Truman Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the resident's representative was notified of a new bruise for 1 of 1 resident (R5)who was reviewed for skin injury. Findings include: R25's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated diagnosis of Alzheimer's Disease, Non-Alzheimer's dementia with behavioral disturbance and hemiplegia (complete paralysis on one side of body) and hemiparesis (partial weakness on one side). R2 had severe cognitive impairment with moderate hearing loss and adequate vision. R25 had delirium with symptoms of inattention and disorganized thinking but no behaviors. R25 was dependent on staff for all activities of daily living. R25's plan of care last revised on 4/30/25, indicated R5 had a cognitive impairment as indicated by her diagnosis of Alzheimer's disease and was unable to answer questions. Interventions included allowing R25 time to process information; approach R25 from the front, make eye contact and explain cares before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident medication status was accurately coded in the Minimum Data Set (MDS) assessment for 1 of 1 resident (R21) reviewed for medications, specifically insulin. Findings include:R21's face sheet received on 1/6/26, included diagnosis of type 2 diabetes mellitus (when the body does not produce enough insulin or use it properly).R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R21 had diabetes.R21's physician orders included Trulicity (Trulicity is not insulin. It is a glucagon-like peptide-1 (GLP-1) receptor agonist which controls blood sugar by signaling brain to feel full, slowing digestion and stimulating insulin release) subcutaneous solution pen-injector 0.75 mg (milligram) /0.5 ml (milliliters) at bedtime every Wednesday related to type 2 diabetes mellitus. R21's care plan dated 10/14/25, indicated R21 had diabetes type 2 and required medication for control.R21's MDS, Section N indicated the number of days that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a falls care plan for 1 of 1 resident (R5) was updated to include the current interventions. Finding include: R5's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R5 understands and is understood and had intact cognition. R5 was dependent on staff with transfers, and partial to moderate assistance with oral hygiene, independent with eating and requires substantial to maximal assistance with dressing and personal hygiene. R5 uses a manual wheelchair for mobility. R5's diagnoses included high blood pressure, coronary artery disease, renal insufficiency, diabetes mellitus, depression and asthma. R5's plan of care last updated 8/20/25, indicated R5 was at moderate fall risk as evidenced by the most recent Morse Fall Scale score (a fall scale calculator that predicts risk of falling) related to impaired cognitive function which can affect her reasoning. Interventions included R5 had a low bed so she can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident medication status was accurately coded in the Minimum Data Set (MDS) assessment for 1 of 2 residents (R17) reviewed for medications. Findings include: R17's facesheet printed on 11/14/24, included diagnosis of type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar). R17's current quarterly MDS assessment dated [DATE], indicated the number of days that insulin injections were received during the last seven days, as seven. R17's admission MDS dated [DATE], indicated the same, as did R17's significant change MDS dated [DATE]. R17's physician orders included: --glimepiride 1 mg (milligram), give 0.5 mg by mouth in the morning related to type 2 diabetes mellitus --Jardiance 25 mg by mouth in the morning related to type 2 diabetes mellitus --Orders did not include insulin injections R17's care plan dated 4/30/24, indicated he was on an oral diabetic medication for management. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that identified R1 had failed to use call light appropriately and/or refusals to use the call light for 1 of 1 (R1) resident reviewed for care plan. Findings include: R1's, 7/07/24 quarterly Minimum Data Set (MDS) identified R1 had severely cognitive impairment, little interest, or pleasure in doing things, and feeling down, depressed, or hopeless for never to 1 day. R1 was dependent on staff with cares and was incontinent with bowel and bladder. R1 had a diagnosis of anxiety and manic depression. R1 had taken antipsychotic and antidepressant on a routine basis. R1's, undated care plan identified R1 had verbal aggression related to her bipolar disorder and the goal was for R1 to have 1 or fewer episodes per week. Staff interventions were to administer medication, analyze places, times, circumstances, triggers and what de-escalate the behaviors. Staff were to understand R1's situation and allow time to express her feelings, provide choices for care and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to complete appropriate assessments and failed to reposition and document that repositioning for 1 of 1 resident (R1). Review of the report filed to the State Agency identified on 8/13/24 at 2:30 p.m., two nursing assistants placed R1 on a bedpan at approximately 12:30 p.m., and was found by staff remaining on the bed pan at approximately 4:15 p.m., when R1 call out to staff notifying them staff had forgotten to return and remove R1 off the bed pan. R1's, 7/07/24 quarterly Minimum Data Set (MDS) identified R1 had severely cognitive impairment, little interest, or pleasure in doing things, and feeling down, depressed, or hopeless for never to 1 day. R1 was dependent on staff with cares and was incontinent with bowel and bladder. R1 had a diagnosis of anxiety and manic depression. R1 had taken antipsychotic and antidepressant on a routine basis. Interview on 8/20/24 at 9:07 a.m., with family member (FM)-A stated she received a phone call from the facility's registered nurse (RN)-A of R1 had been found with a bedpan under her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, facility failed to ensure 1 of 1 nursing assistant (NA)-C was deemed competent upon hire or yearly thereafter to provide care to residents. Findings include: Review of NA-C's employee file identified a hire date of 6/03/24. Review of NA-C timesheets identified she had worked at the facility on 6/16, 6/17, 6/19, 6/20, 6/21, 6/24, 6/25, 6/27, 6/28, 6/29, 6/30, 7/01, 7/02, 7/03, 7/05, 7/06, 7/07, 7/08, 7/09, 7/11, 7/12, 7/13, 8/05, 8/06, 8/07, 8/08, 8/09, 8/10, 8/11, 8/12, 8/14, 8/15 and 8/16/24. Review of NA-C, 5/08/24 Relias (online training program) identified she had completed a clinical asssessment training. The facility did not provide facility specific competencies for NA-C upon hire. Interview on 8/21/24 at 3:31 p.m., with administrator and director of nursing agreed competency training should be given to all employees to reflect current knowledge of the facilitys resident specific needs and services. Review of January 2024 Orientation policy identified the facility would provide department orientation plan that would reflect the skills and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate supplemental oxygen was delivered according to physician orders and failed to revise or develop a respiratory care plan for 2 of 2 residents (R1 and R2) reviewed for respiratory care. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], identified R1 had moderately impaired cognition and diagnoses which included chronic obstructive pulmonary disease (disease of the lungs). R1 required staff assist with dressing, toileting, transferring, and personal hygiene. The MDS also identified use of oxygen therapy. R1's hospital Physician's Plan of Care dated 3/13/24, indicated R1 had been hospitalized for aspiration pneumonia, COVID-19, and urinary tract infections (UTI). Further ordered R1 to receive continuous supplemental oxygen (O2) therapy at 1-3 liters per minute (LPM) by nasal cannula to keep 02 saturation greater than 90%. R1's hospital Physician's Plan of Care dated 3/15/24, indicated R1 had been observed at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 1 of 1 residents (R8) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 22 residents residing in the facility. Findings include: During an interview on 2/27/24 at 12:41 p.m., with R8 who was the resident council president, and who according to a quarterly Minimum Data Set (MDS) assessment dated [DATE], was cognitively intact. The interview took place in R8's room due to the facility being in Covid-19 outbreak status. R8 stated mail was delivered to the facility on Saturdays, described as a small stack of mail wrapped up, and the nursing staff locked it away until Monday when the activities director delivered it. Review of resident council meeting minutes from January 2023 through February 2024, (minus two months: February and September 2023), indicated R8 had been present at each of the 12 meetings. During an interview on 2/27/24 at 11:28 a.m., nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide ongoing communication to residents about their rights (e.g., through resident groups). This had the potential to affect all 22 residents residing in the facility. Findings include: During an interview on 2/27/24 at 12:41 p.m., with R8 who was the resident council president, and who according to a quarterly Minimum Data Set (MDS) assessment dated [DATE], was cognitively intact. The interview took place in R8's room due to the facility being in Covid-19 outbreak status. R8 stated the resident council met monthly and meetings were facilitated by the activities director who also took minutes for the meetings. R8 stated she did not recall resident rights ever being talked about or reviewed at resident council meetings. Review of resident council meeting minutes from January 2023 through February 2024, (minus two months: February and September 2023), indicated nothing regarding resident rights. The minutes indicated R8 had been present at each of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to have an integrated care plan to coordinate services between the facility and the hospice agency to ensure those services were being provided for 1 of 1 resident (R6) reviewed for hospice care. Findings include: R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R6 was rarely/never understood, dependent on staff for dressing, hygiene, transfers, utilized a wheelchair, received hospice care, and diagnoses indicated non-traumatic brain dysfunction, and non-Alzheimer's dementia. R6's care plan dated 12/13/23, indicated R6 was receiving hospice services and interventions included: consult with physician and social services to have hospice care for resident in the facility, encourage support system of family and friends, hospice provider: . (name of agency) Hospice, keep the environment quiet and calm, observe closely for signs of pain, administer pain medications as ordered. On 2/26/24, at 2:17 p.m., licensed practice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.