Inspection Reports for
Livingston Manor Care Center
939 E BIRCH DR, CHILLICOTHE, MO, 64601-2189
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
31 residents
Based on a August 2025 inspection.
Occupancy over time
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 11
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, safety, and facility management.
Findings
The facility was found deficient in multiple areas including improper management of resident personal funds, inadequate surety bond coverage, failure to complete employee background checks, incomplete discharge summaries, improper respiratory care, insufficient RN staffing coverage, failure to maintain medication refrigerator temperatures, inaccurate menu posting and meal preparation, unsanitary kitchen conditions, and lack of a documented water management program.
Deficiencies (11)
Failed to properly hold, secure, and manage each resident's personal money deposited with the nursing home, including failure to reimburse discharged residents timely.
Failed to maintain a surety bond amount sufficient to cover residents' funds held in the Resident Trust Fund account.
Failed to complete employee background checks, including Certified Nurse Aide Registry checks, prior to staff working with residents.
Failed to complete discharge summaries for two sampled residents.
Failed to provide safe and appropriate respiratory care, including undated oxygen and nebulizer tubing and lack of CPAP orders for a resident.
Failed to ensure a registered nurse was on duty for eight consecutive hours per day, seven days per week.
Failed to ensure medication room refrigerator temperature was checked daily and maintained properly.
Failed to ensure menus were posted in advance, followed, and residents were provided choices consistent with their preferences.
Failed to ensure pureed food was prepared with a smooth, pudding-like consistency without chunks.
Failed to maintain kitchen and food storage areas in a sanitary manner, including food stored uncovered or undated and dirty kitchen surfaces.
Failed to establish and maintain a documented water management program to minimize risk of Legionella outbreaks.
Report Facts
Facility census: 31
Resident trust fund average monthly balance: 36673.99
Required surety bond amount: 56775
Surety bond amount: 60000
Deficiency counts: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in respiratory care deficiency related to oxygen and CPAP management |
| Business Office Manager | Interviewed regarding resident personal funds management | |
| Administrator | Interviewed regarding multiple deficiencies including resident funds, surety bond, respiratory care, and staffing | |
| Dietary Manager | Interviewed regarding menu planning and kitchen sanitation deficiencies | |
| Social Services Director | Interviewed regarding discharge summary deficiencies | |
| Director of Nursing | Interviewed regarding discharge summaries, respiratory care, and staffing | |
| Maintenance Supervisor | Interviewed regarding water management program deficiency |
Inspection Report
Routine
Census: 31
Deficiencies: 2
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with nutritional menu planning and food service sanitation standards at Livingston Manor Care Center.
Findings
The facility failed to ensure menus were posted in advance and followed, affecting three sampled residents. Additionally, the kitchen and food storage areas were found to be unsanitary with multiple sanitation violations observed.
Deficiencies (2)
Menus were not posted in advance and were not followed, affecting residents' nutritional needs and choices.
Food was not stored in a sanitary manner and the kitchen was not maintained in a sanitary condition.
Report Facts
Residents affected: 3
Facility census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding menu choices and kitchen sanitation | |
| Activities Director | Interviewed regarding resident meal choices on memory care unit | |
| Registered Dietitian | Interviewed regarding food storage and kitchen sanitation | |
| Administrator | Interviewed regarding expectations for dietary department and kitchen sanitation |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Jun 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #2 physically abused Resident #1 by hitting him/her in the head.
Complaint Details
The complaint investigation found that Resident #2 hit Resident #1 in the head on 5/23/25. The facility staff did not place Resident #2 on increased supervision until the resident was moved to the secured memory care unit on 5/29/25. Neither resident recalled the incident or was targeting the other. The physician adjusted Resident #2's medication and started antibiotics after a positive urine analysis for infection.
Findings
The facility failed to protect Resident #1 from physical abuse by Resident #2. Staff did not place Resident #2 on increased monitoring until six days after the incident, despite the facility's abuse policy requiring protective measures. Resident #2 was moved to a secured memory care unit only after approval from the responsible party.
Deficiencies (1)
Failure to protect Resident #1 from physical abuse by Resident #2, including delayed increased monitoring of Resident #2 after the incident.
Report Facts
Residents affected: 2
Facility census: 37
Date of incident: May 23, 2025
Date Resident #2 moved to secured unit: May 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reviewed camera footage and described incident; instructed staff to monitor Resident #2 closely | |
| Charge Nurse | Assessed residents after incident and notified physician, administrator, and responsible parties | |
| Physician | Reviewed and adjusted Resident #2's medication and ordered urine analysis | |
| Dietary Staff | Notified nursing staff of the incident and intervened during the abuse |
Inspection Report
Routine
Census: 33
Deficiencies: 4
Date: Apr 5, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, specifically regarding hand hygiene and use of personal protective equipment during wound care.
Findings
The facility failed to maintain standard infection control precautions, including inadequate hand hygiene during glove changes and failure to wear protective gowns during wound care for residents on Enhanced Barrier Precautions (EBP). The facility lacked PPE carts and signage near resident rooms and did not obtain physician orders for EBP. These deficiencies affected two sampled residents.
Deficiencies (4)
Failure to perform hand hygiene with glove changes during wound care for two residents.
Failure to wear personal protective gowns when assisting with wound care for a resident on Enhanced Barrier Precautions.
Lack of PPE carts and signage near or outside resident rooms indicating EBP precautions.
Failure to obtain physician orders to implement Enhanced Barrier Precautions for residents with wounds.
Report Facts
Facility census: 33
Number of residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings related to failure to perform hand hygiene and improper glove use during wound care |
| CNA A | Certified Nurse Aide | Named in findings related to failure to perform hand hygiene and improper use of protective gowns |
| Director of Nursing | Director of Nursing | Provided interview detailing expected infection control practices and deficiencies |
Inspection Report
Routine
Census: 29
Deficiencies: 24
Date: May 30, 2024
Visit Reason
Routine state inspection of Livingston Manor Care Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide dignified care, inadequate resident council grievance handling, improper management of resident funds, incomplete resident rights education, inaccurate resident assessments and care plans, medication administration errors, environmental maintenance issues, and infection control lapses.
Deficiencies (24)
Staff failed to treat residents with dignity and respect during meal assistance and blood sugar monitoring in the dining room.
Facility failed to act promptly and resolve resident grievances and did not maintain documentation of concerns or follow-up.
Residents lacked access to personal funds after business hours and facility failed to maintain proper accounting of resident funds.
Facility failed to inform residents of their rights periodically during their stay.
Facility failed to clarify and document advance directive status for a resident, with conflicting code status orders.
Facility used incorrect Medicare Advance Beneficiary Notice forms for some residents.
Facility environment was not maintained in a clean, comfortable, and homelike manner with issues including temperature control, broken tiles, dust, odors, and missing blinds.
Facility failed to ensure residents had access to grievance forms, the ability to file anonymous grievances, and knowledge of grievance officers.
Facility failed to complete required background checks, disqualification list checks, and nurse aide registry checks prior to employment for multiple staff.
Facility failed to complete accurate comprehensive assessments and care plans reflecting resident preferences and needs for multiple residents.
Facility failed to employ a qualified activity professional and failed to provide meaningful activities to residents, especially those with dementia.
Facility failed to provide appropriate pressure ulcer care including offloading heels, completing skin assessments, and dressing checks.
Staff failed to lock wheelchairs during mechanical lifts for resident transfers.
Staff failed to provide proper catheter care including cleaning catheter tubing and drainage spout and placing graduate on a barrier.
Staff failed to provide proper respiratory care including ensuring oxygen tubing was dated and changed weekly, humidifier bottle contained sterile water, and tubing was not on the floor.
Facility failed to assess residents for bed rail entrapment risks, obtain physician orders, and measure entrapment zones for installed bed rails.
Staff failed to provide adequate personal hygiene care including perineal care, oral care, face and hand washing, and shaving per resident preferences.
Staff failed to provide safe and effective medication administration including crushing enteric coated tablets, improper nasal spray administration, and failure to prime insulin pens.
Facility failed to ensure medications were properly labeled, stored, and not left at bedside; medication carts were unclean.
Facility failed to complete discharge summary for a discharged resident.
Facility failed to employ a registered nurse for eight consecutive hours per day, seven days per week.
Facility failed to ensure food safety including hand hygiene, food temperature monitoring, dishwasher testing, food labeling and storage, and sanitation practices.
Facility failed to maintain an effective infection prevention and control program including incomplete tuberculosis screening and lack of hand sanitizer on memory care unit.
Call light systems were not accessible or functional for multiple residents with call lights out of reach, draped over bed fixtures, or missing cords.
Report Facts
Medication errors: 8
Resident census: 29
Medication administration omissions: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in medication administration errors including insulin pen priming and nasal spray administration |
| CNA H | Certified Nurse Aide | Named in catheter care and perineal care deficiencies |
| CNA I | Certified Nurse Aide | Named in catheter care and call light accessibility |
| Dietary Manager | Dietary Manager | Named in hand hygiene and food safety deficiencies; lacked certification |
| Administrator | Administrator | Named in multiple interviews regarding facility expectations and deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding facility expectations and deficiencies |
| Activity Director | Activity Director | Named in activity program deficiencies and lack of certification |
| Maintenance Supervisor | Maintenance Supervisor | Named in environmental and call light maintenance deficiencies |
| Business Office Manager | Business Office Manager | Named in employee background check and resident funds deficiencies |
Inspection Report
Abbreviated Survey
Census: 29
Deficiencies: 3
Date: Feb 26, 2024
Visit Reason
The visit was conducted due to allegations and observations of resident to resident sexual abuse and failure to timely report and investigate these incidents.
Findings
The facility failed to protect residents from sexual abuse by another resident, failed to timely report the abuse to the state authorities, and failed to thoroughly investigate and document the incidents. Immediate jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (3)
Failed to protect residents from resident to resident sexual abuse.
Failed to timely report allegations of resident to resident sexual abuse to the Department of Health and Senior Services.
Failed to follow facility policy and thoroughly investigate allegations of resident to resident sexual abuse.
Report Facts
Facility census: 29
Delay in management: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to report and investigate sexual abuse incidents |
| LPN B | Licensed Practical Nurse | Witnessed sexual abuse incident but failed to report to Administrator |
| Certified Medication Technician A | Certified Medication Technician | Observed and reported sexual abuse incident between residents |
| Administrator | Facility Administrator | Unaware of incidents until reported; expected timely reporting and investigation |
| DON | Director of Nursing | Expected to be notified of abuse incidents and to ensure investigations |
| Transportation aide | Facility Transportation Aide | Observed sexual abuse incident and later reported it to Administrator |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 25, 2023
Visit Reason
Annual survey inspection of Livingston Manor Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 4
Date: Oct 5, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to resident trust fund security, treatment and care according to orders, food preparation consistency, and kitchen sanitation.
Findings
The facility failed to maintain an adequate surety bond for resident funds, failed to properly assess and notify physicians regarding a resident's change in condition leading to death, served pureed food with inappropriate consistency, and failed to maintain kitchen sanitation and proper sanitizer levels in the dishwasher.
Deficiencies (4)
Failed to maintain a surety bond in an amount to cover any loss or theft of residents' money held in the Resident Trust Fund account.
Failed to assess and notify physician of a resident's change in condition and seizure-like activity, and improperly managed a dislodged urinary catheter leading to resident death.
Failed to ensure pureed food was prepared with a smooth, pudding-like consistency without lumps or chunks for residents with pureed diet orders.
Failed to ensure kitchen sanitation including proper dishwasher sanitizer levels, storage of toxic materials away from food, and maintenance of kitchen facilities.
Report Facts
Facility census: 39
Surety bond amount: 40000
Required surety bond amount: 45000
Dishwasher sanitizer ppm: 0
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings related to failure to assess and notify physician about resident's seizure and catheter issues |
| CNA G | Certified Nurse's Aide | Witnessed resident seizure and assisted in care |
| Administrator | Involved in resident care decisions and interviews regarding deficiencies | |
| TS A | Transportation Staff | Assisted in transporting resident to hospital |
| CNA C | Certified Nurse's Aide | Assisted in transporting resident and reported condition |
| Dietary Manager | Responsible for food preparation and interviewed regarding pureed food consistency | |
| Dietary Aide A | Responsible for dishwashing and sanitizer testing | |
| Maintenance Director | Responsible for kitchen repairs | |
| Hospital Nurse A | Provided hospital triage and care information | |
| PCP A | Primary Care Physician | Provided expectations for resident care and communication |
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