Treemont Health Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 12 (Resident #7) residents reviewed for pharmacy services.- The facility failed to administer Resident #7's Vancomycin HCl Intravenous Solution (antibiotic) 500 MG/100ML and Ampicillin-Sulbactam Sodium (antibiotic) Intravenous Solution Reconstituted 3g (2g-1g) GM on 5/6/26. These failures could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #55) residents reviewed for intravenous fluids.-The facility failed to ensure Resident #55 's subclavian central line's dry dressing was changed every 5 to 7 days per facility policies and procedures, including orders for monitoring the site. The nurse did not maintain sterile technique while changing subclavian central line dressing on 12/3/25,This deficient practice could place residents at risk of serious harm, injury or death by exposing residents to infections in the blood stream and serious illness. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 35% based on 11 errors out of 31 opportunities, which involved 4 of 9 residents (Residents #5, #23, #53 and #55) and 2 of 4 staff (MA A, MA B and LVN C) reviewed for medication errors.1. The facility failed to ensure MA A administered Magnesium Oxide (used as a dietary supplement to address magnesium deficiency and as an antacid to relieve heart burn and indigestion). It was initialed as given on 12/1/2025 to Resident #53.2. The facility failed to ensure MA A administered Arginald Powder (used to support wound healing, particularly for chronic and slow-to-heal wounds). It was initialed as given on 12/1/2025 to Resident #5.3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen and 5 of 12 residents reviewed for food procurement.-The facility failed to ensure leftover foods were not stored past used by date.-The facility provided food trays containing a hamburger that was at 68 Fahrenheit and spaghetti with meat sauce at 63.2 Fahrenheit and the chef salad was at 63 Fahrenheit. These failures have the potential to place all residents who ate food prepared by the kitchen at risk of food borne illness and disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with incontinent bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #55) reviewed for incontinent care. -The facility failed to ensure CNA A put on a gown and changed gloves and cleaned Resident #55's scrotum and buttocks before putting on a clean brief during Foley catheter and incontinent care on 12/2/25. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #32). -The facility failed to ensure LVN B used sterile technique during tracheotomy care and suctioning, did not clean around trach site, and did not remove inner canula to clean for Resident #32. - This failure could place residents with a tracheotomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administration of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #42) of 7 residents reviewed for pharmacy services. -Resident #42's Tylenol was delivered on 12/02/2025 at 9:45a.m. when the physician's order said to administer it at 8:00a.m. The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order. [...]

Inspectors wroteBased on record review and interviews, the facility failed to send to the attending physician and the facility's medical director and director of nursing medication irregularity the pharmacist identified during review for 1 of 2 resident (Resident #23) reviewed for medication review.-The facility failed to act on Pharmacist's recommendation for Resident #23 's Baclofen. This failure could place residents at risk of adverse reaction related to taking medications. Record review of Resident #23's face sheet, dated 12/1/25, reflected a 72 -years -old female who admitted to the facility on [DATE] readmitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #23) of 9 residents reviewed for pharmacy services.-MA A did not administer Carvedilol (medication used to help your heart by lowering blood pressure) with meals to Resident #23 as ordered by the physician on 12/2/25. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.

Inspectors wroteBased on observation and interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services.-The facility dumpster lids and doors were not secured. This failure could place residents at risk of infection and a decreased home-like environment from pests and rodents. Observation on 12/05/2025 at 8:45 a.m., revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and the door was wide open. In an interview with the dietary food manager on 12/05/2025 at 9:20 a.m., with the dietary food manager, he stated that the dumpster doors must be closed to keep vermin, pests, and insects out of the dumpster from entering the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 4 residents (Resident #55) and 1 of 3 staffs (CNA A) reviewed for infection control. -The facility failed to ensure CNA A performed hand hygiene including washing hands before wearing gloves before incontinent care and washing hands between glove change during incontinent care on Resident #55. This failure could place residents at risk for spread of infection and cross contamination to residents causing resident illness and/or distress. Record review of Resident #55's face sheet dated 12/03/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (main kitchen) reviewed for sanitary kitchen. The facility failed to ensure the thermometer on the low temperature dishwashing machine was in working condition. This failure could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 out of 12 residents (Resident #34) reviewed for ADL care. - The facility staff failed to provide timely incontinence care to Resident #34. This failure could place residents at risk of skin breakdown, pain, and infection.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 2 of 12 months (July and August 2024) reviewed for RN coverage. The facility failed to ensure they had an RN on duty for the weekends during July and August 2024. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 11% based on 3 errors out of 26 opportunities, which involved 3 of 6 residents (Residents #22, #29 and #148) and 2 of 4 staff (MA A and LVN B) reviewed for medication errors. 1. The facility failed to ensure MA A administered the correct dose of Nicotine gum to Resident #29. 2. The facility failed to ensure MA A administered the correct dose of Acetaminophen to Resident #22. 3. The facility failed to ensure LVN B administered Cefepime 2 gram IV to Resident #148 at the rate indicated on the pharmacy label. These failures could place residents at risk of inadequate therapeutic outcomes.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 10 staff (LVN C, LVN D, and LVN E) reviewed for developing and implementing abuse and neglect policies. - The facility failed to develop and implement abuse policies for review of an employee EMR and criminal history at least once every 12 months. These failures could place residents at risk of abuse, neglect, and misappropriation of property.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure grievances were resolved for 3 of 3 (confidential group) residents reviewed (Resident #1) for grievances. The facility did not document or follow-up on Resident's grievances from group who expressed concerns during resident council meetings for April, May, June, and July of 2023. This deficient practice could affect 1 resident who attended resident council meetings during April, May, June and 3 residents who attended resident council meeting during July 2023 and could contribute to grievances not being resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #22) reviewed for the develop and implement comprehensive care plans. - The facility failed to ensure Resident #22's comprehensive care plan included the resident's repeated refusal of Dronabinol (A medication used to treat nausea and vomiting). This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.