Trego Co-Lemke Memorial Hospital Ltcu

Inspectors wroteThe facility identified a census of 30 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure staff reported witnessed staff-to-resident alleged abuse incidents to facility administration. Between an unknown date in September 2025 and November 16, 2025, several facility staff witnessed numerous alleged incidents of staff-to-resident abuse by the alleged perpetrator, Certified Nurse's Aide (CNA) M, and impacted cognitively impaired Residents (R) 1, R2, and R3. Facility staff witnessed CNA M flick, yell, yank, and forcefully restrain cognitively impaired residents over the approximately 3-month time frame. The failure of numerous staff to report allegations of abuse to the facility administration placed all of the residents who resided in the facility in immediate jeopardy.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 35 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella and other waterborne pathogens). This placed the residents in the facility at risk for infectious disease. Findings Included: - On 06/04/25 at 10:05 AM, Maintenance Staff U stated he had a log pointing out weekly flushing places, but was unaware of any routine facility water management checks. [...]

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on record review, and interview, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all residents who reside at the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of resident-to-resident abuse of Resident (R) 14, when R29 grabbed her knee, would not let go, and caused her knee to become reddened. This placed R14 at risk for injury and ongoing abuse.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to report to administration a resident-to-resident altercation for one resident, Resident (R) 14, when R29 grabbed her knee, would not let go, and caused her knee to become reddened. This placed R14 at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide services consistent with the standards of care for one of four residents reviewed for a urinary catheter (a tube inserted into the bladder to drain urine) or urinary tract infection (UTI). This placed Resident (R) 20 at risk for catheter-related complications and future UTIs.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for one resident, Resident (R) 29. This placed R29 at risk for physical decline and fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move).

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop and implement an antibiotic stewardship policy to ensure the appropriate and effective use of antibiotics, reducing antibiotic resistance and improving patient outcomes. This placed the 35 residents who resided in the facility at increased risk of receiving an infection and/or negative effects of antibiotic use.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to treat Resident (R) 25 with respect and dignity and failed to promote quality of life when staff performed an accucheck (blood sugar test) in a non-private area. This placed the resident at risk for impaired dignity.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a comprehensive care plan to include Resident (R) 25's diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). This deficient practice placed the resident at risk for inappropriate care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement pressure reducing or offloading interventions to promote healing for Resident (R) 34, had a stage three (full thickness pressure injury extending through the skin into the tissue below) heel pressure ulcer. This placed the resident at risk for delayed healing, worsening of the wound, or additional pressure injuries.

Inspectors wroteThe facility had a census of 34. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the consultant pharmacist (CP) identified and reported the lack of a stop date for Resident (R) 34's as needed (PRN) psychotropic (altering mood or thoughts) medication. The facility further failed to ensure the CP identified and reported the lack of pulse monitoring prior to administration of R19's metoprolol (blood pressure medication). This placed the resident at risk for unnecessary medication side effects.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with five residents sampled for unnecessary medications. Based on observation, record review, interview, the facility failed to ensure nursing staff monitored a pulse prior to administering Resident (R) 19 metoprolol (a beta-blocker medication used to treat and lower blood pressure and pulse rate). This placed R19 at risk for unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to place a stop date on an as needed (prn) psychotropic (medication used to treat mental health disorders) medication for Resident (R) 34. This placed the resident at risk for unnecessary medications and related complications.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure communication and collaboration between the facility and hospice provider which included a description of the services, medication, and equipment provided to Resident (R)21. This deficient practice created a risk for missed opportunities for services and delayed treatment.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for two of three days of the onsite survey.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to cover clean linens and/or clothing when delivering to resident rooms and failed to review or update infection control policies annually. This deficient practice placed the residents at increased risk for infection.