Inspection Reports for
Truman Healthcare &Amp; Rehabilitation Center
206 WEST FIRST ST, LAMAR, MO, 64759-1291
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
173% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
83% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Date: Dec 19, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding food safety practices in the facility's kitchen, specifically concerns about staff not wearing hairnets and beard nets properly and improper hand washing and glove use during food preparation.
Complaint Details
Complaint 2690751 triggered the investigation. The complaint focused on improper use of hair and beard nets and hand hygiene during food preparation. The report includes substantiation through observations and staff interviews confirming the issues.
Findings
The facility failed to ensure food was protected from contamination due to staff not wearing hair and beard nets correctly and improper hand washing and glove changing procedures. Observations and interviews confirmed staff, including the Dietary Manager, did not always cover hair and beards fully or wash hands between glove changes, risking contamination of residents' food.
Deficiencies (2)
Staff failed to wear hairnets and beard nets appropriately while preparing residents' food, risking contamination.
Staff failed to use proper hand washing and glove use procedures, including not washing hands between glove changes, risking contamination.
Report Facts
Facility census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA A | Dietary Aide | Observed not wearing beard net properly and acknowledged forgetting to wear it at times. |
| DM | Dietary Manager | Observed not covering hair fully with hairnet and not washing hands between glove changes; responsible for ensuring staff compliance. |
| DON | Director of Nursing | Interviewed regarding staff responsibilities for ensuring proper hairnet and glove use. |
Inspection Report
Deficiencies: 4
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident protection, treatment and care, pressure ulcer care, and pharmaceutical services at Truman Healthcare & Rehabilitation Center.
Findings
The report identifies multiple deficiencies with minimal harm or potential for actual harm affecting a few residents, including protection from wrongful use of belongings, appropriate treatment and care, pressure ulcer care, and pharmaceutical services. Specific deficiency texts are not available.
Deficiencies (4)
Protect each resident from the wrongful use of the resident's belongings or money.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspection Report
Routine
Census: 104
Deficiencies: 17
Date: Apr 15, 2025
Visit Reason
Routine inspection of Truman Healthcare & Rehabilitation Center to assess compliance with regulatory requirements including resident funds management, abuse prevention, restraint use, PASARR screening, care planning, activities, restorative therapy, medication administration, food service, and infection control.
Findings
The facility had multiple deficiencies including failure to properly manage resident funds, protect residents from abuse, ensure appropriate use and documentation of restraints, complete PASARR screenings, develop comprehensive care plans, provide adequate activities, maintain a restorative therapy program, prevent medication errors, maintain food safety and sanitation, and ensure infection control practices including timely TB screening and hand hygiene.
Deficiencies (17)
Failed to maintain a system assuring full, complete, and separate accounting of each resident's personal funds when staff used personal accounts for resident shopping without facility record keeping.
Failed to protect resident from abuse when staff continued to provide care against resident's refusals and rough handling was reported.
Failed to ensure complete assessments, physician orders, consents, care plans, and ongoing evaluations for use of physical restraints (bed rails and seat belts).
Failed to timely report and thoroughly investigate allegations of possible resident-to-resident sexual abuse and failed to report to state within required timeframes.
Failed to ensure PASARR level I and II screenings were completed and maintained in resident records prior to admission.
Failed to develop and implement comprehensive care plans addressing dementia, skin integrity, medications, and activity preferences for multiple residents.
Failed to provide adequate and varied activity programs meeting resident needs, especially on the Special Care Unit, and failed to care plan activities.
Failed to identify need for restorative therapy, develop care plans, and provide restorative therapy services to maintain residents' range of motion and mobility.
Failed to ensure smoking assessments and care plans were complete and accurate, and resident was found with unauthorized THC/CBD vape devices in room.
Failed to document risk assessment, informed consent, care planning, and ongoing assessments for use of bed rails for two residents.
Failed to document targeted behavioral symptoms supporting use of antipsychotic medication and failed to monitor and care plan for these behaviors.
Medication errors occurred when staff administered blood pressure medication against physician ordered parameters on multiple occasions and missed doses of antipsychotic medication were noted.
Facility failed to employ a qualified dietary manager with required certification and education in food service management.
Food was served at temperatures below recommended safe and appetizing levels; dishwashing machine did not reach required wash and rinse temperatures or sanitizer levels; kitchen equipment and handwashing sink were dirty; staff consumed food in kitchen and dishwashing areas.
Staff ate food in dishwashing and kitchen areas over clean dishes, risking contamination.
Failed to ensure hand hygiene was performed before, during, and after resident cares; staff failed to wash hands after providing catheter and incontinent care.
Failed to ensure timely two-step tuberculosis screening for seven staff members prior to working on the floor.
Report Facts
Medication errors: 3
Resident census: 104
Dishwasher temperature: 100
Dishwasher sanitizer PPM: 100
Number of staff without timely TB screening: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT F | Certified Medication Technician | Did not have negative two-step TB test prior to working on floor. |
| DA G | Dietary Aide | Did not have negative two-step TB test prior to working on floor. |
| LPN H | Licensed Practical Nurse | Did not have negative two-step TB test prior to working on floor. |
| CNA I | Certified Nursing Assistant | Did not have negative two-step TB test prior to working on floor. |
| CNA J | Certified Nursing Assistant | Did not have negative two-step TB test prior to working on floor. |
| RN K | Registered Nurse | Did not have negative two-step TB test prior to working on floor. |
| DA E | Dietary Aide | Did not have negative two-step TB test prior to working on floor. |
| Dietary Manager | Dietary Manager | Not certified dietary manager, no CDM course enrollment, no Serve Safe certification. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 6
Date: Apr 15, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, misappropriation of property, failure to report abuse, and medication errors at Truman Healthcare & Rehabilitation Center.
Complaint Details
The complaint investigation involved allegations of abuse including forced care after refusals, misappropriation of narcotic medications and resident funds, failure to report abuse allegations timely to the state agency, and failure to conduct and submit thorough abuse investigations. The facility census was 104.
Findings
The facility failed to protect residents from abuse, including forcing care against refusals, misappropriation of medications and resident property, failure to report abuse allegations timely, incomplete abuse investigations, and failure to provide consistent wound care and documentation. A medication technician replaced missing narcotic pills with personal medication, and the facility failed to document and report this properly. Resident wounds were not consistently assessed or treated as ordered.
Deficiencies (6)
Facility failed to protect a resident from abuse when a staff member forced care after refusals.
Facility failed to protect residents from misappropriation of personal property and medications.
Facility failed to timely report allegations of abuse involving two residents.
Facility failed to thoroughly investigate and submit abuse investigations within five days.
Facility failed to provide consistent wound care and document refusals and wound assessments.
Facility failed to provide pharmaceutical services meeting resident needs when a medication technician replaced missing narcotic pills with personal medication and a nurse administered one dose without proper documentation or reporting.
Report Facts
Census: 104
Medication doses administered: 2
Medication doses missing: 2
Unauthorized purchases: 782.01
Wound measurements: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT D | Certified Medication Technician | Replaced missing narcotic pills with personal medication and taped them into resident's medication card |
| LPN A | Licensed Practical Nurse | Administered narcotic medication with taped-in pills without noticing |
| RN E | Registered Nurse | Counted narcotics with CMT D and found missing pills; notified ADON and Administrator |
| ADON | Assistant Director of Nursing | Investigated medication discrepancy and abuse allegations |
| DON | Director of Nursing | Oversaw abuse investigations and medication administration policies |
| Administrator | Facility Administrator | Responsible for facility compliance and abuse reporting |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of resident-to-resident sexual abuse involving two residents within the required two-hour timeframe.
Complaint Details
The complaint involved an allegation of resident-to-resident sexual abuse between Resident #1 and Resident #2. The facility failed to report the incident to the Department of Health and Senior Services on 08/03/23 within the required two-hour timeframe. Multiple staff interviews confirmed awareness of reporting requirements but the report was not made timely.
Findings
The facility failed to report the alleged resident-to-resident sexual abuse to the State Survey Agency within the required two hours. Interviews with multiple staff confirmed the reporting requirement, but the facility did not document or self-report the incident timely. The deficiency was cited with minimal harm and affected a few residents.
Deficiencies (1)
Failure to timely report suspected resident-to-resident sexual abuse to the State Survey Agency within two hours.
Report Facts
Facility census: 91
Medication dosage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide E | Certified Nurse Aide | Interviewed regarding reporting procedures and incident response |
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed regarding reporting procedures and incident response |
| Certified Nurse Aide G | Certified Nurse Aide | Interviewed regarding reporting procedures and incident response |
| Registered Nurse H | Registered Nurse | Interviewed regarding reporting procedures and incident response |
| Registered Nurse A | Registered Nurse | Interviewed regarding reporting procedures and incident response |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding reporting procedures and incident response |
| Corporate Nurse | Corporate Nurse | Interviewed regarding reporting procedures and incident response |
Inspection Report
Routine
Deficiencies: 9
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, staffing, and facility conditions at Truman Healthcare & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to involve residents in care planning, lack of physician orders for self-administration of medication, unsafe and unsanitary conditions in the secured dementia care unit, inadequate monitoring and care planning for weight loss, insufficient pain management following a resident fall, lack of qualified dietary management staff, incomplete facility assessment regarding services provided, malfunctioning resident call light system, and ineffective pest control program resulting in excessive flies throughout the facility.
Deficiencies (9)
Failed to ensure two residents were included in all aspects of person-centered care planning.
Failed to ensure one resident had a physician's order and assessment for self-administration of medication.
Failed to provide a safe, clean, comfortable, and homelike environment on the secured dementia care unit with multiple maintenance and sanitation issues.
Failed to have a process to identify and address weight loss for one resident.
Failed to provide appropriate and timely pain management for one resident who fell out of bed.
Failed to employ a qualified Director of Food and Nutrition services.
Facility assessment did not list tracheostomy care as a service provided despite caring for a resident requiring it.
Failed to ensure all residents had working call light systems in bathrooms and bathing areas; system was outdated and malfunctioning.
Failed to maintain an effective pest control program; excessive flies observed throughout the facility including kitchen and dining areas.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 25
Residents affected: 1
Residents affected: 1
Residents affected: 93
Residents affected: 93
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed lack of documentation for resident care plan meetings and facility assessment omissions | |
| Regional Nurse Consultant | Confirmed lack of documentation for resident care plan meetings and facility assessment omissions | |
| Assistant Director of Nursing | ADON | Confirmed no doctor's order for self-administration of medication and described process |
| Registered Nurse 1 | RN | Confirmed resident self-administers TUMS without doctor's order |
| Maintenance Director | MD | Described maintenance issues and pest control program |
| Rehabilitation Director | RD | Clarified responsibility for wheelchair arm replacement |
| Housekeeping Director | HD | Described cleaning practices related to urine odor |
| MDS Coordinator 1 | MDSC1 | Discussed care plan backlog |
| MDS Coordinator 2 | MDSC2 | Discussed care plan backlog |
| Director of Nursing | DON | Discussed pain management expectations and resident fall |
| Licensed Practical Nurse 3 | LPN 3 | Provided information on resident pain and call light system |
| Infection Preventionist | IP | Commented on resident's chronic pain |
| Certified Medication Technician 4 | CMT 4 | Commented on call light system issues |
| Nursing Assistant 3 | NA 3 | Commented on call light system issues |
| Administrator | Discussed dietary management staffing and call light system issues |
Inspection Report
Routine
Census: 89
Deficiencies: 1
Date: Apr 18, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing a safe, clean, comfortable, and homelike environment for residents, specifically regarding maintenance issues such as a handrail left on the floor for an extended period.
Findings
The facility failed to maintain a safe and homelike environment as a handrail between resident rooms was left detached and lying on the floor for approximately three months despite multiple reports to maintenance. Staff and residents confirmed awareness of the issue, and the facility lacked a policy regarding maintenance of walls or handrails.
Deficiencies (1)
Failure to provide a safe, clean, comfortable, and homelike environment due to a handrail left in the floor for an extended period.
Report Facts
Facility census: 89
Duration handrail down: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician (CMT) A | Reported handrail down for two to three months and awareness of resident complaints | |
| Certified Nursing Assistant (CNA) B | Reported handrail down for at least three months and maintenance responsibility | |
| Licensed Practical Nurse (LPN) C | Reported handrail down for months and maintenance responsibility | |
| Licensed Practical Nurse (LPN) D | Reported handrail down for over three months and maintenance request process | |
| Maintenance Director | Reported maintenance log book and unawareness of current handrail issue | |
| Administrator and Director of Nursing (DON) | Reported unawareness of handrail down and maintenance request process |
Inspection Report
Census: 92
Deficiencies: 5
Date: Nov 22, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to infection control, medication administration, bed safety, food safety, and other aspects of resident care.
Findings
The facility was found deficient in multiple areas including failure to administer antibiotics as ordered and follow-up on urinary tract infections, failure to document and obtain consent for use of bed rails, medication administration errors with a high error rate, improper food handling and storage practices, and inadequate infection control practices related to glucometer disinfection.
Deficiencies (5)
Failure to assure administration of antibiotics as ordered and failure to follow-up with physician's orders for rechecking urinalysis after treatment for UTIs in two residents.
Failure to document completion of measurements to ensure no gaps that could cause injury or entrapment related to bed rails for multiple residents; failure to obtain physician orders, care plans, or consent for side rails for one resident.
Medication error rate of 69.23% due to failure to administer medications according to physician's orders and standards of practice affecting five residents.
Failure to properly dry dishes before storage, stacking wet dishes, and storage of dented cans in food preparation area.
Failure to properly disinfect glucometers and protect test strips from contamination during blood glucose testing affecting two residents.
Report Facts
Facility census: 92
Medication errors: 18
Medication error rate: 69.23
Residents affected by medication errors: 5
Dented cans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT K | Certified Medication Technician | Named in medication administration observations and interviews regarding medication timing and insulin administration |
| CMT E | Certified Medication Technician | Named in medication administration observations and interviews regarding medication timing and insulin administration |
| CMT J | Certified Medication Technician | Named in observations and interviews regarding glucometer use and disinfection |
| DA F | Dietary Aide | Named in observations of food handling and hygiene practices |
| DA L | Dietary Aide | Named in interview regarding dish drying practices |
| Dietary Manager | Named in interviews regarding food safety and hygiene practices | |
| Director of Nursing | Director of Nursing (DON) | Named in interviews regarding medication administration and infection control practices |
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in interviews regarding urinary tract infection management |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in interviews regarding infection control and urinary tract infection management |
| Maintenance Staff | Named in interview regarding bed rail safety measurements |
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