Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Truman Lake Manor Inc during CMS and state inspections, most recent first.
Incomplete neurological assessments after resident falls. The facility failed to start neuro checks for a resident after an unwitnessed fall and failed to complete required neuro assessments for two other residents after falls with head injury concerns. The affected residents had diagnoses including dementia, impaired mobility, and repeated falls, and documentation showed bruising, hematomas, and later complaints of head pain or pain to the eyebrow/face. Staff interviews confirmed neuro checks should have been initiated and continued for unwitnessed falls and falls involving possible head injury.
Nurse aide training and competency requirements were not met when a nurse aide worked more than four months without documentation of completing the CNA training program. The facility stated it could not secure a CNA instructor in time, so the aide was briefly terminated and rehired part-time while enrolled in an online CNA class, with the DON and ADON monitoring module and test completion.
Kitchen staff failed to keep food-contact areas clean and failed to air dry dishes before stacking or storing them. Surveyors observed a dirty can opener, toaster, and prep table with food crumbs and grease/lint buildup, and multiple plastic cups, mugs, plate covers, bowls, and drinking glasses stacked upside down with water trapped inside and no air flow. Staff interviews showed inconsistent cleaning practices and acknowledged that dishes were not always left to dry completely before being put away.
Bed rail safety checks showed Zone 1 gaps of 7 inches for three residents, exceeding the FDA maximum of 4 3/4 inches. One resident had Bell’s palsy, falls history, reduced mobility, and cognitive impairment; another had Alzheimer’s disease, dementia, a tibia fracture, and needed max assist for bed mobility; and a third had quadriplegia and needed max assist for bed mobility. Observations found large square openings in the rails, a mattress separated from the frame, and staff interviews showed the Housekeeping Supervisor measured the rails while nursing leadership kept the forms and was responsible for compliance.
Inconsistent code status documentation was found for two residents. One resident had DNR orders in the EMR and POS, but the room sticker, care plan, and physical chart binder showed full code, while staff knew the status had changed but did not know when or why all areas were not updated. Another resident had DNR orders and a DNR care plan, but the DNR paperwork was missing from the binder and the binder spine was labeled full code; an LPN said CPR would be started because there was no DNR indicator. Staff interviews showed confusion about where code status should be documented and who was responsible for keeping the EMR, paper chart, and room indicators consistent.
The facility failed to timely report suspected abuse, neglect, or theft and did not ensure that the results of its investigations were reported to the proper authorities. This uncorrected citation is linked to a complaint investigation and references prior survey events that also identified problems with timely reporting and communication of investigation outcomes.
A deficiency was cited for the facility’s ongoing failure to respond appropriately to all alleged violations. The citation remains uncorrected and is associated with prior survey events and a complaint investigation, indicating repeated noncompliance with requirements to address reported concerns, though no specific resident details are provided.
Failure to protect residents from sexual and physical abuse: A resident with dementia and severe cognitive impairment repeatedly entered other residents’ rooms, kissed, touched, grabbed, and struck peers, including forcing unwanted contact and invading personal space. Several residents were upset or resisted the contact, but the record showed no new care plan interventions for protection, no physician notification for the resident’s escalating behaviors, and no documentation or assessment for several affected residents.
The facility failed to follow its abuse reporting policy when a resident with paranoid schizophrenia and moderate cognitive impairment alleged that another resident was sexually assaulting them, using explicit verbal statements and gestures. An LPN documented the allegation and concluded it was impossible based on the other resident’s apparent condition and the belief it was a hallucination, did not notify administration, and did not report the allegation to the state. DHSS records confirmed no report was made. Staff interviews revealed inconsistent understanding of required time frames and processes for reporting abuse allegations, while leadership stated that such allegations should be reported to administration immediately and to the state within two hours.
A resident with schizophrenia, moderate cognitive impairment, delusions, and verbal behavioral symptoms made a specific verbal allegation of sexual abuse by another resident, including describing the act with a hand gesture. An LPN documented the allegation and told the resident the act was impossible and that racial slurs were not tolerated, but did not perform or document a resident assessment, did not initiate or document any protective measures, and only relayed the information in shift report. The medical record contained no further assessment, notifications, or follow-up related to the allegation, and facility leadership later stated they were unaware of the report and that no required abuse investigation with interviews and chart review had been completed or submitted.
A nurse aide worked as an NA for nine months without active CNA certification, despite the facility policy and staff statements that certification had to be completed within four months. Record review showed no documentation of certification completion, the CNA registry showed no active certification, and staffing sheets showed the aide continued working night shifts as an NA. The NA, CNA Instructor, DON, and Administrator all stated the aide should have been certified within the required time frame, but he/she was not moved to another department or terminated.
The facility failed to ensure that the newly appointed Medical Director, Physician A, was actively involved in implementing care policies and coordinating medical care. Despite agreeing to the role, Physician A had not signed a formal contract and had not participated in QAPI meetings, as confirmed by the Director of Nursing and the Administrator. This lack of involvement contravened the facility's policies, which require the Medical Director to oversee physician services and participate in quality improvement efforts.
A resident in a memory care unit had an unsecured bottle of Brukinsa, a cancer medication, in their room, contrary to facility policy requiring secure storage. The resident, who was cognitively intact and chose the unit for a private room, had no dementia diagnosis. Staff acknowledged the medication should not have been left unsecured, posing a risk to other wandering residents.
The facility failed to store and prepare food according to professional standards, leading to potential contamination. Observations revealed improperly sealed, labeled, and dated food items, use of dented cans, inadequate hand hygiene, improper dishwashing, and an unclean ice machine. Staff interviews confirmed these practices were not consistently followed.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Multiple staff members, including CNAs and the Administrator, did not wear appropriate PPE while assisting or conversing with residents on the designated COVID hall. COVID-positive staff were observed not wearing PPE, contrary to the facility's policy and CDC guidelines.
The facility failed to notify a resident's physician of significant changes in the resident's condition following the death of the resident's spouse and the discontinuation of an anti-anxiety medication. The resident exhibited increased emotional distress and behavioral changes, but staff did not document or report these changes to the physician as required by facility policies.
The facility failed to ensure a clean and homelike environment for two residents whose rooms had cracked and missing floor tiles. One resident, who uses an electric wheelchair, reported the issue had persisted for over two years, while another resident with COPD and OCD had a bathroom floor in disrepair. Maintenance was aware but had not yet completed the necessary repairs.
A facility failed to document an order change and perform dressing changes as ordered for a resident with a G/J-tube, resulting in routinely saturated dressings and potential risk of infection. The DON admitted to forgetting to enter the new order into the electronic medical record, leading to the deficiency.
The facility failed to follow care plans for transferring a resident and did not implement planned fall interventions for another resident. One resident, who required a mechanical lift, was manually transferred without a gait belt, and another resident, assessed as a fall risk, did not have a fall mat in place while in bed, leading to unsafe conditions.
A resident with bipolar disease, vascular dementia, and reduced mobility experienced a 10-day delay in receiving antibiotic treatment for a UTI due to the facility's failure to follow up with the physician after abnormal urinalysis results. Staff acknowledged difficulties in reaching the physician and admitted that they should have continued to call daily until a response was received.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by administering Lasix outside of ordered parameters and not providing the required potassium supplement. Despite specific blood pressure thresholds and the need for potassium on days Lasix was given, staff repeatedly administered Lasix when the resident's blood pressure was too low and failed to administer potassium.
Incomplete Neurological Assessments After Resident Falls
Penalty
Summary
The facility failed to ensure residents received neurological assessments in accordance with professional standards of practice after falls with potential head injury. Facility policy stated neurological assessments were indicated following an unwitnessed fall, following a fall involving head injury, or when indicated by resident condition, and included frequent vital signs with assessments at specified intervals over 72 hours. Survey review found that nursing staff did not initiate neurological assessments for one resident after an unwitnessed fall and did not complete required neurological assessments for two other residents after falls that involved head injury concerns. Resident #45 had diagnoses including cerebral infarction, dementia, lack of coordination, muscle weakness, and repeated falls, and was cognitively impaired. After an unwitnessed fall, staff did not document the start of neurological assessments, and no fall follow-up assessments were documented in the nursing progress notes over the next two days. During interview, an RN stated neuro checks should be started for unwitnessed falls or falls with head injury unless the resident could state they did not hit their head, and that this resident could not tell staff whether he/she hit his/her head. Resident #56 had diagnoses including dementia, unsteadiness on feet, and reduced mobility. After staff found the resident sitting on the floor with bruising and discoloration to the face and arms from previous falls, neurological checks were initiated, but the neurological assessment form did not document the initial assessment or the final three shifts of the assessment timeframe. Later notes documented a hematoma to the forehead and face and complaints of head pain. Resident #61, who had dementia and impaired cognitive function, was found on the floor with a hematoma over the right eye and neuro checks were initiated, but the neurological assessment form did not document three hourly assessments or five shift assessments. Later documentation noted a large hematoma to the right eyebrow and complaints of pain treated with ibuprofen.
Nurse aide worked beyond 4 months without completed CNA training
Penalty
Summary
The facility failed to ensure nurse aides were not used for more than four months without completing the required training and competency evaluation. Review of the facility policy showed nurse aides must complete a state-approved training program and that the facility would not employ any individual as a nurse aide for more than four months unless the individual was competent and had completed the required training and competency evaluation program or had otherwise been deemed competent under the applicable requirements. Review of NA A’s personnel file showed a hire date of 01/12/26, but there was no documentation that the nurse aide training program had been completed. The facility’s online CNA class schedule and sign-in sheet showed NA A started classes on 04/27/26. During interviews, NA A, the Administrator, the DON, and the ADON stated the facility did not have a CNA instructor available in time for NA A to complete the classes, clinical training, and certification within the required four months. The Administrator said NA A was terminated for about one week and then rehired on a part-time basis while completing the online class, and the DON and ADON said the ADON monitored completion of online modules and knowledge tests while the aides worked toward certification.
Kitchen Sanitation and Dish Drying Failures
Penalty
Summary
Food was not protected from possible contamination because kitchen staff failed to keep food-contact areas clean and failed to air dry dishes. During observation, the can opener had food crumbs and a grease/lint mixture, the toaster had food crumbs and a grease/lint mixture, and the prep table to the right of the stove was dirty with a grease/lint mixture. The facility’s cleaning policy stated that the can opener and small food preparation equipment were to be cleaned after each use and the toaster daily, but the kitchen cleaning schedule did not include the toaster and staff described inconsistent cleaning practices. The Dietary Aide, Dietary Manager, Administrator, and other dietary staff each described expectations for cleaning, but also acknowledged that some items were not always completed or were cleaned only when noticed. The facility also failed to ensure dishes were allowed to drain and air-dry before being stacked or stored. Observations showed multiple items, including large plastic water glasses, coffee mugs, plate covers, bowls, and clear drinking glasses, stacked upside down with no air flow and water trapped inside in a room next to the kitchen. The facility policy stated that pots and pans were to be drained and air-dried on the drain counter, and staff interviews reflected that dishes should remain on the drying rack until dry or sit in a tray to air dry. The Administrator stated he expected dishes to be completely dry before being put away and that kitchen staff had been trained to do this.
Bed Rail Gap Measurements Exceeded Allowed Standards
Penalty
Summary
The facility failed to maintain an effective program to identify possible resident entrapment when side rail gap measurements for three residents exceeded the maximum allowed standards. Surveyors reviewed FDA guidance and facility policies that required bed frames, mattresses, and bed rails to be checked for compatibility and for all gaps to remain within safety dimensions. The facility’s Bed Rail Safety Check form listed a maximum Zone 1 gap of 4 3/4 inches, yet the form did not identify allowances for Zones 5, 6, or 7. Resident #63 had diagnoses including Bell’s palsy, history of falls, lack of coordination, reduced mobility, and cognitive impairment involving function and awareness. The resident’s quarterly MDS showed the resident was cognitively intact and independently mobile. The resident had consent and a physician order for bilateral upper half rails to assist with repositioning and bed mobility. A quarterly bed rail safety check documented Zone 1 measurements of 7 inches on each side of the bed, exceeding the allowed maximum by 2 1/4 inches. During observation, the resident was in bed with the right upper side rail raised, the mattress was crooked and separated from the bedrail, bare metal frame was exposed, and the bedrail had a large square opening in the middle. The Housekeeping Supervisor later measured the rail and found a 7 inch by 7 inch opening. Resident #2 had diagnoses including cellulitis of the left lower limb, Alzheimer’s disease, dementia, osteoarthritis in both knees, violent behaviors, muscle weakness, fracture to the right tibia, and reduced mobility. The resident’s annual MDS showed severely impaired cognition for decision making and substantial to maximal assistance needs for bed mobility and transfers. The care plan directed half side-rails up x 2 per physician orders for safety during care provision and to assist with bed mobility. A completed bed rail safety check documented Zone 1 measurements of 7 inches on each side of the bed, but pass/fail was not indicated. Observations showed the resident in bed with both side rails raised and each rail had a large square opening in the middle. The resident stated the side rails were used to help reposition in bed, and the Housekeeping Supervisor later measured both upper rails at 7 inches by 7 inches. Resident #7 had diagnoses including quadriplegia, anxiety, and depression. The resident’s quarterly MDS showed cognitive intactness for decision making and substantial to maximal assistance needs for bed mobility and transfers. The care plan directed half side-rails up x 2 for safety during care provision and to assist with bed mobility, and the informed consent stated a half partial rail was to be used at all times when the resident was in bed. A bed rail safety check documented a Zone 1 measurement of 7 inches on the left side, exceeding the allowed maximum by 2 1/4 inches, with pass/fail not indicated. During observation, the resident’s bed was pushed against the wall with a half bedrail on the left side, and later the Housekeeping Supervisor measured one upright rail with a large square opening measuring 7 inches by 7 inches. Staff interviews showed the Housekeeping Supervisor performed the measurements, nursing leadership kept the forms, and the MDS Coordinator, DON, and Administrator were identified as responsible for compliance.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure a process was in place to clearly and consistently document each resident’s code status preference when two residents had inconsistent code status documentation across the electronic record, physical chart, and room indicators. The deficiency was identified during observation, interview, and record review for a sample of 22 residents in a facility census of 64. For one resident, the electronic face sheet showed DNR, the current physician order sheet showed DNR, and the resident’s MDS showed the resident was cognitively intact. However, the resident’s room nameplate had a green dot indicating full code, the care plan identified the resident as full code with life-saving interventions, the physical chart binder spine had a green full code sticker, and the binder also contained a signed DNR sheet. Staff interviews showed multiple employees were aware the resident’s code status had changed to DNR, but none could identify when the change occurred, and the Social Worker stated staff did not update the documentation in each area. For another resident, the face sheet and physician order sheet showed DNR, and the care plan stated the resident wished to be DNR and that CPR should not be initiated. The resident’s annual MDS showed severely impaired cognition for decision making. During observation, the Social Worker could not find the resident’s DNR documentation in the binder, and the binder spine had a green full code label. An LPN stated that if the resident were in medical crisis, CPR would be provided because there was no indicator for DNR. Staff interviews also showed inconsistent understanding of where code status should be documented and who was responsible for verifying that the face sheet, POS, physical chart, and room sticker matched.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The deficiency involves the facility’s failure to timely report suspected abuse, neglect, or theft and to report the results of the related investigation to the proper authorities. The citation remains uncorrected and is associated with a complaint investigation identified as #2787573. The report references prior, related examples of the same or similar deficient practice documented under event IDs 1DFDCA-H1 and 1DFDCA-H2, with specified exit dates, indicating that surveyors previously identified issues with timely reporting and communication of investigation outcomes to appropriate agencies. No additional clinical or resident-specific details are provided in this report excerpt.
Ongoing Failure to Respond Appropriately to Alleged Violations
Penalty
Summary
A deficiency was cited related to the facility’s failure to respond appropriately to all alleged violations. The citation remains uncorrected and is linked to prior survey findings identified under event ID 1DFDCA-H1 and event ID 1DFDCA-H2, as well as a specific complaint investigation (Complaint #2787573). The report indicates that surveyors previously identified similar issues during earlier events, and the current citation reflects ongoing noncompliance with requirements to address and respond to alleged violations, but it does not provide additional clinical or resident-specific details.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect residents on the memory care unit from sexual and physical abuse by a resident with dementia and severe cognitive impairment who repeatedly targeted other residents. Resident #1’s record showed a history of physical and verbal behaviors toward others, intrusive wandering, and sexually aggressive behavior. The care plan already identified the resident as having a history of being verbally aggressive, physically aggressive, intrusive to peers’ space and belongings, and sexually aggressive toward staff and peers, but the record review showed no new interventions added to protect other residents when the behaviors escalated. Nursing notes documented repeated incidents in which Resident #1 entered other residents’ rooms, attempted to climb into a sleeping resident’s bed, grabbed residents, kissed residents, touched breasts and private areas, forced a tongue into another resident’s mouth, slapped a resident’s leg, and attempted to strike a resident with a glass vase. The resident also followed residents of the opposite sex, called them a significant other, attempted unwanted hugs and kisses, removed bedding and personal items from rooms, and became physically and verbally aggressive when redirected. Several residents, including Residents #2, #3, #4, and #5, were involved in these incidents and were described as upset, resisting the contact, or calling for help. The record showed the facility did not document assessment or notification for several of the affected residents after the incidents, including no documentation for Resident #3, Resident #4, or Resident #5 related to the events. The facility also did not notify Resident #1’s physician of the behaviors or implement new interventions on the care plan to protect residents. Staff interviews confirmed they considered the conduct sexual and physical abuse, and one staff member witnessed Resident #1 kiss Resident #5 on the top of the head, but the nurse’s progress notes did not document that incident. The facility census was 67.
Failure to Report Resident’s Allegation of Sexual Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of possible abuse was immediately reported to management and within two hours to the State Survey Agency, as required by its Abuse Investigation and Reporting policy. The policy, revised July 2017, required that all alleged violations involving abuse, neglect, exploitation, mistreatment, or injuries of unknown origin be promptly reported to local, state, and federal agencies and that abuse or serious bodily injury be reported no later than two hours after the allegation. Despite this, the allegation made by one resident was not reported to the Department of Health and Senior Services (DHSS), and there was no documentation that facility administration was notified. The resident involved had been admitted with diagnoses including paranoid schizophrenia and had a quarterly MDS indicating moderate cognitive impairment, delusions, and verbal behavioral symptoms directed at others. On the night in question, an LPN documented that the resident returned from the emergency room and was yelling and screaming, stating that the "N word" next door was putting his penis in the resident’s buttocks. The LPN further documented that the resident used a hand gesture to describe the alleged sexual act. The LPN noted that the other resident was asleep and believed at the time that this resident was unable to get out of bed unassisted, and explained to the resident that the allegation was impossible and that racial slurs were not tolerated. The progress note did not include any notifications to administration or external authorities regarding this allegation of possible abuse. In a subsequent interview, the LPN stated that he/she did not think the allegation should be reported because of the resident’s diagnosis of paranoid schizophrenia and believed it was a hallucination, and therefore did not notify the Administrator. Other staff interviews showed inconsistent understanding of reporting requirements: some CNAs and nurses stated that abuse allegations should be reported to the charge nurse, DON, Administrator, and to the state within two hours, while one CNA believed the state should be notified within 24 hours, and one LPN was unsure whether the allegation should be reported to the state. The ADON and Administrator both stated that abuse allegations should be taken seriously, reported to administration immediately, and reported to the state within two hours, and acknowledged that this resident’s allegation should have been treated as possible abuse and reported and investigated, which did not occur.
Failure to Investigate and Protect Resident After Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate and document an allegation of abuse and to document steps taken to protect a resident following that allegation. Facility policy on Abuse Investigation and Reporting required that all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown origin be promptly reported and thoroughly investigated, with the Administrator assigning an investigator and the investigation including review of documentation, medical records, and interviews with the reporter, resident, witnesses, staff, and others. The policy also required private interviews and written, signed, and dated witness statements. Despite these requirements, when a resident with paranoid schizophrenia, moderate cognitive impairment, delusions, and verbal behavioral symptoms alleged that another resident was putting his penis in the resident’s buttocks, the responsible LPN only documented the allegation and a brief interaction with the resident, without initiating or documenting any investigative steps or protective measures. The resident’s progress note described the resident yelling and making a specific sexual abuse allegation, including a hand gesture indicating penetration, and the LPN’s response that the alleged perpetrator was asleep and that the act was impossible, along with a statement that racial slurs and name calling were not tolerated. There was no documentation of a physical assessment, notifications, or further follow-up related to the sexual abuse allegation in the electronic medical record. The LPN later stated that no assessment was completed, that the allegation was reported only in shift report, and that the resident would have been moved and monitored if the LPN had believed the allegation was credible. The Administrator and ADON reported that they were unaware of the allegation, that an assessment and investigation with staff and resident interviews and chart review should have occurred, and that investigations should be completed within five days, but no investigation report had been submitted to the state agency as of the surveyor’s review date.
Failure to Ensure Nurse Aide Certification Within Required Time Frame
Penalty
Summary
The facility failed to ensure that all nurse aides completed the required competency and certification process within four months of beginning work as a nurse aide. Review of the policy titled Nurse Aide Qualifications and Training Requirements showed that nurse aides were not to be employed for more than four months unless they were competent and had completed a training program and competency evaluation program or an approved competency evaluation program. Despite this requirement, one nurse aide, NA G, worked as a nurse aide for nine months without obtaining active CNA certification in Missouri. Record review showed NA G’s first date of employment as a nurse aide, the start and completion dates of CNA classes, and that staff did not have documentation showing completion of the CNA certification process. The CNA registry also showed NA G did not have an active CNA certification. Facility staffing sheets showed NA G continued working 12-hour night shifts as a nurse aide during the period reviewed. During interviews, NA G stated he/she was not certified, did not know how much time was allowed to get certified, did not complete the classes within four months, and had continued working as a nurse aide without being terminated or moved to another department. The CNA Instructor, DON, and Administrator each stated that nurse aides had four months to get certified and that NA G should have been certified within that time frame, but NA G was not moved or terminated and continued working as a nurse aide past the required period.
Lack of Active Medical Director Involvement
Penalty
Summary
The facility failed to employ a medical director who was actively involved in the implementation of care policies and coordination of medical care. Physician A, who agreed to be the Medical Director on July 1, 2024, had not signed a formal contract and was not aware of his responsibilities. The facility did not ensure that Physician A participated in completing or updating the facility assessment or attended the Quality Assessment and Assurance (QAA) Committee meetings. Interviews with the Director of Nursing and the Administrator confirmed that Physician A had not attended any QAPI committee meetings since assuming the role. The facility's policy outlined that the Medical Director should oversee physician services, review practitioner credentials, and participate in quality improvement efforts, among other responsibilities. However, the lack of a formal contract and the absence of participation in QAPI meetings indicated a failure to adhere to these policies. The facility census was 70, but the report does not provide specific details about the impact on individual residents or their medical conditions.
Unsecured Medication Poses Risk in Memory Care Unit
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident on the memory care unit had an unsecured and unattended bottle of medication in their room. The medication, Brukinsa, is a prescription drug used to treat chronic lymphocytic leukemia and has serious potential side effects, including fatal hemorrhage and infections. The facility's policy requires medications to be stored securely and only accessible to authorized personnel, but this was not adhered to in this instance. The resident involved was admitted after back surgery and chose to stay in the secured care unit for a private room, despite not having a diagnosis of dementia. The resident was cognitively intact but required staff supervision for various activities. The resident's room was cluttered, and the medication was left unsecured on the sink counter, posing a risk to other residents who frequently wandered into rooms. Staff, including an LPN and the Director of Nursing, acknowledged the medication should not have been left in the room and recognized the potential risk to other residents. The facility's policies on medication storage and administration were not followed, leading to this deficiency. The unsecured medication was accessible to wandering residents, creating a potential hazard in the secured care unit.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards, leading to potential contamination. Observations revealed that food items in the refrigerator and freezer were not sealed, labeled, or dated. This included various items such as french toast sticks, sausage patties, ground meat, sliced American cheese, and a turkey breast. Staff interviews confirmed that food should be dated and sealed, and any undated items should be discarded. However, these practices were not consistently followed, as evidenced by repeated observations over several days showing the same issues with food storage. Additionally, the facility did not properly handle dented cans, which were found on shelves alongside other food items. Dented cans of cream of mushroom soup, apple fruit filling, tapioca pudding, black beans, and whole potatoes were observed. Despite the facility's policy to set aside and discard dented cans, these were used in meal preparation, posing a risk of contamination. Staff interviews indicated awareness of the policy, but the Dietary Manager admitted to using a dented can of tapioca pudding due to insufficient supply. The facility also failed to adhere to proper hand hygiene and dishwashing protocols. Observations showed that staff did not wash hands or change gloves between different food preparation tasks, and did not properly clean and sanitize equipment between uses. For instance, a cook was observed using the same gloves to handle various food items and equipment without washing hands or changing gloves. The blender used for pureeing food was only rinsed with hot water between uses, without proper washing or sanitizing. Furthermore, the ice machine was found to have white substances and black spots, indicating inadequate cleaning. Staff interviews revealed inconsistencies in cleaning responsibilities and documentation, with maintenance staff admitting to not documenting the cleaning of the ice machine.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Multiple staff members, including CNAs and the Administrator, did not wear appropriate PPE while assisting or conversing with residents on the designated COVID hall. Observations and interviews revealed that staff who tested positive for COVID-19 were not wearing PPE, contrary to the facility's policy and CDC guidelines. The facility's policy required the use of N95 masks, gowns, gloves, and eye protection for staff working on the COVID unit, but this was not adhered to by COVID-positive staff. The Administrator and several CNAs were observed not wearing PPE while serving meals and interacting with residents on the COVID unit. The Administrator, who had tested positive for COVID-19, stated that staff working on the COVID hall did not have to wear PPE if they were positive for COVID-19. This practice was confirmed by multiple staff members, including CNAs and LPNs, who believed that COVID-positive staff did not need to wear PPE while working on the COVID unit. The Director of Nursing/Infection Preventionist confirmed that the facility had multiple residents test positive for COVID-19 and created a COVID unit instead of isolating each resident to their room. The facility policy required staff to wear N95 masks throughout the facility and additional PPE when working on the COVID unit. However, the Director of Nursing/Infection Preventionist stated that COVID-positive staff did not have to wear PPE if they worked on the COVID unit, which was a deviation from the facility's policy and CDC guidelines.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's physician of significant changes in the resident's condition following the death of the resident's spouse and the discontinuation of an anti-anxiety medication. The resident, who had severe cognitive impairment and a history of Alzheimer's disease, type two diabetes, and depression, experienced increased emotional distress and behavioral changes after the medication was stopped. Despite these changes, staff did not document or report the resident's condition to the physician as required by the facility's policies on medication tapering and changes in a resident's condition. The resident's progress notes indicated multiple instances where the resident exhibited tearfulness, paranoia, and refusal to eat, yet there was no documentation of physician notification. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, revealed that not all staff were aware of the medication change or the resident's recent behavioral changes. The staff acknowledged that the physician should have been notified of these changes, but this did not occur. The Director of Nursing and the Social Service Director both confirmed that significant life events and changes in behavior should be documented and reported to the physician. The facility's failure to follow these protocols resulted in a deficiency, as the resident's physician was not informed of the resident's spouse's death or the subsequent behavioral changes, which could have impacted the resident's care and treatment plan.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment for residents, specifically in the cases of two residents whose rooms had cracked and missing floor tiles. Resident #1, who has paraplegia and uses an electric wheelchair, reported that the tiles in their room had been broken and missing for over two years. The resident expressed concerns about the inability to properly clean the floor. Housekeeping staff confirmed the issue had been reported to maintenance several months ago, but the tiles had not been replaced due to the unavailability of matching tiles from the 1980s. The Maintenance Supervisor acknowledged the need to relocate the resident to repair the floor but had not yet done so. The Administrator confirmed that the resident would need to be moved to another room for the repairs to be completed. Resident #7, who has COPD and obsessive-compulsive disorder, also had cracked and missing floor tiles in their bathroom. The resident stated that the bathroom floor had been in disrepair for a while and expressed a desire for it to be fixed. The Maintenance Supervisor was unaware of the issue until it was brought to his attention during the survey. Staff interviews revealed that broken tiles were commonly reported to maintenance, but repairs were slow due to the age of the building and the need to complete repairs in stages. The Director of Nursing and the Administrator acknowledged the ongoing issues with broken and missing tiles in resident rooms. The Administrator mentioned that some tiles had been replaced and that he had consulted with a company about using an epoxy pour for bathroom floors instead of re-tiling. Despite these acknowledgments, the facility had not yet addressed the specific deficiencies in the rooms of Resident #1 and Resident #7, leading to an environment that was not clean or homelike for these residents.
Failure to Document and Perform Dressing Changes
Penalty
Summary
The facility failed to provide care in accordance with standards of practice when staff did not document an order change and complete dressing changes as ordered for one resident. Resident #59, who had diagnoses including chronic pancreatitis, chronic kidney disease, COPD, and hypertension, required daily dressing changes for a G/J-tube. Despite a new order to change the dressing twice per day due to increased drainage and signs of infection, this order was not documented in the resident's medical record, leading to the resident having routinely saturated dressings. Observations over several days showed the resident's G/J-tube dressing to be saturated, and interviews with the resident and staff confirmed that the dressing was not being changed as frequently as needed. The resident expressed discomfort and concern about potential infection due to the wet dressings. Staff interviews revealed that while some were aware of the saturated dressings, the new order for twice-daily changes was not communicated or documented properly. The Director of Nursing admitted to forgetting to enter the new order into the electronic medical record, which resulted in the failure to perform the necessary dressing changes. The Administrator also confirmed that staff are expected to follow physician orders and document them immediately in the electronic medical record. This lapse in documentation and care led to the resident experiencing discomfort and potential risk of infection due to the saturated dressings.
Failure to Follow Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to maintain an environment free of safety hazards by not following the care plan for transferring a resident and not implementing planned fall interventions for another resident. Resident #52, who was care planned to need a mechanical lift for transfers, was manually transferred by two CNAs without using a gait belt. The resident, diagnosed with dementia and psychotic disorder, was observed being transferred from a wheelchair to a bed with the CNAs placing their hands under the resident's arms, which is against the facility's policy. Interviews with the CNAs and other staff revealed inconsistencies in understanding and following the care plan, with some staff believing the resident could bear weight despite the care plan indicating the need for a mechanical lift due to the resident's stiffness and inability to bear weight safely. The Director of Nursing and the Administrator confirmed that the resident should have been transferred using a mechanical lift as per the care plan for both the resident's and staff's safety. The facility also failed to implement planned fall interventions for Resident #46, who was assessed as a fall risk. The resident, diagnosed with conversion disorder with seizures, muscle weakness, lack of coordination, and reduced mobility, had a physician's order for fall mats to be in place while in bed. However, observations showed that the fall mat was not in place on multiple occasions, and the resident was found on the floor next to the bed without the fall mat in place. Interviews with CNAs, LPNs, and the DON confirmed that the fall mat should have been used whenever the resident was in bed, as indicated in the care plan. The Administrator also stated that staff should follow the fall interventions put in place for residents at risk of falling. These deficiencies highlight the facility's failure to adhere to care plans and safety protocols, resulting in unsafe conditions for the residents. The lack of proper transfer techniques and failure to implement fall prevention measures directly contradict the facility's policies and the residents' care plans, putting the residents at risk of injury.
Delay in Treatment for UTI Due to Lack of Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with a positive urine culture received timely follow-up care, resulting in a delay in treatment for a urinary tract infection (UTI). Resident #32, who had diagnoses including bipolar disease, vascular dementia, and reduced mobility, was found to have abnormal urinalysis results on 02/06/24. Despite the results indicating a significant infection, the staff only faxed the results to the physician and did not receive a response or new orders until 02/16/24, leading to a 10-day delay in starting the antibiotic treatment. The resident's medical record showed no documentation of follow-up actions taken by the staff to obtain a timely response from the physician during this period. Interviews with the facility's staff, including LPNs, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the physician preferred to receive results via fax and was difficult to reach at times. The staff acknowledged that they should have continued to call the physician daily until a response was received. The DON and the Administrator both expressed that they expected the antibiotic order to be obtained much sooner and that the nurses should have communicated more effectively to ensure timely treatment. The delay in obtaining the antibiotic order was attributed to a lapse in follow-up and communication among the nursing staff and the physician.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs, specifically in the case of one resident who was administered Lasix outside of the ordered parameters and was not given the required potassium supplement. The resident, who had a history of cardiac issues including the presence of a cardiac pacemaker, atrial fibrillation, and hypertension, was prescribed Lasix with specific blood pressure parameters and a potassium supplement to be administered on the same days as the Lasix. However, staff repeatedly administered Lasix even when the resident's blood pressure readings were outside the prescribed parameters and failed to administer the potassium supplement on those days. The resident's Medication Administration Record (MAR) for February and March 2024 showed multiple instances where the resident's blood pressure was below the required threshold, yet Lasix was still administered. Additionally, the potassium supplement was not given on any of these occasions. Interviews with various staff members, including a Certified Medication Technician (CMT), a Registered Nurse (RN), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the resident's physician, confirmed that the staff did not follow the physician's orders regarding the administration of Lasix and potassium. The staff acknowledged that they should have held the Lasix when the resident's blood pressure was below the specified parameters and should have administered the potassium supplement on the days Lasix was given. The Director of Nursing and the resident's physician both emphasized the importance of adhering to the physician's orders to prevent potential complications related to the resident's heart condition and electrolyte balance. The facility's failure to follow these orders resulted in a deficiency in the resident's care regimen.
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What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lowry City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clinton Healthcare And Rehabilitation Center | 16 mi | ★★★★★ | 0 | 0 |
| Appleton City Manor | 16.6 mi | ★★★★★ | 2 | 1 |
| Adair Village | 17.7 mi | ★★★★★ | 12 | 0 |
| Aspire Senior Living Warsaw | 20.6 mi | ★★★★★ | 1 | 0 |
| Northwood Hills Care Center | 24.4 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.