Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Truman Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cognitive impairment, bipolar disorder, and aggressive behaviors had a UA ordered to check for possible causes of the behavior changes, but the order was not entered into the chart timely and the urine sample was not obtained for eight days. Staff documented only one failed attempt because the resident was sleeping, with no other attempts or notifications to the FNP recorded. Interviews showed the nurse did not enter the order, did not document collection attempts, and did not notify the FNP when the specimen could not be obtained.
A resident with Alzheimer’s disease and severe cognitive impairment, known for physical and verbal aggression, became involved in an altercation with a CNA during which visitors and staff reported that the CNA yelled, cursed, and made threatening statements, including references to handcuffs and hitting back. Staff, including an RN and CMT, recognized such conduct as abuse and understood that all abuse allegations must be reported to the state within two hours, and the RN reported the allegation to the Administrator and DON. The DON acknowledged that inappropriate things were said while the CNA tried to get away from the resident, and the Administrator acknowledged the handcuff comment was not appropriate, but neither treated the incident as abuse, and the facility did not self-report the allegation to the State Survey Agency as required.
The facility failed to investigate an allegation of verbal abuse when a CNA allegedly yelled, cursed, and made threatening statements toward a cognitively impaired resident with Alzheimer's disease and behavioral symptoms. A visitor reported the incident to an RN, who believed it was abuse and notified the Administrator, and another staff member reported a similar threatening statement relayed by a visitor. Although facility policy required the Administrator or designee to investigate and complete a written abuse/neglect investigation report with written statements from involved staff, the DON did not interview the CNA or obtain statements, the Administrator did not speak with the CNA before or after the CNA left employment, and no written investigation was documented in the medical record or with DHSS. The CNA later admitted to using profanity and suggesting the resident could leave in handcuffs, and acknowledged this could be considered abuse, yet the required abuse investigation process was not carried out.
A resident with a recent below-knee amputation, CAD, Parkinson’s disease, neuropathy, vertigo, and documented fall risk was care planned and evaluated by PT/OT as needing assistance and at least supervision or touching assistance for transfers, toileting, and tub/shower use. Despite this, an aide who had escorted the resident to the shower room was told by a nurse that the resident did not need help, and the resident ultimately showered and transferred to the toilet alone. The resident then lost balance and fell against the toilet, reopening the amputation site. Multiple staff, including therapy, CNAs, nursing, the DON, the MDS coordinator, and the physician, later stated the resident required standby or supervision for transfers and showers, while some were unsure of the exact assistance level, demonstrating that the resident was left unsupervised contrary to assessed needs.
A resident with CAD, Parkinson’s disease, neuropathy, and a recent below-the-knee amputation, who ate meals in their room and was on a carb-consistent diet with goals to maintain weight and consume 75% of meals, did not receive at least one scheduled dinner and had to actively seek out a missed breakfast tray. The facility’s policy required three daily meals at typical times or per resident preference, but interviews showed that CNAs, nursing aides, kitchen staff, the DM, an LPN, the DON, and the Administrator had conflicting understandings of who was responsible for taking meal orders, communicating them to dietary, tracking who ate, and ensuring all residents received trays. Staff acknowledged that the resident reported missed meals and that the resident had missed at least two meals, yet these incidents were not reported to the DON and the expected checks between dietary and nursing when a meal order was missing did not occur, resulting in failure to provide meals in accordance with the resident’s needs and the facility’s policy.
Staff failed to use proper hair and beard nets and did not follow handwashing and glove protocols during food preparation and service. A dietary aide with facial hair did not wear a beard net, and the dietary manager wore a hairnet that did not cover all hair. The dietary manager also changed gloves without washing hands and handled ready-to-eat food with contaminated gloves, contrary to facility policy and FDA guidelines.
Two residents were not protected from misappropriation of their property and funds when a CMT replaced missing narcotic pain medication with personal pills and an Activity Director made over $700 in unauthorized purchases using a resident's debit card. In both cases, facility staff failed to follow protocols for medication management and financial oversight, resulting in the wrongful use of resident belongings and money.
A resident with multiple wounds under the abdominal folds did not consistently receive wound care as ordered, with several missed treatments and incomplete documentation of refusals. Staff interviews confirmed that wound care and refusals should be documented and care planned, but records showed gaps in both treatment administration and weekly skin assessments. This lack of consistent care and documentation led to the resident developing cellulitis, requiring antibiotic therapy.
A resident with multiple comorbidities and moderate risk for pressure ulcers developed a new open sore, but staff failed to consistently complete and document weekly skin assessments, did not include the wound and its care in the care plan, and missed at least one wound care treatment without documentation. Staff interviews revealed inconsistent practices in wound assessment and care planning, and the resident reported having to request wound care and doubted that proper wound measurements were being performed.
A CMT brought in narcotic pain medication from their own prescription to replace missing tablets in a resident's medication card, resulting in a non-facility-supplied pill being administered to a resident. The incident involved improper documentation, failure to follow controlled substance protocols, and delayed reporting to management. The resident had chronic pain and other medical conditions but was unaware of the medication error.
Delayed UA Order Entry and Specimen Collection
Penalty
Summary
The facility failed to provide care according to orders and standards of practice when a urine analysis (UA) ordered for a resident with significant cognitive impairment, bipolar disorder, aggressive behaviors, and wandering behaviors was not transcribed into the electronic record timely, was not obtained timely, and was not followed by physician notification or documentation of the delay. The family nurse practitioner (FNP) ordered a UA with culture and sensitivity to evaluate possible causes of the resident’s increased aggression and planned to review the results at follow-up, but the order was not entered into the physician order sheet until three days later. After the order was eventually entered, staff did not obtain the urine sample for eight days after the original order. The treatment record showed one note that the order was not completed because the resident was sleeping, but there were no other documented attempts to collect the specimen. Nursing notes from the period also did not document attempts to complete the UA order. The FNP later documented that the UA had still not been obtained when the resident was seen for follow-up. During interviews, the FNP stated the nurse was expected to enter the order and notify him/her if the urine sample could not be obtained in a timely manner, and said staff did not tell him/her about failed attempts to collect the specimen. RN staff and leadership stated the nurse should attempt collection as soon as possible, document unsuccessful attempts, inform the next shift, and notify the FNP if the sample could not be obtained within 24 hours. Staff interviews also showed the order was not entered by the nurse when received and that attempts to collect the urine were not documented.
Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of employee-to-resident verbal abuse to the State Survey Agency (DHSS) within the required two-hour timeframe. Facility policy required zero tolerance for abuse, including verbal and mental abuse, and directed that suspected incidents be reported to appropriate authorities in accordance with federal and state law, including the Missouri Elderly Abuse and Neglect Hotline. Despite this, an allegation that a CNA yelled and used profane, threatening language toward a resident was not self-reported to DHSS. The resident involved had Alzheimer’s disease, dementia with behavioral disturbances, and severe cognitive impairment, with documented potential for physical and verbal aggression and difficulty with redirection. On the day of the incident, staff documentation indicated the resident had been aggressive with multiple staff, grabbed a CMT by the wrists, wandered into other residents’ rooms, and was not easily redirected. Around this time, a visitor reported to RN C that a CNA had yelled and cursed at the resident, including statements that the resident should be taken out in handcuffs and threats to knock the resident down. Another staff member reported that a visitor heard the CNA say that if the resident hit the CNA, the CNA would hit the resident back. Multiple staff interviews confirmed that yelling or cursing at a resident is considered abuse and that all allegations of abuse or neglect must be reported to the state within two hours. RN C stated that the incident was reported to the Administrator the day it occurred and that RN C believed it was abuse and told the DON it should be reported. The DON acknowledged that visitors heard the CNA yelling at the resident and that inappropriate things were said, but did not consider it abuse and did not speak with the CNA about the incident. The Administrator acknowledged that the CNA told the resident they needed to be in handcuffs and that this was not appropriate, but did not view the altercation as abuse and was not informed that visitors heard cursing or threats. DHSS records showed the facility did not self-report this allegation of employee-to-resident abuse, resulting in the cited deficiency.
Failure to Investigate Allegation of Verbal Abuse Toward a Resident
Penalty
Summary
The facility failed to ensure that an allegation of employee-to-resident verbal abuse was thoroughly investigated in accordance with its Abuse Prevention Program policy. The policy required that when any incident or allegation of abuse, neglect, mistreatment, or misappropriation occurred, the Administrator or designee would investigate, complete a written Resident Abuse/Neglect Investigation Report, obtain written findings from all individuals participating in the investigation, and involve the Social Service Designee as appropriate. Despite these requirements, no written investigation or abuse/neglect investigation report was completed for the allegation involving a CNA and one resident. The resident involved had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and hypertension, with care plan interventions noting potential for physical and verbal aggression related to Alzheimer's disease and severe cognitive impairment documented on the MDS. The record showed the resident had recently been aggressive with multiple staff, cornering a CMT and grabbing their wrists, and was described as wandering, not easily redirected, and having a stern and angry demeanor. On the date of the incident, a visitor reported to an RN that a CNA yelled and cursed at the resident, stating the resident should be taken out in handcuffs and threatening to knock the resident down. Another staff member reported that a visitor told them they heard the CNA say that if the resident hit the CNA, the CNA would hit the resident back. The RN who received the initial report believed the incident constituted abuse and reported it to the Administrator. Despite these reports, the DON did not speak with the CNA, did not obtain written statements from the CNA or any staff, and did not know if an investigation had been opened. The Administrator acknowledged that it was not appropriate for staff to tell a resident they needed to be in handcuffs and stated that she asked staff if they heard or saw the altercation, with all denying direct observation, but she did not speak with the CNA before or after the CNA left employment. The CNA later admitted to telling the resident to stop “fucking” hitting them and that the resident was lucky not to go out in handcuffs, and acknowledged that yelling or cursing at a resident could be considered abuse. Review of the resident’s medical record and DHSS records showed no documentation of an investigation into the allegation of employee-to-resident abuse, and staff interviews confirmed that administration did not initiate or complete the required written investigation.
Resident Left Unsupervised in Shower/Toilet Area Resulting in Fall After Amputation
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and assistance during bathing and toileting for a resident with significant fall risk factors. The resident had a recent below-the-knee amputation, diagnoses including CAD, Parkinson’s disease, and neuropathy, and therapy evaluations documenting decreased strength, balance, activity tolerance, vertigo, unsteady gait, poor standing balance, and a high fall risk. The resident’s care plan and PT/OT evaluations indicated the need for assistance with transfers, including sit-to-stand, toilet transfers, and tub/shower transfers with supervision or touching assistance, and noted that the resident required assistance with activities of daily living and transfers. On the day of the incident, staff assisted the resident to the shower room. At the shower room door, the aide who had been assisting the resident was told by a nurse that the resident did not need assistance with showering, reportedly based on the belief that the plan of care indicated the resident was independent with showers. The resident verbally stated to staff that assistance was needed due to instability, and the aide agreed, but the aide ultimately left after the resident said he/she did not want to get the aide in trouble and would shower independently. The resident then showered alone, transferred independently to the toilet to get dressed, and subsequently lost balance and fell against the toilet, landing on the buttocks and reopening the amputation site. Interviews with multiple staff members, including therapy staff, CNAs, nursing assistants, the LPN, the DON, the MDS coordinator, and the facility physician, consistently indicated that the resident required at least standby or supervision assistance for transfers, toileting, and showers, particularly due to the recent amputation and fall risk. Staff also reported that the resident was alone in the shower room and bathroom at the time of the fall, and several staff members were unsure of the exact assistance level required or what the care plan specified. The facility’s own accident/incident policy required prompt investigation and documentation of accidents, but the deficiency centers on the failure to provide the supervision and assistance with transfers and showering that were indicated by the resident’s condition and therapy assessments, resulting in the resident being left unattended and experiencing a fall.
Failure to Ensure Timely Meal Service and Delivery of Trays to a Resident Eating in Room
Penalty
Summary
The deficiency involves the facility’s failure to provide meals in a timely manner in accordance with a resident’s needs and preferences, resulting in missed meals for one cognitively intact resident. The facility’s policy, titled “Frequency of Meals,” required that each resident receive at least three meals daily at times comparable to typical community mealtimes or in accordance with resident needs, preferences, requests, and the plan of care, and that no more than 14 hours elapse between the evening meal and breakfast. Resident #2, admitted for rehabilitation after a below-the-knee amputation and with diagnoses including CAD, Parkinson’s disease, and neuropathy, had a care plan that included a carb-consistent diet, goals to maintain stable weight, avoid nutritional deficits, and consume 75% of the ordered diet daily. The resident ate meals in his/her room due to hand tremors associated with Parkinson’s disease. The resident reported that on one evening, staff came to the room at approximately 7:30 p.m. to pick up a dinner tray, but the resident had never received a dinner tray that night. The resident further reported that the following morning, he/she did not receive a breakfast tray and had to “chase down” the breakfast tray around 9:30 a.m., and also reported to the Social Services staff that an aide came to get a tray on the evening in question even though no dinner had been served. Therapy staff and the Director of Rehab confirmed that the resident told them he/she had not received a dinner tray on that date. Another nursing aide stated the resident had missed two meals, one lunch and one dinner, though the aide could not recall the specific days. Interviews with multiple staff revealed inconsistent and unclear practices and responsibilities for ordering, preparing, and delivering meal trays to residents who eat in their rooms. CNAs, nursing aides, kitchen staff, the DM, an LPN, the DON, and the Administrator each described differing understandings of who was responsible for taking meal orders, communicating them to the kitchen, tracking who ate, and ensuring all residents received their meals. The DM and kitchen staff indicated that when no menu or order is received, kitchen staff are supposed to check with nursing staff or the charge nurse, and the cook stated that unmarked names on the roster should be checked with the charge nurse. However, staff also reported that the resident’s missed meals were not reported to the DON, and there was no indication that the required checks and communication occurred to ensure the resident received all scheduled meals in accordance with facility policy and the resident’s care plan.
Improper Food Handling Due to Inadequate Hair Restraints and Hand Hygiene
Penalty
Summary
The facility failed to ensure that food was protected from possible contamination during storage, preparation, and service due to improper use of hair and beard nets, as well as inadequate hand hygiene and glove use by dietary staff. Observations revealed that a dietary aide with substantial facial hair was not wearing a beard net while preparing uncovered plates of food, and when a beard net was eventually donned, it did not fully cover all facial hair. The dietary manager was also observed wearing a hairnet that did not cover all hair, specifically leaving bangs exposed, and did not correct the dietary aide's improper beard net use. Multiple staff interviews confirmed that hair and beard nets should be worn at all times in the kitchen and must fully cover all hair to prevent food contamination, but these protocols were not followed during food preparation and service. Further observations showed that the dietary manager did not follow proper handwashing procedures between glove changes. The manager was seen removing gloves and putting on new ones without washing hands, then continued to handle food and utensils. Additionally, the manager touched ready-to-eat food items, such as hamburger buns and grilled cheese sandwiches, with gloves that had become contaminated from previous tasks. Staff interviews consistently indicated that hands should be washed before donning new gloves and that failure to do so could contaminate food, but these procedures were not adhered to during the observed meal service. The facility's own policies, as well as the FDA 2013 Food Code, require strict adherence to personal hygiene, including the use of effective hair restraints and proper handwashing and glove use to prevent food contamination. Despite these requirements, both the dietary manager and dietary aide failed to comply with established protocols, and the dietary manager did not enforce corrective actions when improper practices were observed. The director of nursing confirmed that the dietary manager was responsible for ensuring compliance with these standards.
Failure to Protect Residents from Misappropriation of Property and Funds
Penalty
Summary
The facility failed to protect residents from misappropriation of personal property in two separate incidents involving two residents. In the first case, a resident with chronic pain, anxiety, depression, and a history of stroke was prescribed Hydrocodone-Acetaminophen (Norco) for pain management. On a specific day, it was discovered during a controlled medication count that two tablets of the resident's Norco were missing. The Certified Medication Technician (CMT) involved could not account for the missing tablets and subsequently retrieved two pills from their own personal prescription, taping them into the resident's medication card to correct the count. The CMT admitted to this action during an interview, acknowledging it was inappropriate, but denied taking the resident's medication. The Registered Nurse (RN) who participated in the count did not immediately report the incident, and the facility's procedures for handling discrepancies in controlled medication counts were not followed as required by policy. In the second incident, another resident, who was cognitively intact but required assistance with daily activities, experienced over $700 in unauthorized purchases on their Direct Express debit card. The facility's former Activity Director (AD) had access to the resident's card to make purchases on the resident's behalf. The resident discovered the fraudulent charges and reported them to staff, stating that the AD admitted to using the card for personal purchases and promised to reimburse the resident with cigarettes and candy. However, after the AD's termination, the resident did not receive further compensation. The Business Office Manager and the resident reviewed bank statements and identified multiple unauthorized transactions for items the resident did not possess. The Social Services staff assisted the resident in canceling the card and reporting the charges but did not notify Adult Protective Services or the elder abuse hotline. Both incidents demonstrate failures in the facility's systems for safeguarding resident property and money. In the first case, there was a lack of adherence to controlled medication handling protocols, and in the second, there was insufficient oversight of staff access to resident funds and inadequate reporting of suspected misappropriation. The residents involved were not fully protected from the wrongful use of their belongings or money, as required by facility policy.
Failure to Document and Administer Wound Care and Refusals Resulting in Infection
Penalty
Summary
The facility failed to provide the highest quality of care and ensure that a resident with skin concerns received treatment and care in accordance with professional standards of practice. The resident, who was cognitively intact and required substantial to maximum assistance for mobility, had a history of high blood pressure, obesity, and chronic pain. Over the course of several weeks, the resident developed multiple open areas and wounds under the abdominal folds and pannus, which were documented in skin assessments and required specific wound care treatments per physician orders. Despite clear orders for wound care, the facility did not consistently document the administration of treatments or the resident's refusals. The Treatment Administration Record and Medication Administration Record showed multiple instances where wound care was not administered, with some entries noting resident refusal and others lacking any supporting documentation or explanation. Additionally, there were gaps in weekly skin assessments, and measurements were sometimes omitted. The resident reported that treatments were often missed or delayed, particularly when they were in bed, and staff did not return to provide care when requested. Interviews with facility staff, including the ADON, LPNs, DON, and the MDS/Care Plan coordinator, confirmed that refusals and wound care should be documented and care planned, and that weekly skin assessments were expected. However, staff were not always aware of missed assessments or incomplete documentation. The lack of consistent documentation and follow-through on wound care and refusals ultimately led to the resident developing cellulitis, requiring antibiotic treatment and further physician intervention.
Failure to Accurately Monitor, Document, and Care Plan Pressure Ulcer
Penalty
Summary
The facility failed to provide the highest quality of care by not accurately and completely monitoring and documenting wounds for a resident at risk for pressure ulcers. Despite the facility's policies requiring weekly wound assessments, documentation of wound descriptors, and care planning for all wounds, there were multiple instances where these protocols were not followed. The resident, who had diagnoses including multiple sclerosis, hypertension, and kidney failure, was assessed as being at moderate risk for pressure ulcers and required substantial to maximum assistance for mobility. Upon re-admission, the resident developed a new open sore on the left buttock, which was documented and treated per physician orders, but subsequent weekly skin assessments failed to consistently identify or document the wound. Review of the resident's records showed that weekly skin assessments often indicated no skin issues, even after the wound was identified, and there were missed or refused assessments that were not followed up appropriately. The care plan did not address the resident's wound or its treatment, despite the presence of a physician order for wound care. Additionally, there was a missed wound care treatment with no supporting documentation, and after a certain date, no further skin assessments were documented in the electronic medical record. Interviews with staff, including the DON, ADON, LPNs, and the MDS/Care Plan Coordinator, revealed inconsistencies in completing weekly skin assessments and a lack of clarity regarding responsibility for wound measurement and documentation. The resident reported having to request wound care from staff, expressed concerns that wound care was not performed as required, and believed that staff did not measure the wound weekly. Observations confirmed the presence of open areas and non-blanchable redness on the resident's buttocks. Staff interviews corroborated that weekly skin assessments were not consistently completed, wounds were not always care planned, and floor nurses did not measure wounds. The facility did not have a current wound care nurse, and the DON was expected to assume those responsibilities.
Improper Use of Staff's Personal Narcotic Medication for Resident
Penalty
Summary
A deficiency occurred when a Certified Medication Technician (CMT) brought narcotic pain medication tablets from their personal prescription into the facility and placed them into a resident's medication card. This action was taken after a discrepancy was found during the controlled medication count, where two tablets of the resident's prescribed Norco were missing. The CMT, unable to account for the missing tablets, retrieved two pills of the same medication and strength from their vehicle and taped them into the resident's medication card to correct the count. Subsequently, a staff member administered one of these non-facility-supplied pills to the resident for pain management, as documented in the medication administration record. The administration of this medication was not properly documented by the CMT on the medication administration record, and there was no entry in the resident's progress notes regarding the medication error, assessment of the resident's condition, or notification of the resident's physician following the incident. The facility's procedures for handling controlled substances and documentation were not followed, and the use of a staff member's personal medication for a resident was confirmed to be unacceptable practice by the facility's pharmacy representative. The resident involved had a history of chronic pain, low back pain, anxiety disorder, major depression, and stroke, and was cognitively intact and independent with most activities of daily living. The resident was not aware of any misappropriation of medication or property and did not report any recent increase in sedation or pain. Interviews with staff revealed confusion and lack of adherence to proper protocols regarding the administration and documentation of controlled medications, as well as delayed reporting of the incident to facility management.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lamar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Shepherd Community Care And Rehabilitation | 19.6 mi | ★★★★★ | 0 | 0 |
| Moore Few Care Center | 22.7 mi | ★★★★★ | 0 | 0 |
| Arma Operator, Llc | 23.2 mi | ★★★★★ | 1 | 0 |
| Medicalodges Frontenac | 23.4 mi | ★★★★★ | 0 | 0 |
| Pittsburg Care And Rehab | 23.9 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Truman Healthcare & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.