Truman Lake Manor Inc

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to initiate neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits) for one resident (Resident #45) after an unwitnessed fall and failed to complete neurological assessments for two residents (Residents #56 and #61) after each resident sustained a fall with potential for head injury. The facility census was 64. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure nurse aides (NA) were not used more than four months without completing required training and evaluations when the facility did not have an effective process in place to ensure certified nurse aide (CNA) training programs were completed timely for NAs resulting in one NA (NA A) working longer than four months in the facility without completing the CNA training course. The facility census was 64. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was protected from possible contamination at all times when staff failed to keep all food-contact areas clean and when staff failed to air dry dishes. The facility had a census of 64.1. Review of the Food & Drug Administration (FDA) 2022 Food Code showed the objective of cleaning focuses on the need to remove organic matter from foodcontact surfaces so that sanitization can occur and to remove soil from non-foodcontact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to an effective program to identify areas of possible resident entrapment when the facility failed to ensure the side rail gap measurements were within acceptable standards to protect the safety of residents when the zone one (within the rail) measurements for the side rails of three residents (Residents #63, #2, and # 7) were greater than the maximum allowed to prevent entrapment of a body part. The facility census was 64. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a process was in place to clearly and consistently documented each resident's code status preference (if resident wished to receive cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when a person's heartbeat or breathing stops)) when two resident's records (Residents #9 and #8) had inconsistent code status documentation. A sample of 22 was reviewed in a facility with a facility census of 64. [...]

Inspectors wroteThis citation is uncorrected. For prior examples, please see event ID 1DFDCA-H1, exit date 01/07/26, for details. Please refer to event ID 1DFDCA-H2, exit date 03/09/26, for details.

Inspectors wroteThis citation is uncorrected. For prior examples, please see event ID 1DFDCA-H1, exit date 01/07/26, for details. 1. Please refer to event ID 1DFDCA-H2, exit date 03/09/26, for details.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents on the memory care unit from sexual and physical abuse. Resident #1 exhibited repeated behaviors against others, including touching breasts, forceful kissing, unwanted hugs, slapping of the leg. The attempts at unwanted contact impacted four residents (Resident #2, #3, #4, and #5) who exhibited signs of being upset with the contact. The facility did not notify Resident #1's physician of the behaviors or implement new interventions on the care plan to protect residents. The facility census was 67. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of possible abuse made by one resident (Resident #1). The facility census was 71. [...]

Inspectors wroteBased on interview and record review, the facility failed to all allegations of abuse were investigated timely and steps taken to protect residents were documented when the facility did not complete a timely documented investigation with steps taken to protect the resident documented after an allegation of abuse was made by one resident (Resident #1). The facility had a census of 71. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all nurse aides (NA) completed the required competency and certified process within four months of beginning work as an NA, when one NA (NA G) worked nine months as a NA without obtaining the required certification. The facility census was 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to employee a medical director who was actively involved in the implementation of care policies and assisted with coordination of medical care when the facility had not entered into a contract with the medical director and ensured he/she was aware of his/her medical director responsibilities and when when the facility failed to ensure the medical director participated and was involved in completing/updated the facility assessment and attended the Quality Assessment and Assurance (QAA) Committee meeting. The facility census was 70. Review of the facility policy titled Medical Director, dated July 2016, showed the following: -Physician services shall be under the supervision of the Medical Director; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible for all residents when medications when one resident (Resident #1) had an almost full bottle of medication in his/her room, on the memory care unit, unsecured and unattended by authorized personnel. The facility had a census of 70. Review of a facility policy titled Storage of Medication, dated April 2019, showed the following: -The facility stored all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls; -Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to seal and date stored food in refrigerator and freezer; failed to discard dented cans when staff stored dented cans on the shelves along with cans of food staff used to prepare resident food; failed to follow proper hand hygiene while serving food; failed to wash dishes properly between the preparation of separate food items; and failed to keep ice machine free of white substances. The facility's census was 62. 1. Review of the facility's policy titled, Food Storage (Dry, Refrigerated and Frozen), dated 2016, showed the following: -Food shall be stored on shelves in a clean, dry area, free from contaminants. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program, based on facility policy and standards of practice, when multiple staff did not wear face coverings and appropriate personal protective equipment (PPE) while assisting/conversing with 14 residents on the designated hall during a coronavirus disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) outbreak in the facility. The facility census was 62. Review of the facility's policy titled Covid-19 Prevention, Response and Reporting, revised 01/01/24, showed the following: -It is the policy of the facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify residents' physicians of all changes in condition when when staff failed to ensure one resident's (Resident #29) physician was aware of the death of the resident's spouse prior to discontinuing an antianxiety medication and failed to report changes in the resident's condition after the discontinuation of the anti-anxiety medication. The facility census was 62. Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction (GDR), revised [DATE], showed when a medication is tapered or stopped, the staff will closely monitor the resident and will inform the physician if there is a return or worsening of symptoms. Review of the facility's policy titled, Change in a Resident's Condition or Status, revised [DATE], showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to repair floors in resident rooms for two residents (Resident #1 and Resident #7) out of a sample of 20 residents. The facility census was 62. Review of the facility's policy titled, Maintenance Service, revised December 2009, showed the following: -Maintenance service shall be provided to all areas of the building, grounds, and equipment; -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to, maintaining the building in good repair and free from hazards. 1. Review of Resident 1's face sheet (admission data) showed the following: -admission date of 07/24/20; [...]

Inspectors wroteReview of the facility policy titled Telephone Orders, undated, showed the following: -Verbal telephone orders may only be received by licensed personnel; -Orders must be recorded in the resident's medical record; -The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. 1. Review of Resident #59's face sheet (a brief resident profile sheet) showed the following information: -admission date of 09/26/23; -Diagnoses included chronic pancreatitis (the organ becomes permanently damaged from inflammation), gastrostomy (a surgical incision into the stomach), chronic kidney disease stage 2 (mild kidney damage), chronic obstructive pulmonary disease (COPD - a group of lung diseases making it difficult to breathe), and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of safety hazards when staff failed follow the care plan when transferring one resident (Resident #52) of two sampled residents who was care planned to need a mechanical lift for transfers and when the staff failed to implement planned fall intervention for one resident (Resident #46), assessed as a fall risk, when staff did not have a fall mat in place when the resident was in bed. The facility census was 62. 1. Review of the facility policy Safe Lifting and Movement of Residents, revised July 2017, showed the following: -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure incontinent residents received care and appropriate treatment to prevent and treat urinary tract infections when staff failed to follow-up with the physician regarding hi/her response to a positive urine culture for one resident (Resident #32) resulting in a delay of care. A sample of 20 residents was reviewed in a facility with a census of 62. 1. Review of Resident #32's face sheet showed the following: -admission date of 11/07/23; -Diagnoses included bipolar disease (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), vascular dementia, and reduced mobility. Review of the resident's laboratory results, reported on 02/06/24, showed the following: -Clarity-hazy (reference range:clear); -Nitrite (abnormal presence in urine) - positive (reference range: negative); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all resident's drug regimens were free from unnecessary drugs when staff failed to provide adequate monitoring related to the administration of one resident's (Resident #49) Lasix (a diuretic medication) and potassium resulting in staff administering the Lasix out of ordered parameters and failing to administer the potassium. A sample of 20 residents was reviewed in a facility with a census of 62. Review of the facility's policy titled Medication and Treatment Orders, revised July 2016, showed the following: -Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control (IPC) as the infection preventionist (IP) for the facility's infection prevention control program. The census was 50. Record review showed the facility did not provide a policy related to the position of infection preventionist. 1. During an interview 1/27/2022, at 3:26 P.M., the Director of Nursing (DON) said the former DON was the IP for the facility. She was the interim DON and filled the role of the facility's IP staff member. The facility was in the process of hiring a new DON and planned to have that staff complete the training. The DON said she did not have specialized infection preventionist training and had not started the Centers for Disease Control and Prevention's (CDC) IP training.

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond in an amount sufficient to ensure full protection of resident funds. The facility's census was 50. Record review showed the facility did not provide a policy regarding resident funds or surety bond. 1. Record review of the Department of Health and Senior Services (DHSS) records showed the facility had an approved bond for $45,000.00. Record review of the facility's reconciled bank statements from January 2021 through December 2021, showed an average monthly balance of $96,000.00. Based on this amount, the facility needed a bond of at least $144,000.00 (one and a half times the average monthly balance). During an interview on 1/27/2022, at 9:31 A.M., the business office manager said he/she did not know the amount or process of the surety bond. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or alternative denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Residents #24 and #27) who remained in the facility and one resident (Resident #205) who discharged home upon discharge from Medicare Part A services. The facility census was 50. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on interview and record review, the facility failed to check criminal background checks (CBC) or Nurse Aide (NA) registry (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term are facility) for a federal indicator prior to starting employment and continued resident contact for five staff (Registered Nurse (RN) N, Certified Nursing Assistant (CNA) I, Dietary O, CNA P, and RN A) out of six sampled staff . The facility census was 50. Record review of the facility's (undated) policy titled Abuse Prevention Program, dated 2001 and revised 12/2016, showed the following information: -The facility will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer for four residents (Resident #5, #15, #24 and #45). A sample of 21 residents was selected for review out of a facility census of 50. Record review of the facility's policy titled Transfer or Discharge Notice, dated December 2016, showed the following information: -The resident and/or resident representative will be notified in writing of the following information: -The reason for the transfer or discharge; -The effective date of the transfer or discharge; -The location to which the resident is being transferred or discharged ; -The facility bed hold policy; -The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; [...]

Inspectors wroteBased on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for three residents (Residents #5, #15, and #24) who were transferred out to the hospital. A sample of 21 residents was selected for review; the facility census was 50. Record review of the facility's policy titled Transfer or Discharge Notice, dated December 2016, showed the the resident and/or resident representative will be notified in writing of the facility bed hold policy. Record review of the facility's Emergency Transfer Notice, dated August 2018, showed facility staff must date and sign that the Bed Hold Guidelines was given to the resident/resident representative and attach a copy of the guidelines to the transfer form. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a a risk/benefit review and document alternatives attempted prior to bed rail use for one resident (Resident #15); failed to obtain informed consent for the use of bed rails for one resident (Resident #18); and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for six residents (Residents #2, #15, #18,#24, #27, and #37); and failed to address the use bed rails in the residents' care plans for three residents (Residents #18, #24, and #37). The facility census was 50. Record review showed the facility did not provide a policy pertaining to the use of bed rails to aide residents in positioning or pertaining to completing gap/safety measurements prior to a resident's use of bed rails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep food safe from potential contamination when surfaces had a build-up of grease and lint; staff stacked dishes while still wet; did not have a policy to ensure dented cans were not used; and had unlabeled/undated items in the freezer. The facility census was 50. 1. Record review of the facility's policy, titled Food Receiving and Storage, dated 2001 and revised July 2014, showed food services, or other designated staff, will maintain clean food storage areas at all times. Record review of the 2013 Missouri Food Code showed the following information: -Physical facilities shall be cleaned as often as necessary to keep them in sanitary condition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program that provided a safe and sanitary environment for all residents during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic when staff failed to follow their policy and standards of practice when staff failed to wear personal facemasks appropriately around multiple residents (including Resident #5, #9, #26 #35, #36, #42, #49, and #51) in the COVID isolation unit. The facility failed to ensure staff followed acceptable standards of practice for infection control when they did not properly clean and disinfect glucometers (digital machine used to test the glucose/sugar level in blood) for three randomly observed residents (Resident #13, #14, and #28). The facility census was 50. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccines (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain and spinal cord membranes, typically caused by an infection), and sepsis (potentially life-threatening complication of an infection)) to three residents (Resident #5, #37, and #202) following the residents' admission to the facility, or to document any prior pneumococcal vaccine history. The facility census was 50. Record review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following information: -Two pneumococcal vaccines are recommended for adults; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document post fall nursing monitoring, including full neurological checks (check level consciousness) for 72 hours, for one resident (Resident #27), who sustained falls with a head injury. The facility census was 50. Record review of the facility's fall policies showed the policies did not address follow-up assessments such as neurological checks, including how often to complete the checks, how long to complete the checks, and what was part of the checks. Record review of Saunder's Medical-Surgical Nursing, 4th edition, 2002, showed that neurological assessments (neuro checks) can detect early signs of central nervous system (brain) deterioration and are commonly done after a person sustains a head injury to detect complications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a process was in place to routinely test wanderguards (electronic device used to prevent elopements) for effectiveness for one resident (Resident #47) with a history of exit seeking behaviors. The facility census was 50. Record review of the facility policy, titled Emergency Procedure-Missing Resident, revised August 2018, showed the following information: -Resident elopement resulting in a missing person is considered a facility emergency; -Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a procedure in place to ensure staff changed oxygen equipment, and documented the change, per professional standards and failed to administer and care plan oxygen use per physicians' orders for two residents (Resident #3 and Resident #24). The facility census was 50. Record review of the facility's policy, titled Oxygen (O2) Therapy, dated 11//28/2017, showed the following information: -Oxygen therapy may be provided through various types of supply and delivery systems. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheters, oxygen canisters, cylinders or concentrators; [...]

Inspectors wroteBased on observation and interview, the facility failed to post daily nurse staffing information in a clear and readable format in a prominent place readily accessible to residents and visitors. The facility census was 50. 1. Observation showed the facility did not post nurse staffing information in a prominent place accessible to residents and visitors on the following dates and times: -On 1/23/2022 at 11:59 A.M., -On 1/24/2022 at 1:00 P.M. -On 1/25/2022 at 3:30 P.M.; -On 1/26/2022 at 9:59 A.M.; -On 1/27/2022 at 8:45 A.M. During an interview on 1/26/2022, at 11:04 A.M., the Director of Nursing (DON) said the night shift nurse was responsible for posting the daily nurse staff information every night, but it had not been done for some time. It had fallen behind and had not being monitored. [...]