Twin Pines Adult Care Center
TWIN PINES ADULT CARE CENTER in KIRKSVILLE, MO — inspection on February 24, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 2/19/26 at 2:25 P.M., CNA D said the following:-He/She knew about the staff squirting each other with water;-It happened on a busy, stressful day when CMT I decided to cheer people up by squirting water.
During an interview on 2/19/26 at 9:00 A.M., CNA D said the following:-He/She knew about the incident in the dining room related to a staff member being yelled at in front of the whole dining room;-The incident occurred about a week and half to two weeks ago;-Nursing administration told CNA F to help the other unit, but CNA F didn't want to because he/she had showers to complete on this unit;-CNA F ate lunch in the dining room with the residents, the facility encouraged staff to eat with the residents to engage them in conversations;-The Director of QAPI told CNA F to get back to work because there was too much left to do;-CNA F told the Director of QAPI that he/she had ten minutes left on lunch break, but the Director of QAPI told CNA F to get back to work anyway;-The interaction upset Resident #8 and the spouse;-Residents and family members were in the dining room when it happened, and they looked surprised. 2.
Review of Resident 7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, complete by facility staff, dated 11/23/25, showed the following:-Cognitively intact;-Understands others;-Made self-understood;-No behaviors.
Review of the resident's Care Plan, dated 9/15/25, showed the following:-The resident had an impaired communication/a potential for communication impairment due to hearing deficit;-Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternate communication tools as needed.
During an interview on 2/13/26 at 2:50 P.M. and 2/19/26 at 8:55 A.M. the resident said the following:-The staff didn't treat the resident with respect;-At night, the staff played music loud enough to keep him/her awake;-The night shift staff told him/her it couldn't be turned down because other residents enjoyed it;-The resident couldn't remember the night staff member's name;-He/She told the nurse on the next shift after it happened. 4.
During an interview on 2/24/26 at 9:36 A.M., the Director of Nursing said the following:-Her expectation was for staff to treat all residents with dignity and respect;-The facility was the residents' home and staff should treat it as such;-Her expectation was nursing administration disciplined staff members away from residents, families, and visitors;-She was unaware the night shift was playing music at night;-She was unaware the staff were squirting each other with water in front of residents;-Her expectation was staff to not be rushed when caring for residents and to not be unnecessarily rough. No one had reported anything about that to her.
During an interview on 2/24/26 at 1:22 P.M., the Administrator said the following:-His expectation was for staff to treat all residents with dignity and respect and not be rough when providing care;-The staff should treat the residents like a loved one. #2744230
265198 02/24/2026
Twin Pines Adult Care Center 1900 S Jamison Kirksville, MO 63501
During an interview on 2/19/26 at 8:49 A.M., Licensed Practical Nurse (LPN) H said the
he/she called the resident's family regarding the resident being transferred to the hospital. It should have been documented in the nurse notes;-The nurses were supposed to call the resident's family when sending a resident to the hospital and when there was a significant change in physical or mental status;-If a family member had a problem with a resident's medication, the nurse was supposed to contact the physician and follow up with the family member.
During an interview on 2/20/26 at 12:48 P.M., the resident's emergency contact #2 said the following:-On 1/14/26, the facility sent the resident to the hospital but did not contact any of the family;-A friend saw the resident going into the hospital's emergency department and called family member #1 to ask what was happening to the resident;-That was how the family found out the resident was in the hospital.
Review of the resident's Nurse Notes showed no documentation of the resident or family being notified when colchicine medication was started or when the instruction was changed. No documentation of the resident or family being notified when the methotrexate was changed from as needed to scheduled daily.
There was no documentation staff notified the resident's family when the resident transferred to the hospital.
During an interview on 2/24/26 at 1:22 P.M., the Director of Nursing said the following:-Her expectation was the nurse notify the resident's family when the resident was sent to the emergency department;-Since the resident was his/her own responsible party, the nursing staff was not required to notify the family when a medication hanged, unless the family requested to be informed. 2725731
265198 02/24/2026
Twin Pines Adult Care Center 1900 S Jamison Kirksville, MO 63501
During interview on 2/13/26 at 11:42 A.M., CNA D said the following:-Nursing staff was supposed to clock in at 6:45 A.M., and received report from the off going staff;-The kitchen staff had the breakfast trays plated and in the cart at 7:00 A.M.,-It took longer than 15 minutes to get everything done with the off going staff and getting the remainder of residents ready for the day;-By the time the nursing staff were available to pass out trays, the food was room temperature.
During interview on 2/13/26 at 11:55 A.M., Licensed Practical Nurse (LPN) E saidresidents complained about the food being cold.
Observation of the test tray, the last tray served after all the resident had been served on 2/13/26 at 12:45 P.M., showed the following: - The fried chicken thigh was 116 degrees Fahrenheit;-The green beans were 112 degrees Fahrenheit.
During interview on 2/18/26 at 8:02 A.M., the Dietary Manager said the following:-His expectation was the kitchen staff checked the temperature of the food before it left the kitchen and again before the trays were served to residents;-He was not aware of any resident complaints about cold food;-His expectation was the food was maintained at the temperature per policy at a minimum of 120 degrees Fahrenheit by the time the resident received the meal tray.
During interview on 2/24/26 at 1:22 P.M., the Administrator said the following:-His expectation was the residents' food reached and were maintained at the temperature per the regulations;-If the food was not at the correct temperature, then there needed to be an investigation to determine why food temperatures were not appropriate. #2722550