Inspection Reports for
Truman Healthcare &Amp; Rehabilitation Center
206 WEST FIRST ST, LAMAR, MO, 64759-1291
Back to Facility Profile31 Reports
Inspection Report — Dec 19, 2025
Complaint Investigation CMS
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
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 — Jun 5, 2025
CMS
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 — Apr 15, 2025
Routine CMS
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
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 — Apr 15, 2025
Complaint Investigation CMS
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
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 — Aug 9, 2023
Plan of Correction State
Date: Aug 9, 2023
Visit Reason
The inspection was conducted in response to allegations of resident to resident sexual abuse and failure to report the incident within the required time frame.
Complaint Details
The visit was complaint-related due to allegations of resident to resident sexual abuse. The allegation was substantiated as the facility failed to report the incident within the required timeframe.
Findings
The facility failed to report an allegation of resident to resident sexual abuse within the required two-hour timeframe. Interviews and record reviews confirmed the failure to notify the appropriate authorities timely.
Deficiencies (2)
F609: The facility failed to report to the State Survey Agency an allegation of resident to resident sexual abuse involving two residents within the required two-hour timeframe.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property as required by regulation.
Report Facts
Completion date for plan of correction: Sep 8, 2023
Inspection Report — Aug 9, 2023
Complaint Investigation CMS
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
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 — Jul 18, 2023
Life Safety State
Date: Jul 18, 2023
Visit Reason
The inspection was a life safety code survey conducted to evaluate the facility's compliance with fire safety and building construction standards.
Findings
The facility failed to maintain the integrity of building construction fire barriers, ensure sprinkler heads were free from debris and corrosion, maintain smoking area grounds, maintain electrical systems properly, and ensure proper oxygen cylinder storage. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (6)
K161: The facility failed to maintain the one-hour fire rating of ceilings and walls due to unsealed penetrations, allowing smoke passage between attic and resident areas.
K353: The facility failed to ensure sprinkler heads were free from debris and corrosion, risking delayed fire suppression.
K741: The facility failed to maintain smoking area grounds free of cigarette butts, risking fire hazards.
K911: The facility failed to maintain electrical wiring properly, including an unsecured electrical switch, risking fire due to improper installation.
K920: The facility failed to maintain electrical equipment power strips and extension cords according to safety standards, risking fire or electrical injury.
K923: The facility failed to ensure proper oxygen cylinder storage, risking fire hazards due to unsecured cylinders.
Report Facts
Number of cigarette butts: 20
Number of cigarette butts: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named as responsible for compliance with fire safety, sprinkler maintenance, smoking area maintenance, and electrical safety | |
| Administrator | Named as responsible for compliance with fire safety, sprinkler maintenance, smoking area maintenance, and electrical safety | |
| Nursing staff and Medical Records | Responsible for compliance with oxygen cylinder storage | |
| Central Supply Certified Medication Technician (CMT) | Responsible for compliance with oxygen cylinder storage |
Inspection Report — Jul 14, 2023
Routine CMS
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 — Jul 14, 2023
Re-Inspection State
Date: Jul 14, 2023
Visit Reason
A recertification and complaint survey was conducted to assess compliance with federal regulations at Truman Healthcare & Rehabilitation Center.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in resident participation in care planning, self-administration of medications, safe and homelike environment, nutrition and hydration status maintenance, pain management, staffing, facility assessment, resident call system, and pest control program.
Deficiencies (9)
F553 The facility failed to ensure two residents were afforded the opportunity to be included in all aspects of person-centered care planning.
F554 The facility failed to ensure one resident had a physician's order and care plan for self-administration of medication, increasing risk of inaccurate medication administration.
F584 The facility failed to provide a safe, clean, comfortable, and homelike environment for one of three halls, specifically the secured dementia care unit, with multiple maintenance and sanitation issues.
F692 The facility failed to have a process to identify and address weight loss for one resident, and ensure acceptable nutritional status for residents.
F697 The facility failed to ensure one resident received appropriate and timely pain management after a fall, including assessment and intervention.
F801 The facility failed to employ sufficient qualified dietary staff to provide adequate nutrition services for 93 residents.
F838 The facility failed to conduct a comprehensive facility assessment including all services provided, such as tracheostomy care.
F919 The facility failed to ensure residents had a functioning call system to summon staff assistance at all times.
F925 The facility failed to maintain an effective pest control program, resulting in excessive flies throughout the facility.
Report Facts
Sample Size: 42
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 93
Inspection Report — Apr 18, 2023
Routine CMS
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
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 — Apr 18, 2023
Annual Inspection State
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with health and safety regulations at Truman Healthcare & Rehabilitation Center.
Findings
The facility failed to provide a safe, clean, comfortable, and homelike environment due to a handrail being left on the floor for an extended period. Multiple staff interviews confirmed the handrail had been down for at least two to three months without proper maintenance or repair.
Deficiencies (3)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility did not maintain a safe, clean, and comfortable environment as a handrail was left on the floor for an extended period, posing a safety risk to residents.
A1067 Handrails: Handrails were not provided on both sides of all corridors and aisles used by residents, with corridor handrails lacking proper ends returning to the wall.
A6015 Walls/Ceilings/Doors/Windows Clean: Walls and ceilings, including doors, windows, and skylights, were not clean and maintained in good repair.
Report Facts
Inspection Report — Apr 18, 2023
Life Safety State
Date: Apr 18, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, focusing on building construction type, height, and fire safety features.
Findings
The facility failed to maintain the integrity of the building construction by not maintaining the one-hour fire rating of ceilings due to unsealed penetrations, which could allow smoke to pass between areas. Additionally, the smoke detector in the 100 hallway was hanging down for months and was not properly maintained or repaired.
Deficiencies (2)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and areas below, risking smoke passage affecting residents and staff. The smoke detector in the 100 hallway was hanging down for months and was not repaired despite maintenance requests.
A3001: The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2), with reference to K161 deficiencies.
Report Facts
Inspection Report — Mar 15, 2022
Routine State
Date: Mar 15, 2022
Visit Reason
The inspection was conducted to assess compliance with COVID-19 vaccination requirements for facility staff at Truman Healthcare & Rehabilitation Center.
Findings
The facility failed to ensure 100% of staff were fully vaccinated against COVID-19 or granted a qualifying exemption. One staff member had a medical exemption that was not signed by a medical provider, and the facility did not fully comply with vaccination documentation and exemption procedures.
Deficiencies (1)
F888 COVID-19 Vaccination of facility staff. The facility failed to ensure all staff were fully vaccinated or had qualifying exemptions as required by federal regulations. One staff member's medical exemption was not signed by a medical provider.
Report Facts
Total staff: 110
Staff partially or completely vaccinated: 61
Staff with exemption: 49
Inspection Report — Nov 15, 2021
Complaint Investigation State
Date: Nov 15, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's responsible party about medication order changes and failure to document discussions with the physician and responsible party.
Complaint Details
The complaint investigation substantiated that the facility failed to notify the responsible party of medication order changes and failed to document discussions with the physician and responsible party. The facility census was 91 at the time of inspection.
Findings
The facility failed to notify one resident's responsible party when medication order changes were made and failed to document discussions with the physician and responsible party. Additionally, the facility failed to provide or arrange transportation for nail care for one resident.
Deficiencies (5)
F580: The facility failed to notify one resident's responsible party of medication order changes and failed to document discussions with the physician and responsible party regarding medication allergies and changes.
F687: The facility failed to provide or arrange transportation for nail care for one resident in need of nail care on toes.
A4054: The facility failed to ensure a safe and effective system of medication distribution, administration, control, and use as evidenced by issues referenced in F580.
A4076: The facility failed to ensure residents were well-groomed and dressed appropriately, as evidenced by failure to provide adequate foot care.
A4087: The facility failed to notify the responsible party or designee of significant changes in the resident's condition, as evidenced by failure to notify regarding medication changes and admission information.
Report Facts
Deficiencies cited: 5
Inspection Report — Oct 5, 2021
Abbreviated Survey State
Date: Oct 5, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report — Jul 27, 2021
Plan of Correction State
Date: Jul 27, 2021
Visit Reason
The inspection was conducted due to deficiencies related to misappropriation and exploitation of resident property and medication management issues.
Findings
The facility failed to protect residents from misappropriation of property and medication, including missing narcotic pain medication and unauthorized purchases made with a resident's prepaid credit card. Multiple policy and procedural deficiencies were identified regarding medication disposal, narcotic counts, and resident fund use.
Deficiencies (3)
F602: The facility failed to protect residents from misappropriation of property and medication, including missing narcotic pain medication and unauthorized purchases made with a resident's prepaid credit card.
A4054: There was no safe and effective system of medication distribution, administration, control, and use as evidenced by the findings in F602.
A9002: The operator failed to use the personal funds of residents exclusively for their use, as unauthorized purchases were made with a resident's prepaid credit card.
Report Facts
Tablets of Seroquel: 42
Oxycodone tablets missing: 60
Unauthorized purchase total: 110.01
Reimbursed amount: 346.83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed taking medications from E-kit and overflow bin; admitted to taking medications due to drug problem |
| CNA I | Certified Nursing Assistant | Admitted possession of resident's card and reimbursed resident for unauthorized purchases |
| RN F | Registered Nurse | Provided information on discontinued medication handling and narcotic counts |
| Administrator | Facility Administrator | Interviewed regarding missing medications and observed video surveillance |
Inspection Report — Feb 24, 2021
Routine State
Date: Feb 24, 2021
Visit Reason
The inspection was conducted to assess the facility's pest control program and ensure compliance with regulatory requirements regarding pest and rodent control.
Findings
The facility failed to maintain an effective pest control program, evidenced by the presence of rodents, cockroaches, and spiders in multiple areas. Observations and interviews confirmed ongoing pest issues despite monthly pest control treatments.
Deficiencies (2)
F925 Maintain an effective pest control program so that the facility is free of pests and rodents. The facility failed to ensure the building remained free of roaches and rodents, including in residents' living areas.
A6039 Effective measures to minimize rodents, flies, cockroaches, and other insects were not met. The premises harbored pests as evidenced by multiple observations and resident reports.
Report Facts
Completion date for plan of correction: Apr 9, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Interviewed regarding pest issues and pest control measures |
| Housekeeper J | Housekeeper | Reported seeing live and dead roaches in the facility |
| Registered Nurse | Registered Nurse | Reported recent sightings of mice and cockroaches |
| Maintenance Supervisor | Maintenance Supervisor | Reported resident complaints and pest control activities |
| Facility Administrator | Facility Administrator | Provided statements about pest control contract and facility conditions |
Inspection Report — Dec 23, 2020
Abbreviated Survey State
Date: Dec 23, 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 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report — Dec 1, 2020
Complaint Investigation State
Date: Dec 1, 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.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 15, 2020
Abbreviated Survey State
Date: Sep 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's 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 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report — Aug 21, 2020
Complaint Investigation State
Date: Aug 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 30, 2020
Routine State
Date: Jul 30, 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 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report — Jul 3, 2020
Complaint Investigation State
Date: Jul 3, 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.
Complaint Details
This was a complaint investigation related to COVID-19 infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 17, 2020
Abbreviated Survey State
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with emergency preparedness regulations and safe environment standards.
Findings
The facility was found in compliance with COVID-19 emergency preparedness requirements but failed to maintain air temperatures within the required range of 71 to 81 degrees Fahrenheit, with temperatures reaching up to 86 degrees. The facility had 101 residents at the time of the survey.
Deficiencies (2)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain air temperatures between 71 and 81 degrees Fahrenheit as required, with observed temperatures exceeding 81 degrees in multiple resident rooms.
A3029 Cooling System 71-85 Degrees: The facility did not cool resident-accessible areas when air temperatures exceeded 85 degrees Fahrenheit, violating the regulation requiring cooling to at least 71 degrees Fahrenheit.
Report Facts
Inspection Report — Apr 8, 2020
Abbreviated Survey State
Date: Apr 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.
Complaint Details
No state licensure deficiencies were cited as a result of this second inspection and complaint investigation. No deficiencies were cited on this interim and complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited during this inspection and complaint investigation.
Inspection Report — Nov 22, 2019
Annual Inspection State
Date: Nov 22, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations at Truman Healthcare & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including medication administration, infection control, bed rail safety, and food safety. Several residents had issues related to urinary tract infections and medication errors were documented.
Deficiencies (5)
F 690: The facility failed to assure administration of antibiotics as ordered and failed to update care plans for residents with urinary tract infections. Staff did not follow physician orders for rechecking urinalysis after antibiotic treatment.
F 700: The facility failed to ensure proper assessment, installation, and maintenance of bed rails for residents, resulting in potential injury risks. Documentation of measurements and consents for bed rails was incomplete.
F 759: Medication error rates exceeded 5 percent, with 18 errors out of 26 opportunities affecting five residents. The facility failed to administer medications according to physician orders and standards of practice.
F 812: The facility failed to maintain food safety standards, including proper hand hygiene, glove use, and preventing contamination of food items. Wet dishes and dented food containers were observed in storage and preparation areas.
F 880: The facility failed to establish and maintain an infection prevention and control program that meets regulatory requirements. Hand hygiene and disinfection procedures were inadequate, risking spread of communicable diseases.
Report Facts
Medication errors: 18
Medication error rate: 69.23
Inspection Report — Nov 22, 2019
Life Safety State
Date: Nov 22, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Truman Healthcare & Rehabilitation Center.
Findings
The facility failed to maintain walls free of penetrations to resist smoke passage, maintain adequate exit illumination, ensure proper installation of fire alarm systems, prevent use of prohibited portable space heaters, and maintain electrical receptacles in good working order. These deficiencies potentially affected all residents, staff, and occupants in the facility.
Deficiencies (5)
K161 Building Construction Type and Height: The facility failed to maintain walls free of penetrations to resist the passage of smoke, potentially affecting all residents and occupants.
K281 Illumination of Means of Egress: The facility failed to maintain adequate exit illumination; the 200 hall exit pathway light was not functioning at the time of survey.
K341 Fire Alarm System - Installation: The facility failed to ensure all components of the fire alarm system, including smoke detectors, were properly installed and maintained.
K781 Portable Space Heaters: The facility failed to prevent the use of a space heater in the barber shop without documentation that it did not exceed 212°F, potentially affecting one smoke zone.
K912 Electrical Systems - Receptacles: The facility failed to maintain electrical components in good working order; an uncovered junction box was observed under the nurses' desk.
Report Facts
Inspection Report — Nov 22, 2019
CMS
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
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 |
Inspection Report — Apr 23, 2019
Complaint Investigation State
Date: Apr 23, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse involving a resident and a staff member at Truman Healthcare & Rehabilitation Center.
Complaint Details
The complaint investigation substantiated that the Dietary Manager had an inappropriate relationship with Resident #1, including kissing and other interactions. The facility failed to report the abuse allegation to the State Survey Agency within the required two-hour timeframe.
Findings
The facility failed to protect one resident from abuse by a staff member, specifically the Dietary Manager, who had an inappropriate relationship with the resident. The facility also failed to report the abuse allegation to the State Survey Agency within the required two-hour timeframe.
Deficiencies (4)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to protect Resident #1 from abuse by a staff member who had an inappropriate relationship with the resident. The facility census was 93.
F609 Reporting of Alleged Violations: The facility failed to report allegations of abuse involving Resident #1 to the State Survey Agency within two hours of staff becoming aware of the allegation.
A4073 Protective Oversight, Voluntary Leave: The facility did not meet requirements for twenty-four hour protective oversight and supervision for residents on voluntary leave, related to the abuse findings.
A8023 Develop/Implement Abuse/Neglect Policies: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse, and failed to require timely reporting of abuse allegations.
Report Facts
Reporting timeframe: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in abuse findings for inappropriate relationship with Resident #1 | |
| Administrator | Involved in investigative interviews and reporting | |
| Director of Nursing | Has open door policy for reporting abuse and involved in investigation | |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding knowledge of Dietary Manager and resident relationship |
| Registered Nurse (RN) B | Registered Nurse | Interviewed regarding observations of Dietary Manager and resident relationship |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Interviewed regarding observations of Dietary Manager and resident relationship |
Inspection Report — Nov 29, 2018
Annual Inspection State
Date: Nov 29, 2018
Visit Reason
The inspection was conducted as an annual recertification survey and licensure inspection for Truman Healthcare & Rehabilitation Center.
Findings
No emergency preparedness deficiencies or state licensure deficiencies were cited as a result of this inspection. The facility meets applicable provisions of the 2012 edition of the Life Safety Code.
Inspection Report — Nov 29, 2018
Annual Inspection State
Date: Nov 29, 2018
Visit Reason
The inspection was an annual survey of Truman Healthcare & Rehabilitation Center to assess compliance with federal regulations, including review of residents' medical records and facility policies.
Findings
The facility failed to ensure accurate and consistent documentation of residents' wishes regarding CPR and advance directives. Deficiencies were also found in the administration and monitoring of psychotropic medications, including failure to obtain stop dates for PRN orders and inadequate documentation of medication effectiveness.
Deficiencies (3)
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to ensure seven residents' medical records accurately and consistently indicated their CPR wishes and advance directives.
F758 Psychotropic Drugs: The facility failed to obtain stop dates for PRN psychotropic medications within 14 days and did not document effectiveness for one resident, resulting in inadequate indications and monitoring.
F759 Medication Errors: The facility failed to administer three medications as ordered, resulting in a medication error rate of 10.34% during observation.
Report Facts
Medication error rate: 10.34
Medications ordered: 29
Medications not administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruza J. Selvey | Administrator | Signed the inspection report and plan of correction |
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