Inspection Reports for
Truman Lake Manor, Inc
600 EAST 7TH ST, LOWRY CITY, MO, 64763-9671
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
59% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Date: Jan 7, 2026
Visit Reason
The inspection was conducted due to a complaint alleging that the facility failed to timely report and investigate an allegation of possible abuse made by a resident (Resident #1).
Complaint Details
The complaint involved an allegation by Resident #1 that another resident had sexually abused him. The allegation was not reported to the state within the required two-hour timeframe, and no investigation or protective measures were documented. Staff interviews confirmed the failure to report and investigate properly. The allegation was not substantiated in the report but was not properly handled.
Findings
The facility failed to immediately report an allegation of possible abuse to management and the state survey agency within two hours, and did not complete a timely documented investigation or take documented steps to protect the resident after the allegation. Staff interviews revealed inconsistent knowledge and failure to follow reporting protocols.
Deficiencies (2)
Failed to timely report suspected abuse to management and the state survey agency within two hours.
Failed to complete a timely documented investigation with steps taken to protect the resident after an allegation of abuse.
Report Facts
Facility census: 71
Investigation completion timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Documented resident's allegation but failed to report it to administration or state and did not complete assessment or investigation |
| Assistant Director of Nursing | ADON | Interviewed regarding abuse investigations and reporting requirements |
| Administrator | Responsible for documenting investigations and reporting abuse allegations; interviewed about reporting failures |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Date: Nov 6, 2024
Visit Reason
The inspection was conducted due to a complaint regarding medication safety and supervision in the nursing home, specifically concerning unsecured medication found in a resident's room on the memory care unit.
Complaint Details
The complaint investigation found that Resident #1 had an unsecured bottle of chemotherapy medication in his/her room on the secured care unit, which could be accessed by wandering residents. The facility had not ensured proper supervision or secured storage of medications. The medical director was new, had not signed a contract, and had not participated in required quality assurance meetings.
Findings
The facility failed to ensure an environment free from accident hazards by allowing an unsecured bottle of chemotherapy medication in a resident's room on the secured care unit. Additionally, the facility failed to employ an actively involved medical director who participated in care policy implementation and quality assurance activities.
Deficiencies (2)
Unsecured medication bottle containing Brukinsa capsules found in Resident #1's room on the memory care unit, posing a potential risk to other residents.
Failure to employ a medical director who was actively involved in implementation of care policies, coordination of medical care, and participation in Quality Assessment and Assurance Committee meetings.
Report Facts
Medication quantity: 120
Sodium Chloride syringes: 50
Facility census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician A | Medical Director | New Medical Director who had not signed a formal contract and had not attended Quality Assessment and Assurance Committee meetings. |
| LPN B | Licensed Practical Nurse | Staff member who was unaware of the resident's whereabouts during medication observation and noted the unsecured medication in Resident #1's room. |
| Director of Nursing | Director of Nursing | Provided information about Resident #1's room placement and concerns about medication safety. |
| Administrator | Administrator | Acknowledged the risk of unsecured medication and confirmed Resident #1 was in the secured care unit by choice. |
Inspection Report
Routine
Census: 62
Deficiencies: 8
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, environment, medication management, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, inadequate maintenance of resident room floors, improper medication administration and monitoring, failure to implement fall prevention interventions, improper food storage and handling, and lapses in infection control practices during a COVID-19 outbreak.
Deficiencies (8)
Failure to notify resident's physician of changes in condition and medication discontinuation.
Failure to repair broken and missing floor tiles in resident rooms, creating an uncleanable surface.
Failure to provide care according to physician orders resulting in saturated dressings and delayed treatment.
Failure to follow care plan for resident transfers and fall prevention interventions.
Failure to follow up with physician and delay in antibiotic treatment for urinary tract infection.
Failure to monitor and administer Lasix and potassium according to ordered parameters.
Failure to properly store, label, and date food items; use of dented cans; improper hand hygiene and glove use during food preparation; and inadequate cleaning of ice machine.
Failure to maintain effective infection prevention and control program during COVID-19 outbreak, including staff not wearing PPE while working on COVID unit.
Report Facts
Facility census: 62
Deficiencies cited: 8
Dented cans observed: 6
Dates Lasix administered out of parameters: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant J | CNA | Mentioned in relation to resident behavior changes and COVID-19 positive status |
| Licensed Practical Nurse P | LPN | Mentioned in relation to resident behavior changes and fall risk interventions |
| Certified Medical Technician Q | CMT | Mentioned in relation to medication changes and fall risk interventions |
| Director of Nursing | DON | Mentioned in relation to medication administration, fall prevention, and infection control |
| Administrator | Mentioned in relation to expectations for staff compliance with policies and procedures | |
| Dietary Aide M | DA | Mentioned in relation to food storage and hygiene practices |
| Dietary Manager | DM | Mentioned in relation to food storage, dented cans, and cleaning practices |
| Certified Nurse Aide B | CNA | Mentioned in relation to fall risk interventions and resident transfers |
| Certified Medication Technician F | CMT | Mentioned in relation to medication administration and monitoring |
| Registered Nurse G | RN | Mentioned in relation to medication administration and infection control |
| Licensed Practical Nurse A | LPN | Mentioned in relation to medication administration and infection control |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 3, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Truman Lake Manor Inc.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 50
Deficiencies: 13
Date: Jan 27, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident fund security, notification of Medicare coverage, abuse prevention, transfer/discharge notification, fall monitoring, elopement prevention, respiratory care, bed rail safety, nurse staffing posting, food safety, infection control, infection preventionist designation, and vaccination policies.
Findings
The facility had multiple deficiencies including inadequate surety bond coverage for resident funds, failure to provide required Medicare notices, incomplete criminal background checks for staff, failure to notify residents or representatives in writing of transfers and bed hold policies, inadequate post-fall neurological monitoring, failure to routinely check wander guards, improper oxygen equipment maintenance, incomplete bed rail risk assessments and consents, failure to post nurse staffing information, unsanitary kitchen conditions, improper infection control practices including improper mask use and glucometer cleaning, lack of a designated infection preventionist with training, and failure to provide or document pneumococcal vaccinations.
Deficiencies (13)
Facility failed to maintain a surety bond in an amount sufficient to ensure full protection of resident funds.
Facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice or alternative denial letter at initiation, reduction, or termination of Medicare Part A benefits for some residents.
Facility failed to complete timely criminal background checks for five staff prior to employment and continued resident contact.
Facility failed to notify resident and/or representative in writing of transfer or discharge to hospital and bed hold policy for several residents.
Facility failed to document post-fall neurological checks for 72 hours for a resident with head injury.
Facility failed to ensure routine checks of wander guards for a resident with exit-seeking behavior.
Facility failed to ensure oxygen equipment and tubing were changed and documented per professional standards for two residents.
Facility failed to complete risk/benefit review, obtain informed consent, complete bed rail safety gap measurements, and address bed rail use in care plans for multiple residents.
Facility failed to post daily nurse staffing information in a clear and accessible manner.
Facility failed to maintain kitchen cleanliness, including grease and dust buildup, stacking wet dishes, lack of policy and practice for dented cans, and unlabeled/undated frozen food items.
Facility failed to maintain infection control practices including improper mask use by staff in COVID unit and inadequate cleaning of glucometers between residents.
Facility failed to designate a qualified infection preventionist with specialized training.
Facility failed to provide pneumococcal vaccines or document prior vaccination history for several residents.
Report Facts
Facility census: 50
Surety bond amount: 45000
Average resident fund balance: 96000
Required bond amount: 144000
Number of staff with delayed CBC checks: 5
Number of residents with transfer notification deficiencies: 4
Number of residents with bed hold notification deficiencies: 3
Number of falls for Resident #27: 2
Number of residents with bed rail safety deficiencies: 6
Dates nurse staffing info not posted: 5
Number of dented cans observed: 3
Number of residents with pneumococcal vaccine deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in glucometer cleaning and fall monitoring deficiencies |
| LPN E | Licensed Practical Nurse | Named in mask wearing and fall monitoring deficiencies |
| CMT F | Certified Medication Technician | Named in mask wearing and infection control deficiencies |
| Housekeeper H | Named in mask wearing and infection control deficiencies | |
| Dietary Aide L | Named in kitchen cleanliness deficiencies | |
| Dietary Aide M | Named in kitchen cleanliness deficiencies | |
| DON | Director of Nursing | Named in infection control, fall monitoring, and staffing posting deficiencies |
| Administrator | Named in multiple deficiencies including infection control, staffing posting, and vaccination | |
| LPN K | Licensed Practical Nurse | Named in glucometer cleaning deficiency |
| NA J | Nursing Assistant | Named in bed rail and infection control deficiencies |
| Kitchen Manager | Named in kitchen cleanliness deficiencies |
Inspection Report
Routine
Census: 37
Deficiencies: 13
Date: Jun 11, 2019
Visit Reason
Routine inspection of Truman Lake Manor Inc nursing home to assess compliance with health and safety regulations, including resident care, staff qualifications, infection control, and facility maintenance.
Findings
The inspection identified multiple deficiencies including failure to maintain a safe and clean environment, incomplete criminal background checks for staff, inadequate resident transfer notifications, incomplete baseline care plans, deficient discharge planning and summaries, use of non-CPR certified staff for resident transport, failure to provide recommended restorative nursing services, lack of dialysis care protocols, failure to ensure nurse aides were certified timely, absence of Legionella prevention plan, and lack of an antibiotic stewardship program.
Deficiencies (13)
Failure to ensure a clean, safe, and homelike environment due to unclean wall vents and lack of backflow preventers on hoses.
Failure to complete Criminal Background Checks or Nurse Aide registry checks timely for four out of five sampled staff.
Failure to notify residents, representatives, and ombudsman in writing of hospital transfers and reasons.
Failure to provide written information on bed hold policy to residents or representatives upon hospital transfer.
Failure to complete baseline care plans within 48 hours, incomplete care plans, and failure to document review or provide copies to residents.
Failure to ensure discharge planning addressed resident goals, needs, caregiver support, and referrals, and failure to include resident and interdisciplinary team.
Failure to provide comprehensive discharge summaries including recapitulation of stay, follow-up appointments, and treatment orders.
Failure to ensure staff transporting full code residents were CPR certified.
Failure to provide restorative nursing services as recommended for residents.
Failure to ensure safe and appropriate dialysis care including lack of physician orders, communication with dialysis center, and staff training.
Failure to ensure nurse aides completed state-approved CNA training within four months of hire.
Failure to implement policies and procedures for inspection, testing, and maintenance of water systems to prevent Legionella growth.
Failure to establish an antibiotic stewardship program including protocols, monitoring, education, and reporting.
Report Facts
Facility census: 37
Residents reviewed: 13
Nursing assistants without certification over 4 months: 5
Restorative care frequency: 3
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA L | Nursing Assistant | Mentioned for working over 16 months without CNA certification |
| NA M | Nursing Assistant | Mentioned for working over 5 months without CNA certification |
| NA N | Nursing Assistant | Mentioned for working over 13 months without CNA certification |
| NA P | Nursing Assistant | Mentioned for working over 12 months without CNA certification |
| NA Q | Nursing Assistant | Mentioned for working over 21 months without CNA certification |
| Maintenance Supervisor | Mentioned for lack of knowledge about backflow preventers and Legionella plan | |
| Business Office Staff C | Mentioned for lack of knowledge about employee background check procedures | |
| Director of Nursing | DON | Mentioned for multiple deficiencies including background checks, care plans, discharge planning, antibiotic stewardship, and restorative therapy |
| Certified Medication Technician G | CMT | Mentioned for completing incomplete discharge summaries |
| Certified Nurse Aide U | CNA | Mentioned for reporting infection signs and symptoms and restorative care observations |
| Restorative Nurse Aide F | RNA | Mentioned for providing restorative care and transporting residents |
| Social Service Designee D | SSD | Mentioned for lack of knowledge about transfer notifications and bed hold policy |
| Administrator | Mentioned for lack of knowledge about transfer notifications, bed hold policy, CPR certification requirements, and antibiotic stewardship |
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