psychotropic medication use including gradual dose reductions, and ensure proper cleaning and maintenance of kitchen equipment including the range hood and ice machine.
Deficiencies (4)
Failed to complete significant change in status assessments for three residents who experienced decline in condition.
Failed to maintain urinary catheter bags and tubing off the floor and below bladder level for three residents, risking infection.
Failed to maintain a system to monitor psychotropic medication use and implement gradual dose reductions for two residents; failed to develop care plans addressing behaviors and non-pharmacological interventions.
Failed to ensure range hood was free of grease and debris and ice machine was free of rust and had appropriate air gap in drain.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 2
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nurse Aide | Mentioned in relation to catheter care deficiencies and observations |
| CNA H | Certified Nurse Aide | Mentioned in relation to catheter care deficiencies and observations |
| CNA J | Certified Nurse Aide | Mentioned in relation to catheter care deficiencies and observations |
| CNA K | Certified Nurse Aide | Mentioned in relation to catheter care deficiencies and observations |
| CNA L | Certified Nurse Assistant | Mentioned in relation to resident assistance and catheter care |
| Director of Nursing | Director of Nursing | Provided interview regarding catheter care and psychotropic medication monitoring |
| Dietary Staff N | Dietary Staff | Mentioned in relation to range hood cleaning |
| Dietary Staff O | Dietary Staff | Mentioned in relation to ice machine maintenance |
| Dietary Manager | Dietary Manager | Provided interview regarding range hood and ice machine maintenance |
| Maintenance Supervisor | Maintenance Supervisor | Provided interview regarding ice machine drain and maintenance |
| MDS Coordinator | MDS Coordinator | Provided interview regarding resident assessments and care plans |
| Administrator | Administrator | Provided interview regarding psychotropic medication monitoring and pharmacy consultant |
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