Trueman Pointe Care Center

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents were assessed for the use of a physical restraint. This affected two (#23 and #41) of two residents reviewed for physical restraints. The facility census was 63.Findings include:1. Review of the medical record for Resident #23 revealed an admission date of 12/23/22 with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, schizophrenia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and bipolar disorder.Review of Resident #23's most recent comprehensive Minimum Data Set (MDS) assessment, dated 03/22/26, revealed Resident #23 had severely impaired cognition and had no impairments to bilateral upper and lower extremities. She required partial/moderate assistance with transfer and substantial/maximal assistance with ambulation.Review of the medical record for Resident #23 revealed a physician order dated 03/27/24 for a pressure sensor alarm (PSA) to the chair 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, medical record review, and staff interview, the facility failed to attempted non-pharmacological interventions for resident behaviors prior to administering as-needed psychotropic medications. This affected one (Resident #10) of five residents reviewed for antipsychotic medication administration. The facility census was 63.Findings include:Review of Resident #10's medical record revealed an admission date of 02/25/26 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance; depression; unspecified psychosis not due to a substance or known physiological condition; and metabolic encephalopathy.Review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had severely impaired cognition.Review of Resident #10's plan of care dated 03/06/26 revealed she was at risk for adverse effects related to psychoactive medication use due to dementia with behaviors and depression. Interventions included to give medications as…

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 observation, staff interview, and medical record review, the facility failed to ensure medications were properly stored. This affected one (#61) of one residents reviewed for medication storage. The facility census was 63.Findings include:Review of the medical record for Resident #61 revealed an admission date of 03/05/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified convulsions, unspecified glaucoma, and chronic pain syndrome.Review of Resident #61's care plan dated 03/26/24 revealed the resident was at risk for alteration in comfort related to chronic pain syndrome, arthritis, general pain, and chronic back pain. Interventions included to administer medications as ordered.Review of Resident #61's physician's orders revealed an order dated 04/21/26 for gabapentin (medication used for seizures or as an analgesic) 400 milligrams (mg) with instructions to give one pill by mouth every eight hours for neuropathy. Resident #61 had no orders to self-administer medications or for medications to be…

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 medical record review, staff interview, and policy review, the facility failed to ensure resident medical records were complete and accurate. This affected three (#2, #9, and #65) residents of 24 residents reviewed for documentation accuracy. The facility census was 63.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 04/02/24 with diagnoses including type one diabetes with diabetic neuropathy, acute chronic respiratory failure, and chronic kidney disease stage three. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had mild cognitive impairment, had adequate vision without devices, and was independently mobile using a manual wheelchair. Review of Resident #2's admitting diagnoses dated 04/03/24 included type one diabetes mellitus with diabetic neuropathy, unspecified (T1D).Review of multiple pulmonology progress notes listed T1D in Resident #2's active diagnoses.Review of multiple physician and nurse…

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 record review and staff interview, the facility failed to ensure Resident #56 received adequate assistance to prevent a fall from bed while care was being provided. This affected one (Resident #56) of three residents reviewed for falls. The facility census was 63. Findings include: Review of the medical record revealed Resident #56 was re-admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes mellitus, aphasia, retention of urine, and encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had cognitive impairment. Resident #56 had impairment to one side and required substantial to maximal assistance for turning. Review of the State Tested Nursing Assistant (STNA) documentation for bed mobility revealed Resident #56 required extensive to total dependence of staff to turn side to side with the assistance of one to two staff. A health status note dated 09/03/24 at 11:00 P.M. revealed Resident #56 slid out of the…

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 review of thee facility policy, observations, resident and staff interview, and record review, the facility failed to ensure residents did not receive foods against their dietary preferences and allergies. This affected one (Resident #34) of one resident reviewed for food preferences. The Facility census was 63. Finding include: Review of the medical record for Resident #34 revealed an admission date of 08/06/19. Diagnoses included respiratory failure, lymphedema, and heart disease. Review of the physician orders dated 04/19/24 revealed Resident #34 had an order for mechanical soft diet with thin consistency, allergies of strawberries and pineapples, with a no added salt and large protein portions. Review of lunch meal ticket dated 09/17/24 revealed Resident #34 had pineapple listed under dislikes and also had it identified in two spots on the meal ticket as well as strawberries. Interview and observation on 09/17/24 around 11:50 A.M. with Kitchen Staff #144 revealed regular diets received melon, mechanical soft received crushed pineapple, and puree diet received puree…

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 interviews and medical record review, the facility failed to implement orders for a pressure ulcer treatment affecting one resident (#10) of three residents reviewed. The facility census was 68. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Findings include: The deficient practice was corrected on 06/22/24 when the facility implemented the following corrective actions: o Staff education was completed on 05/23/24 regarding the initiation and proper transcription of new orders. o Licensed Practical Nurse (LPN) #444 was counseled on 05/23/24 regarding the error. o An initial audit was conducted on 05/23/24 to verify all pressure ulcer orders were accurate. o Additional audits were performed from 05/26/24 to 06/22/24. Review of the medical record for Resident #10, revealed an admission date of 01/24/24. Diagnoses included but were not limited to spastic quadriplegic cerebral palsy, acute and chronic respiratory failure with…

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 resident and staff interviews, review of Facility Reported Incidents (FRI), record review and facility policy review, the facility failed to timely report an allegation of abuse for one resident (Resident #207). This affected one (Resident #207) of one residents reviewed for abuse. The facility census was 54. Findings Include: Review of the medical record for Resident #207 revealed an admission date on 08/06/22 and a discharge date on 08/30/22. Medical diagnoses included stable burst fracture of third lumbar vertebra, morbid obesity, depression, unsteadiness on feet, muscle weakness, unspecified abnormalities of gait and mobility, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #207 had mildly impaired cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #207 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs),…

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 record review, staff interview, and resident interview, the facility failed to administer one resident (Resident #23) Lantus insulin as ordered upon admission. This affected one (Resident #23) of six residents reviewed for medication administration. The facility census was 54. Findings Include: Review of the medical record for Resident #23 revealed an admission date on 06/17/22. Medical diagnoses included displaced bicondylar fracture of right tibia (lower leg), Type II Diabetes Mellitus without complications, major depressive disorder-recurrent, stage three chronic kidney disease, and congestive heart failure (CHF). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #23 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #23 received daily insulin injections. Review of the Medication…

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 medical record reviews and staff interviews, the facility failed to provide timely physician ordered laboratory services for two of six residents (Resident #29 and Resident #37) reviewed for medications. The facility census is 54. Findings include: 1. Review of Resident #29's medical record identified admission to the facility occurred on 12/29/21, with diagnoses including; downs syndrome, constipation and vascular disease. Resident #29 was observed to be verbal and able to make her needs known. Resident #29 was noted with a urinary catheter on 08/10/22. Review of Resident #29's progress notes identified on 08/10/22 at 8:57 P.M. confusion was noted and increased behaviors with staff. The staff called the physician whom ordered a UA C&S (urinalysis/culture/sensitivity). The notes identified on 08/11/22 the staff collected the urine sample which was ready for the laboratory to pick up. The progress notes dated 08/12/22 at 8:14 A.M. identified the specimen was collected incomplete and will attempt to…

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 observations, medical record reviews, facilities isolation guidelines and infection control policies and staff interviews, the facility failed to ensure one of two residents (Resident #29) identified with an infection, was placed into contact isolation as required. The facility census was 54. Findings include: Review of Resident #29's medical records identified admission to the facility occurred on 12/29/21. Resident #29 had medical diagnoses including; downs syndrome, constipation and vascular disease. Review of Resident #29's urinalysis results dated 08/26/22 identified positive results that evidenced two different bacteria (klebsiella pneumoniae and entercoccus Faecalis) were growing. The report also identified resistance markers included; ESBL (extended spectrum [NAME]-lactamase) which is a multi-drug resistant and can not be killed by many of the antibiotics available. Observation of Resident #29 and her room occurred on 08/29/22 at 11:08 A.M. and 08/30/22 at 7:52 A.M. Resident #29's room…

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.