Trego Co-Lemke Memorial Hospital Ltcu

In the surveyor’s words

From the most serious findings on record at Trego Co-Lemke Memorial Hospital Ltcu, in the surveyor’s own words.

• Immediate jeopardy, isolatedF609Nov 19, 2025

  The 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. […]

• Immediate jeopardy, isolatedF689Apr 13, 2021

  The facility had a census of 32 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe and hazard free environment for one of three sampled residents. Certified Nurse Aide (CNA) M worked as a Restorative Aide (RA) without the 32-hour facility required Restorative Aide Training. He put a warm moist pack under Resident (R) 1's neck/upper back area while she laid on the therapy mat without having the correct amount of padding. R1, a severely cognitively impaired resident, had poor safety awareness, required cues to move, and did not always instigate any active movement. […]

• Actual harm, isolatedF689Apr 7, 2022

  The facility had a census of 31 residents with three reviewed for accidents. Based on record review and interview, the facility failed to ensure Resident (R)1 remained free from injuries related to accidents when a hot liquid spill resulted in a second degree burn to R1's right thigh. As a result of the burn, R1 required daily treatments to his groin/thigh and an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag). Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of heart failure (a condition with low heart output and the body becomes congested with fluid), [CONDITION(S)] (rapid, irregular heartbeat) and hypertension (high blood pressure). […]

• No harm, potential for more than minimal, widespreadF801Jun 4, 2025

  The 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. Findings included: - On 06/02/25, a review of the noon meal consisted of a grilled pork burger on a bun, onion rings, corn, and no-bake cookies. On 06/02/25 at 10:30 AM, observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 06/01/25 at 07:50 AM, DS BB verified she was not a Certified Dietary Manager (CDM). […]

• No harm, potential for more than minimal, widespreadF880Jun 4, 2025

  The 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). […]