Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Pines Adult Care Center during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity and respect during personal care, environmental management, and staff-resident interactions. A resident with dementia, anxiety, chronic pain, and total dependence for mobility and hygiene was roughly repositioned in bed, causing pain when an incontinence brief pinched the groin; the CNA continued care despite the resident yelling in pain and later dismissed the resident’s complaints. The same resident and spouse reported the CNA being rough during a shower transfer and described a DON-level manager publicly ordering a CNA back to work in the dining room in front of residents and families. Another cognitively intact resident with a hearing deficit reported that night staff played music loudly, refused to lower the volume, and said it could not be turned down because other residents liked it. Staff, including a CMT, were also reported squirting each other with water in the dining room; when a resident became upset and asked them to stop, the CMT handed the resident a squirter and encouraged participation, which the resident declined.
The facility failed to ensure meals were served at an appetizing temperature, as required by its policy specifying hot foods on room trays should be at or above 120°F and that complaints be logged and investigated. Multiple residents who required setup assistance, including cognitively intact and moderately impaired individuals eating in both rooms and the dining room, reported that their food, including soup and breakfast eggs, was frequently cold. CNAs and an LPN acknowledged ongoing resident complaints and described a tray delivery process in which plated, covered trays sat in carts while nursing staff completed report and morning care, leading to food reaching residents at room temperature. A test tray showed entrée and vegetable temperatures below the facility’s preferred minimum, while the Dietary Manager and Administrator stated expectations that food temperatures be checked and maintained but were unaware of or not acting on resident complaints.
A cognitively intact resident with dementia and rheumatoid arthritis experienced multiple changes to colchicine and methotrexate orders, including holding, resuming, dose adjustments, and conversion from PRN to scheduled dosing, without documented notification to the resident or listed emergency contacts as required by facility policy. Additionally, the resident was transferred by ambulance to a hospital for abnormal vital signs with no documentation that family was informed. Family members reported they were not notified of these medication changes or the hospital transfer and only learned of the hospitalization through a third party. An LPN acknowledged nurses were supposed to notify families of significant changes and transfers, while the DON stated staff did not view family notification for medication changes as required when the resident was his/her own responsible party unless specifically requested.
The facility failed to implement a proper grievance procedure, lacking a designated grievance official, resident awareness of grievance rights, and documentation of investigations. Interviews revealed that residents were unaware of how to file grievances, and the facility did not maintain a grievance log. The newly hired QA staff member had not received any grievances for investigation, and concerns raised during care conferences were not documented.
The facility failed to label and date opened food items in the kitchen, violating their food storage policy. Observations revealed unlabeled containers of sweet and sour sauce, salad dressing, and strawberry halves in the cooler, as well as open cereal boxes in dry storage. Interviews with dietary staff confirmed the oversight, highlighting a lapse in adherence to food safety protocols.
The facility failed to provide required QAPI training to five staff members, including CNAs, an ES staff member, and a Nursing Supervisor, as revealed by personnel file reviews and confirmed by the DON. This deficiency could impact the staff's ability to address concerns through the QAPI program, potentially affecting the care of 72 residents.
The facility failed to conduct timely background checks for three CNAs before their hire, as required by policy. This oversight allowed the CNAs to work multiple shifts before their background checks were completed, potentially compromising resident safety. Interviews confirmed the checks were not completed prior to employment.
The facility failed to provide written transfer notifications to three residents and their representatives, as well as the Ombudsman, during hospitalizations. Despite the facility's policy requiring timely notification and information about transfers, no written notices were documented in the residents' EMRs. Interviews with the DON and Administrator confirmed the lack of communication and documentation, indicating a systemic issue in handling hospital transfers.
The facility failed to provide written bed hold notices to three residents within 24 hours of their emergency hospital transfers, as required by policy. Despite the facility's policy mandating such notices, none were documented for the residents involved. Interviews with the DON and Administrator confirmed the oversight, highlighting a systemic issue in policy adherence.
The facility failed to transmit MDS assessments for three residents within the required 14-day period, as confirmed by the DON. This lapse in timely submission, which is crucial for compliance and reimbursement, was due to a lack of oversight and adherence to facility policy.
The facility failed to ensure that three CNAs completed the required 12 hours of in-service training per year, as mandated by facility policy. Personnel files for these CNAs showed no evidence of the necessary training, which could negatively impact the care of 72 residents. The deficiency was confirmed by the DON.
The facility failed to ensure that two residents who self-administered medications had the necessary assessments, physician's orders, and care plans. One resident with allergic rhinitis was observed with a nasal spray at her bedside without proper documentation, while another resident with COPD self-administered an inhaler without supervision or a physician's order. The facility's policy requires assessments and care plans for self-administration, which were not completed for these residents.
A facility failed to provide timely follow-up information to a physician about a resident's skin condition, delaying treatment. The resident had memory issues and was dependent on staff, with blood blisters documented but not communicated effectively to the physician. Additionally, another resident, who was severely cognitively impaired, was given crushed Tylenol without a physician's order, causing discomfort. The facility did not assess the need for crushing medications, leading to inadequate care.
A resident was unable to call for help after falling in the bathroom due to the removal of the call light, which was not replaced or repaired in a timely manner. The resident, who was cognitively intact and independent in personal hygiene, reported the incident. Staff interviews confirmed the absence of the call light, and the Maintenance Director was aware but had not provided an alternative communication method.
Failure to Maintain Resident Dignity During Care, Noise, and Staff Interactions
Penalty
Summary
Facility staff failed to treat multiple residents with dignity and respect as required by the facility’s Dignity and Respect policy. One resident with dementia, anxiety disorder, chronic pain, moderate cognitive impairment, and total dependence on staff for mobility, transfers, toileting, and hygiene was observed being transferred from a wheelchair to bed with a mechanical lift and then repositioned roughly. After the transfer, CNAs used a reusable incontinence pad to pull the resident down in bed, causing the incontinence brief to remain in place and pinch the resident’s groin. When the resident yelled out, “Stop, you’re hurting me!”, one CNA told the resident to “hold on” and “you’re fine” and continued care without stopping to relieve the discomfort or acknowledge the pain. The same CNA later stated that the resident “always complained.” The same resident and the resident’s spouse reported additional incidents involving staff behavior that did not maintain dignity. The spouse stated that the CNA involved in the transfer was rough and always in a hurry, and described a prior episode during a transfer to a shower chair where the resident yelled out in pain while the CNA continued positioning, telling the resident to “hold on a minute.” The spouse also reported that the resident became upset and anxious when the Director of QAPI confronted a CNA in the dining room, placing hands on hips and repeatedly telling the CNA to get back to work while the CNA was on a lunch break eating with residents. This interaction occurred in front of residents, family members, and visitors and was described as unprofessional and upsetting to the resident. Another resident, cognitively intact with a documented hearing deficit and a care plan requiring staff to allow adequate time to respond and reduce environmental noise, reported that staff did not treat them with respect at night. The resident stated that night shift staff played music loudly enough to keep them awake and refused to turn it down, telling the resident it could not be lowered because other residents enjoyed it. Additionally, staff, including a CMT, were reported to have squirted each other with water in the dining room on a busy, stressful day. The resident with anxiety became upset and told staff to stop, but a CMT approached, handed the resident a squirter, and encouraged the resident to “shoot someone with it,” which the resident did not want to do and did not participate in. The DON later stated she was unaware of the loud music at night and the water-squirting incidents, but her stated expectation was that staff treat residents with dignity and respect and not be rough or rushed when providing care.
Failure to Maintain Palatable Meal Temperatures for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at an appetizing temperature to multiple residents, contrary to its own policy requiring hot foods on room trays to be at or above 120°F and complaints to be logged and investigated. The facility’s policy also called for periodic temperature checks at the point of service and completion of complaint investigations within 72 hours. A test tray taken after all residents were served showed the fried chicken thigh at 116°F and green beans at 112°F, below the facility’s preferred minimum temperature for palatability. Several residents reported that their food was frequently served cold. One cognitively intact resident who required setup assistance had a care plan directing that trays be served first and microwaved for 30 seconds to one minute before delivery, yet the resident stated the facility had a problem with cold food and that staff sometimes removed the tray cover and left while the resident was in the bathroom, resulting in cold food by the time the resident returned. Another cognitively intact resident who preferred to eat in the room and required tray setup assistance reported that soup ordered several times a week was always cold. A resident with moderate cognitive impairment and requiring setup assistance reported that food was frequently cold and that eggs served that morning were too cold to eat. Another resident with moderate cognitive impairment, who ate in the dining room and required setup assistance, stated that sometimes the food was cold. Staff interviews described operational practices that contributed to food cooling before service. A CNA reported that residents complained about cold food and that this CNA microwaved one resident’s food before delivery due to frequent complaints. CNAs explained that the kitchen now plates and covers food and places trays in a cart for staff to deliver, and if nursing staff are busy, trays sit until someone is available to pass them. One CNA stated that nursing staff clock in, receive report, and complete morning care while breakfast trays are already plated in the cart, and that by the time staff are available to pass trays, the food is at room temperature. An LPN confirmed that residents complained about cold food. The Dietary Manager stated his expectation that temperatures be checked before food leaves the kitchen and again before trays are served, and that food be maintained at or above 120°F by the time residents receive it, but he was not aware of any resident complaints. The Administrator stated his expectation that food reach and be maintained at the required temperature and that any deviation be investigated.
Failure to Notify Resident and Family of Medication Changes and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow its own notification of changes policies by not informing a cognitively intact resident and/or the resident’s representatives of multiple medication changes and a hospital transfer. The facility’s policies required that changes in a resident’s condition or treatment be immediately shared with the resident and/or resident representative, that non-immediate changes be communicated on the shift they occurred, and that residents/representatives be educated about risks and benefits to allow informed choice. The resident’s face sheet showed the resident was his/her own responsible party, with two emergency contacts listed, and the admission MDS documented the resident as cognitively intact. Record review showed several physician order changes for colchicine and methotrexate that were not accompanied by documented notification to the resident or emergency contacts. Colchicine 0.6 mg twice daily was ordered on 10/15/25, held on 10/17/25, resumed on 10/20/25, changed to once daily on 10/24/25, and then discontinued on 10/25/25. Nurse notes contained no documentation that the resident or emergency contacts were notified when colchicine was restarted or when the directions changed. Methotrexate 2.5 mg was initially ordered as needed for rheumatoid arthritis flare-ups and later changed on 12/5/25 to a scheduled daily dose, again with no documentation in nurse notes that the resident or emergency contacts were notified of this change. The facility also failed to document notification of the resident’s emergency contacts when the resident was transferred to the hospital for abnormal vital signs on 1/14/26. The transfer form showed the resident was sent to the hospital by ambulance, but nurse notes contained no record of family notification. During interviews, both listed emergency contacts reported they were not informed of the medication changes or the hospital transfer, and one stated the family only learned of the hospital visit when a friend saw the resident entering the emergency department. An LPN stated nurses were supposed to call families for hospital transfers and significant changes, and the DON stated her expectation was that family would be notified when a resident was sent to the emergency department, but also indicated staff did not consider family notification required for medication changes when the resident was his/her own responsible party unless the family had requested it.
Deficiency in Grievance Procedure and Resident Awareness
Penalty
Summary
The facility failed to establish a comprehensive grievance procedure, which included designating a specific individual to lead investigations, informing residents of their right to file grievances, and documenting the results of grievance investigations. This deficiency was identified during interviews, record reviews, and policy reviews, affecting six residents who participated in a group interview. The facility's grievance policy outlined the need for a grievance official to oversee the process, track grievances, and provide written resolutions. However, the facility did not have grievance forms available in the neighborhoods or next to the grievance box, and there was no grievance log or documentation of investigations available for review. During interviews, the facility's administrator admitted to not having a grievance log or documentation of grievance investigations, stating that concerns were handled immediately during resident council meetings. The newly hired QA staff member, responsible for handling grievances, had not received any prior concerns for investigation. Additionally, the MDSC indicated that concerns expressed during care conferences were communicated to the DON or administrator but were not documented on the facility's grievance form. The resident group interview revealed that none of the residents were aware of the grievance process or the newly hired QA staff member, and a review of resident council meeting minutes showed no discussions about grievances or residents' rights to file them.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to ensure that food stored in the kitchen was properly labeled and dated with an open date, which is a violation of their own food storage policy. During an observation, it was found that several food items in the cooler, including a gallon container of sweet and sour sauce, a gallon container of salad dressing, and a five-pound container of strawberry halves, were opened but not labeled with an open date. Additionally, three boxes of cereal in the dry food storage area were also open and lacked an open date. This oversight in labeling and dating opened food items could potentially lead to the spread of foodborne illnesses among the 72 residents who receive meals from the kitchen. Interviews with the dietary staff revealed a lack of adherence to the facility's food storage procedures. A dietary aide acknowledged that items were supposed to be dated when opened to ensure timely disposal of food that had been stored for too long. The Dietary Manager confirmed that staff should have labeled the food items with an open date and mentioned efforts to ensure compliance with this practice. However, at the time of the survey, the deficiency in labeling and dating opened food items was evident, indicating a lapse in following established food safety protocols.
Lack of QAPI Training for Facility Staff
Penalty
Summary
The facility failed to ensure that five out of five employee files reviewed contained evidence of the required Quality Assurance and Performance Improvement (QAPI) training. This deficiency was identified through a review of personnel files and an interview with the Director of Nursing (DON). The personnel files of three Certified Nursing Assistants (CNAs), one Environmental Services (ES) staff member, and one Nursing Supervisor (NS) were examined. The CNAs had dates of hire ranging from March to August 2023, while the ES staff member and NS had been employed since 1987 and 2002, respectively. None of these files showed evidence of QAPI training. During an interview, the DON confirmed the absence of QAPI training for the facility staff. This lack of training had the potential to negatively impact the staff's ability to bring concerns to the QAPI program, which could, in turn, affect the 72 residents residing at the facility.
Failure to Conduct Timely Background Checks for CNAs
Penalty
Summary
The facility failed to ensure that background checks were conducted prior to hiring three Certified Nursing Assistants (CNAs), which is a violation of their policy aimed at safeguarding residents. The policy mandates that Human Resources (HR) initiate and review background checks before any prospective employee is hired. However, the records show that CNA6 was hired and began working before her background check was initiated and completed, with a delay of over a month. Similarly, CNA7's background check was submitted on her date of hire but was not completed until two weeks later, during which time she worked multiple shifts. CNA1 also started working before her background check was initiated and completed, with a delay of nearly a month. Interviews with the facility's Administrator and Infection Preventionist confirmed that the background checks for these employees were not completed before they started their employment, as required by the facility's policy. This oversight had the potential to result in the hiring of staff with unknown histories of abuse, neglect, exploitation, or theft, thereby compromising the safety and well-being of the residents. The facility's failure to adhere to its own policy on background checks represents a significant deficiency in its hiring practices.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notifications of hospital transfers to three residents and their representatives, as well as to the Ombudsman. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's policy requires that residents and their representatives receive timely notification, adequate preparation, and information about their transfer, including appeal rights. However, the facility did not adhere to this policy for three residents who were hospitalized. Resident 21 was transferred to the hospital on two occasions due to anxiety, confusion, and intensifying tremors. Despite these transfers, there was no evidence of a written transfer notification in the resident's electronic medical record (EMR). Similarly, Resident 41 was transferred to the emergency room after testing positive for COVID-19 and experiencing full-body tremors, but again, no written notification was found in the EMR. Interviews with the Director of Nursing (DON) and the Administrator confirmed that these residents did not receive the required written notices. Resident 2, who has chronic obstructive pulmonary disease, type II diabetes mellitus, and unspecified dementia, was transferred to the hospital after becoming unresponsive and confused during supper. The EMR lacked documentation of a written transfer notice for this resident as well. Additionally, the Ombudsman reported not receiving a monthly hospitalization list from the facility since January 2024, a fact confirmed by the DON and the Administrator. This lack of communication and documentation indicates a systemic issue in the facility's handling of hospital transfers.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to three residents, identified as R21, R41, and R2, within 24 hours of their emergency transfers to the hospital. This deficiency was identified through a review of records, interviews, and policy review. The facility's policy requires that residents and their representatives receive written information about the state's bed hold duration and payment amount before a transfer. However, the facility did not adhere to this policy for the residents in question. Resident R21 was transferred to the hospital on two occasions due to anxiety, confusion, and intensifying tremors. Despite these transfers, there was no evidence in the electronic medical record (EMR) that a written bed hold notification was provided. Similarly, Resident R41 was transferred to the emergency room after testing positive for COVID-19 and experiencing full body tremors, but no written bed hold notice was documented in the EMR. Interviews with the Director of Nursing (DON) and the Administrator confirmed that these residents did not receive the required notices. Resident R2 was transferred to the hospital after becoming unresponsive and exhibiting unusual behavior during supper. The EMR showed no documentation of a written bed hold notice being provided at the time of transfer. Interviews with the DON and the Administrator further confirmed that the facility did not provide written bed hold notices to residents or their representatives, indicating a systemic issue in adhering to the facility's policy and state requirements.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of Minimum Data Set (MDS) assessments for three residents, which is a requirement for maintaining compliance and ensuring payment for necessary resident care. The facility's policy mandates that comprehensive assessments be transmitted electronically within 14 days of the care plan completion date, and all other MDS assessments within 14 days of the MDS completion date. However, the review of records for three residents revealed multiple instances where MDS assessments were completed but not transmitted within the required timeframe. For example, one resident had several assessments completed and submitted well beyond the 14-day requirement, with delays ranging from several weeks to over a month. The Director of Nursing (DON) confirmed during an interview that the assessments were indeed transmitted late and acknowledged that they should have been submitted within the stipulated 14 days. The DON also admitted to being unaware of the last time the missing assessment report was reviewed, indicating a lapse in oversight and adherence to the facility's policy. This deficiency in timely transmission of MDS assessments could potentially lead to non-payment for necessary resident care, as timely submission is crucial for compliance and reimbursement processes.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to ensure that three out of five Certified Nursing Assistants (CNAs) completed the required minimum of 12 hours of in-service training per year. This deficiency was identified through a review of personnel files and confirmed by the Director of Nursing (DON). The facility's policy mandates that all nursing employees receive at least 12 hours of in-service education annually, covering essential topics such as resident rights, abuse and neglect, infection control, and care for individuals with cognitive impairments or dementia. The personnel files of CNA1, CNA6, and CNA7 showed no evidence of the required in-service training for their respective employment periods. CNA1 and CNA6 were hired in August 2023, and CNA7 was hired in March 2023, yet none had documentation of completing the necessary training hours. The lack of in-service training could negatively impact the care provided to the 72 residents at the facility, as staff may not be adequately prepared to meet their needs.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications had the necessary assessments, physician's orders, and care plans in place. This deficiency was identified for two residents, R4 and R44, who were observed self-administering medications without the required documentation and assessments. The facility's policy requires an interdisciplinary team to assess a resident's ability to safely self-administer medications, document this in the medical record, and include it in the care plan. However, these steps were not followed for the residents in question. Resident R4, who was admitted with a diagnosis of allergic rhinitis, was observed with a nasal spray on her bedside table, which she self-administered. Although R4 had a physician's order allowing her to keep the nasal spray at her bedside, there was no documented assessment or care plan for self-administration of medication in her electronic medical record. The LPN confirmed the presence of the nasal spray but was unsure if R4 had been assessed or care planned for self-administration. Similarly, Resident R44, diagnosed with COPD, was observed self-administering an inhaler without supervision. The resident's physician orders did not include permission for self-administration, and there was no assessment or care plan documented for this practice. The Nursing Supervisor and DON confirmed the lack of assessment, physician's order, and care plan for R44's self-administration of medications.
Deficiencies in Physician Communication and Medication Administration
Penalty
Summary
The facility failed to provide timely follow-up information to a physician regarding a resident's skin condition, which delayed treatment. Resident 45 was admitted with memory problems and was dependent on staff for daily activities. On multiple occasions, the resident was observed with blood blisters on the right hand, which were documented by nursing staff. However, there was no evidence that the physician received timely updates on the condition, despite the physician's request for information following the resident's return from a hospital stay. The physician confirmed that she had not received the necessary updates to determine the next course of action. Additionally, the facility failed to assess the need to crush medications for another resident, Resident 5, who was severely cognitively impaired. The resident expressed discomfort with crushed Tylenol being administered in applesauce, as it would get under her dentures. Despite this, there was no physician's order to crush the medication, and staff continued to administer it in this manner. The Certified Medication Technician was unaware of any consideration for alternative administration routes, and the Director of Nursing acknowledged the absence of an order to crush medications. These deficiencies highlight the facility's failure to ensure timely and effective treatment for residents, as well as the lack of proper assessment and documentation regarding medication administration. The lack of communication and documentation regarding Resident 45's skin condition and the inappropriate medication administration for Resident 5 increased the risk of inadequate care.
Deficiency in Resident Call System
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathroom of one of the residents, identified as R4. This deficiency was observed during a survey where it was noted that the call light was removed from R4's bathroom to replace the one in her bedroom. As a result, R4 was unable to call for help after falling in the bathroom over the weekend. The resident, who was cognitively intact with a BIMS score of 14 out of 15 and independent in personal hygiene, reported the incident and stated that her family had already discussed the issue with the facility. Further observations on subsequent days confirmed the absence of a call light in R4's bathroom. Interviews with staff, including an LPN and the Maintenance Director, corroborated the missing call light. The Maintenance Director acknowledged awareness of the issue but was unable to repair it and had contacted an outside company for assistance. However, no alternative communication method was provided to R4 in the interim, leaving her without a means to call for assistance while using the restroom.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kirksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kirksville Manor Care Center | 0.4 mi | ★★★★★ | 23 | 0 |
| La Plata Nursing Home | 11.5 mi | ★★★★★ | 0 | 0 |
| Schuyler County Nursing Home District | 20.4 mi | ★★★★★ | 30 | 0 |
| Knox County Nursing Home District | 22 mi | ★★★★★ | 1 | 0 |
| Macon Health Care Center | 29.7 mi | ★★★★★ | 0 | 0 |
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