Trueman Pointe Care Center

In the surveyor’s words

From the most serious findings on record at Trueman Pointe Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 13, 2023

  Based on medical record review, and resident and staff interviews, the facility failed to ensure a resident was transferred safely to prevent an avoidable fall with injury and the fall was not thoroughly investigated to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when State tested Nurse Aide (STNA) #200 attempted to transfer Resident #04 from a wheelchair by lifting the resident by the trousers versus utilizing a gait belt, resulting in Resident #04 falling to the floor and suffering a proximal right fibular fracture just below the surgical equipment that was just placed two weeks prior. This affected one (#04) of three residents reviewed for falls. Facility census was 61. […]

• No harm, potential for more than minimal, isolatedF604May 20, 2026

  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… […]

• No harm, potential for more than minimal, isolatedF605May 20, 2026

  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… […]

• No harm, potential for more than minimal, isolatedF761May 20, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF842May 20, 2026

  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. […]