Inspection Reports for
Kirksville Manor Care Center
1705 E La Harpe St, Kirksville, MO 63501, United States, MO, 63501
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
12.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
36% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 63
Deficiencies: 5
Date: Feb 27, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to nurse aide training, communicable disease employee screening, resident funds management, and criminal background checks as part of regulatory compliance oversight.
Findings
The facility failed to ensure nurse aides completed required training within four months of employment, did not complete timely tuberculosis testing for new employees, failed to provide timely refunds of resident personal funds, and did not request criminal background checks for certain employees. The facility census was 63 at the time of inspection.
Deficiencies (5)
19 CSR 30-85.042(21)(A) Nurse Aide Training Complete in 4 months. The facility failed to ensure three nurse aides completed the nurse aide training program within four months of employment.
19 CSR 30-85.042(27) Communicable Disease-Employees. The facility failed to complete Tuberculin Skin Tests for five new employees as required by policy and regulations.
19 CSR 30-88.010(43) Resident Funds-Itemized Bill. The facility failed to ensure resident funds were placed in a separate account and did not provide timely refunds for seven residents.
19 CSR 30-88.020(4) Resident Fund, Monthly Interest. The facility failed to maintain resident funds in an interest-bearing account and did not credit interest to resident accounts.
State Statute 192.2495.3(1) Background Checks. The facility failed to request criminal background checks for three employees, risking employment of disqualified staff.
Report Facts
Facility census: 63
Residents with delayed refunds: 7
Total resident funds held: 18918.33
Employees hired since last recertification survey: 329
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
Plan of Correction
Census: 58
Deficiencies: 2
Date: Oct 4, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights and dignity regulations, specifically regarding residents' preferences for wearing protective undergarments while in bed.
Findings
The facility failed to protect and promote residents' rights and dignity by not respecting their preferences for wearing pants or briefs in bed, resulting in residents being exposed to passersby. The facility census was 58 at the time of inspection.
Deficiencies (2)
F550 Resident Rights/Exercise of Rights. The facility failed to treat residents with dignity and respect by not honoring their preferences for wearing protective undergarments or pants while in bed, exposing residents to potential embarrassment and lack of privacy.
A8030 Dignity/Privacy. The facility did not meet the requirement to treat residents with consideration and respect, including privacy in treatment and care, as evidenced by residents being exposed and privacy curtains not being used properly.
Report Facts
Facility census: 58
Residents interviewed: 4
Completion dates: Plan of correction completion dates range from 10/18/23 to 11/8/23
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
Plan of Correction
Census: 56
Deficiencies: 2
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to investigate and document deficiencies related to resident safety, specifically regarding accident hazards and supervision involving bed rails at Kirksville Manor Care Center.
Findings
The facility failed to ensure the safety of a resident who sustained injury from rolling in bed rails. Multiple assessments and interviews revealed inadequate monitoring and interventions related to bed rail use, resulting in bruises and increased risk of injury. The facility also failed to document re-evaluation of bed rail safety after incidents.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to ensure the safety of a resident who sustained injury from rolling in bed rails, including bruising to shoulder and eye. The resident was at risk due to inadequate assessment and monitoring of bed rail use and related safety hazards.
A4075 19 CSR 30-85.042(66) Nursing Care per Res Condition Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the findings in F689.
Report Facts
Facility census: 56
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Jan 13, 2021
Visit Reason
The inspection was a COVID-19 focused emergency preparedness survey conducted on January 13, 2021, triggered by concerns related to resident care and infection control during the pandemic.
Complaint Details
The visit was complaint-related, focusing on failure to notify physicians of changes in resident condition and infection control deficiencies during the COVID-19 pandemic. The complaint was substantiated based on findings.
Findings
The facility failed to notify the physician and resident representative of significant changes in a resident's condition, failed to follow professional standards for diabetic care including blood glucose monitoring and notification, and failed to maintain a safe infection control program during the COVID-19 pandemic. Several residents tested positive for COVID-19 and the facility did not isolate or cohort them properly.
Deficiencies (3)
F580 Notification of Changes: The facility failed to notify the physician and resident representative for one resident with a significant change in condition requiring a change in treatment.
F658 Services Provided Meet Professional Standards: The facility failed to follow standards of practice for diabetic care for one resident, including rechecking blood glucose levels, holding diabetic medications, and notifying the physician of low blood glucose levels.
F880 Infection Prevention & Control: The facility failed to maintain a safe infection control program during the COVID-19 pandemic, including failure to isolate COVID-19 positive residents and failure to implement proper testing and cohorting procedures.
Report Facts
Certified Census: 56
Sampled Residents: 15
COVID-19 Positive Residents: 6
COVID-19 Positive Residents: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Report Facts
Regulatory compliance references: 42
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 9, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted on June 9, 2020 to assess compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
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
Plan of Correction
Capacity: 68
Deficiencies: 12
Date: Mar 3, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a regulatory inspection survey conducted on 03/03/2020 at Kirksville Manor Care Center.
Findings
The Plan of Correction addresses multiple deficiencies related to resident care, medication administration, bed safety, and regulatory compliance identified during the survey. The facility outlines corrective actions and timelines to ensure compliance and resident safety.
Deficiencies (12)
F 558: The facility failed to provide effective call light accommodations for residents with Parkinson's disease, resulting in residents being unable to activate or use call lights properly.
F 623: The facility failed to provide proper notice and documentation for resident transfers and discharges, including timely notification to residents, representatives, and the Ombudsman.
F 655: The facility failed to develop and implement comprehensive baseline care plans for residents that meet professional standards of quality care.
F 684: The facility failed to ensure proper use, installation, and maintenance of bed rails, resulting in loose and unsafe bed rails for multiple residents.
F 700: The facility failed to assess and mitigate risks related to bed rail use, including lack of proper policies, assessments, and staff training.
F 727: The facility failed to ensure a full-time Director of Nursing was employed as required by regulations.
F 758: The facility failed to ensure psychotropic medications were administered according to physician orders and regulatory requirements.
F 761: The facility failed to properly store and label medications, including expired and opened medications.
F 803: The facility failed to meet nutritional needs of residents by not providing menus in accordance with established national guidelines.
F 812: The facility failed to maintain food safety standards, including proper storage and disposal of food items.
F 881: The facility failed to implement an effective antibiotic stewardship program and infection control measures.
F 909: The facility failed to conduct regular inspections and maintenance of bed frames, mattresses, and bed rails to prevent entrapment risks.
Report Facts
Facility certified census: 68
Plan of Correction completion dates: 2020
Inspection Report
Life Safety
Census: 75
Capacity: 132
Deficiencies: 5
Date: Mar 3, 2020
Visit Reason
The inspection was a life safety code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain fire safety barriers and sprinkler system maintenance, had unsealed openings in ceilings, lacked self-closing doors in hazardous areas, and did not conduct fire drills at required times. These deficiencies had the potential to affect multiple residents and staff.
Deficiencies (5)
K161: The facility failed to maintain the barrier between the first floor and attic with a fire resistance rating of at least one hour due to unsealed openings in ceilings. This deficient practice had the potential to affect 40 residents and others in five of ten smoke compartments.
K321: Hazardous areas were not protected by self-closing or automatic-closing doors as required, affecting eight residents in one of ten smoke compartments.
K353: The sprinkler system was not properly maintained, with sprinklers covered in dust and debris, potentially affecting all 75 residents in nine smoke compartments.
K712: The facility failed to ensure fire drills were conducted at varied and unexpected times on all shifts, potentially affecting all occupants in ten smoke compartments.
K920: Electrical wiring was not installed and maintained to prevent fire hazards, including use of power strips and extension cords in patient care areas, potentially affecting 32 residents in four smoke compartments.
Report Facts
Facility capacity: 132
Census: 75
Certified census: 68
Number of smoke compartments affected: 10
Number of fire drills reviewed: 12
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: Sep 5, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the management and use of residents' personal funds at Kirksville Manor Care Center.
Complaint Details
Complaint #MO00159614 was investigated. The complaint was substantiated as the facility failed to provide personal spending allowances and proper authorization for fund withdrawals.
Findings
The facility failed to provide the Social Security personal spending allowance monthly to three residents and failed to use residents' personal funds exclusively for the resident with proper written authorization for five residents. Withdrawals were made without proper authorization, and social security allowances were used for past due room and board.
Deficiencies (2)
F 567: The facility failed to provide the Social Security personal spending allowance monthly to three residents and failed to use residents' personal funds exclusively for the resident with written authorization for five residents.
A9002: The operator did not use residents' personal funds exclusively for the resident and only when authorized in writing, violating 19 CSR 30-88.020(2).
Report Facts
Resident census: 77
Residents affected: 5
Residents sample size: 13
Residents sample size: 8
Inspection Report
Plan of Correction
Census: 64
Capacity: 73
Deficiencies: 4
Date: Jul 8, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to nutrition, hydration, and therapeutic diet compliance at Kirksville Manor Care Center.
Findings
The facility failed to ensure appropriate nutrition and hydration for a resident at risk for choking and aspiration, including failure to provide correct therapeutic diets and obtain physician orders. The facility census was 64 certified and nine licensed for a total of 73 residents.
Deficiencies (4)
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure a resident dependent on staff for eating received appropriate foods and fluids, resulting in choking and aspiration risk and subsequent hospitalization and death.
F808 Therapeutic Diet Prescribed by Physician: The facility failed to obtain a physician's order for an altered mechanical soft diet as recommended by the speech language pathologist for one resident.
A4053 Written Orders; Restraints: No medication, treatment, or diet was given without a written order from a person lawfully authorized to prescribe such, except as noted.
A5001 Nutritional Needs Met, Assess Res, Inform Dr: The facility failed to regularly assess and meet the nutritional needs of residents in accordance with physician orders and professional standards.
Report Facts
Facility census certified: 64
Facility census licensed: 9
Total facility capacity: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook H | Named in relation to diet order and counseling | |
| LPN D | Licensed Practical Nurse | Involved in resident assessment and diet order communication |
| CNA A | Certified Nurse Aide | Involved in feeding resident and reporting diet issues |
| CNA C | Certified Nurse Aide | Involved in feeding resident and reporting diet issues |
| Assistant Director of Nurses | ADON | Involved in resident assessment and diet order communication |
| Director of Nurses | DON | Oversight of diet orders and quality monitoring |
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 |
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 7
Date: Jan 31, 2019
Visit Reason
The document is a Plan of Correction submitted by Kirksville Manor Care Center following a survey conducted on 01/31/2019. It addresses deficiencies cited in the facility's inspection report.
Findings
The facility failed to complete significant change assessments for residents after changes in condition, maintain urinary catheter bags and tubing off the floor, monitor psychotropic medication use and gradual dose reductions, and ensure food safety standards including cleaning of range hood and ice machine. Multiple deficiencies were cited related to resident care and facility policies.
Deficiencies (7)
F637: The facility failed to complete a significant change assessment on residents #1, #17, and #28 within 14 days after a significant change in their physical or mental condition.
F690: The facility failed to maintain urinary catheter bags and tubing off the floor for residents with indwelling catheters, risking infection.
F758: The facility failed to maintain a system to monitor residents using psychotropic medications to ensure gradual dose reductions and appropriate use.
F812: The facility failed to ensure the range hood was free of grease and debris and the ice machine was clean and properly drained, risking food contamination.
A4029: The facility failed to implement policies to screen employees for communicable diseases and ensure tuberculosis testing compliance for new hires.
A4074: The facility failed to provide nursing care consistent with residents' conditions, including failure to meet requirements for incontinence care and infection control.
A7042, A7054, A7057: The facility failed to maintain equipment cleaning and sanitizing standards for food service, including ventilation hoods and filters.
Report Facts
Facility census: 76
Residents sampled: 18
Residents with indwelling urinary catheters: 6
Newly hired employees reviewed for TB testing: 10
Residents receiving antipsychotic medications: 2
Inspection Report
Life Safety
Census: 86
Capacity: 132
Deficiencies: 5
Date: Jan 31, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, including emergency lighting, fire alarm systems, sprinkler systems, and corridor door safety.
Findings
The facility failed to meet several Life Safety Code requirements including emergency lighting duration, fire alarm notification, sprinkler system maintenance, and corridor door functionality. Deficiencies had the potential to affect multiple residents across various smoke compartments.
Deficiencies (5)
K291 Emergency lighting was not provided for a minimum of 1.5 hours during power interruption as required. Observations showed emergency lights in the kitchen, dish room, and exit stairwell were not functioning.
K343 Fire alarm system failed to provide audible and visual notification of phone line trouble to the main fire alarm panel. Phone lines were disconnected without triggering alarms.
K353 Sprinkler system was not properly maintained; sprinklers were covered with debris and a plastic bag, affecting 57 residents. Observations showed dried drywall compound and fuzzy debris on multiple sprinkler heads.
K363 Corridor doors failed to close properly due to obstructions such as beds, fall mats, walkers, and wheelchairs. This deficiency affected 76 residents in five smoke compartments.
K363 Doors protecting corridor openings were not free of impediments and did not close as required by NFPA 101. Several doors were blocked or held open improperly.
Report Facts
Facility capacity: 132
Resident census: 86
Residents potentially affected by sprinkler debris: 57
Residents potentially affected by corridor door deficiencies: 76
Residents potentially affected by smoke detector debris: 6
Residents potentially affected by corridor door obstructions: 76
Residents potentially affected by corridor door clearance issues: 76
Inspection Report
Plan of Correction
Census: 106
Deficiencies: 3
Date: Sep 20, 2018
Visit Reason
The inspection was conducted to evaluate compliance with notification of changes requirements following a review of resident care and documentation at Kirksville Manor Care Center.
Findings
The facility failed to notify the resident's physician and family of a significant change in condition for one resident, as required by federal and state regulations. Documentation showed the resident had persistent redness and rash on toes and feet, but staff did not notify the physician or family.
Deficiencies (3)
F580 Notification of Changes: The facility failed to promptly notify the resident's physician and family of a significant change in condition for Resident #1, despite documented skin issues and physician orders.
A4086 Dr Notification-Change in Condition: Facility staff did not notify the resident's physician in accordance with emergency treatment policies after a significant change in condition.
A4087 Notify Responsible Party-Change in Condition: Facility staff failed to immediately notify the resident's designated responsible party of a significant change in condition.
Report Facts
Facility census: 106
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doris Johnson | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 2
Date: Apr 13, 2018
Visit Reason
Annual inspection survey conducted at Kirksville Manor Care Center to assess compliance with federal regulations related to resident care, infection control, and nursing practices.
Findings
The facility failed to provide proper incontinence care with urinary catheters, resulting in catheter bags and tubing touching the floor for multiple residents. Additionally, the facility did not ensure staff washed hands properly and disinfected equipment, increasing infection risks.
Deficiencies (2)
F690: The facility failed to provide incontinence care consistent with standards, as catheter bags and tubing were observed touching the floor for multiple residents. Staff did not consistently follow proper catheter care procedures to prevent urinary tract infections.
F880: The facility failed to maintain an infection prevention and control program, including inadequate hand hygiene and improper disinfection of glucometers and reusable medical equipment. Staff failed to wash hands after resident contact and before handling supplies.
Report Facts
Facility census: 80
Residents with urinary catheters: 14
Sampled residents: 18
Inspection Report
Life Safety
Census: 80
Capacity: 132
Deficiencies: 3
Date: Apr 13, 2018
Visit Reason
The inspection was conducted as a Life Safety Code survey to evaluate compliance with fire safety regulations and the National Fire Protection Association standards.
Findings
The facility failed to maintain smoke barrier doors according to NFPA 101 and NFPA 105 standards, with gaps observed in multiple resident room doors and the service entrance. Additionally, the facility failed to maintain the laundry room area behind the dryer free of lint and debris, creating a fire hazard.
Deficiencies (3)
K374: The facility failed to maintain smoke barrier doors in accordance with NFPA 101 and NFPA 105. Gaps were observed in doors by resident rooms 1, 2, 14, 39, and the service entrance, allowing light to be visible through the gaps.
K932: The facility failed to maintain the area behind the dryer in the laundry room free of lint and debris on the pulley motors, creating a fire hazard. Maintenance staff cleans this area at least every six months.
A2054: Each smoke section shall be separated by one-hour fire-rated walls and doors that are self-closing or held open only by automatic door closers. This regulation was not met as evidenced by K374.
Report Facts
Facility capacity: 132
Census: 80
Report
Oct 4, 2024
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