Treemont Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Treemont Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Dec 1, 2021

  Based on observations, interviews and record reviews, 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 all residents in the facility except those residing on the COVID-19 isolation unit. 1. The facility failed to establish and implement a policy/procedure for transporting residents who tested positive for COVID-19 from the second floor to the first floor COVID-19 isolation unit. 2. The facility failed to ensure signage was placed to alert staff and others of the need for TBP when entering Resident #1's room and/or providing care. 3. […]

• Immediate jeopardy, patternF684Mar 19, 2022

  Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #65) of five residents reviewed for quality of care. The facility failed to care plan, assess, follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to routinely assess a wound to Resident #65's left groin and failed to identify an abscess had formed prior to his hospitalization on [DATE]. These failures resulted in Resident #65 being hospitalized from 03/10/22 through 03/14/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Immediate Jeopardy (IJ) situation was identified on 03/17/22 at 11:47 AM. […]

• Immediate jeopardy, isolatedF689Mar 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to ensure Resident #1,was provided adequate supervision on 03/04/2026 when he eloped from the facility without staff knowing and was found by the local police off the facility grounds. The noncompliance was identified as past noncompliance (PNC). Immediate Jeopardy began on 03/04/26 and ended on 03/04/26. The facility had corrected the noncompliance before the survey began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. […]

• Immediate jeopardy, isolatedF689Oct 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure each resident receives adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents, hazards, and adequate supervision. 1. The facility failed to ensure Resident #1 did not exit the facility without supervision and walk for two miles to a family member's residence on 10/25/2025. An IJ was identified on 10/28/2025. The IJ template was provided to the facility on [DATE] at 04:38 PM. […]

• Immediate jeopardy, isolatedF600Sep 21, 2023

  Based on interviews, and record reviews the facility failed to ensure a resident in the facility was free from sexual, and physical abuse for 1 (Resident #1) of 3 residents reviewed for abuse. The facility failed to protect Resident #1 from abuse when: RN A failed to report to the Administrator (at that time), or the DON when Resident #1 reported significant bruising of unknown origin to the upper thigh, inner thigh, buttocks, groin area, and to the knee on the right leg on 03/08/23. On 07/13/23 Resident #1 provided video to RN A that she had been sexually assaulted by the Dialysis RN. It was determined a past non-compliance Immediate Jeopardy existed from 03/08/23 to 07/17/23. […]