Tremont Rehabilitation & Skilled Care Center

In the surveyor’s words

From the most serious findings on record at Tremont Rehabilitation & Skilled Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Oct 26, 2023

  Based on interviews and record review, the facility failed to notify the physician about changes in condition and to re-evaluate the potential need to alter the treatment plan for two Residents (#141, #67), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #141, to notify the physician of treatment and medication recommendations made by the Wound Consultant physician and to notify the physician of changes to a sacral wound resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) with osteomyelitis (infection of the bone) and sepsis (infection of the blood stream) requiring a 19-day hospital admission and intravenous (IV) antibiotics followed by… […]

• Immediate jeopardy, isolatedF600Oct 26, 2023

  Based on record review, policy review, and interview, the facility failed to protect one Resident (#141) from neglect, out of a total sample of 20 residents. Specifically, for Resident #141 the facility failed to implement recommendations from the wound consultant physician including medications and treatments, failed to provide wound care treatments as ordered to a pressure injury of the sacral area, and neglected to identify, assess, and notify the physician of changes to the sacral wound resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) with osteomyelitis (infection of the bone) and sepsis (infection of the blood stream) requiring a 19-day hospital admission and intravenous… […]

• Immediate jeopardy, isolatedF658Oct 26, 2023

  Based on observations, interviews, and record review, the facility failed to ensure one Resident (#141), out of a total sample of 20 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed for Resident #141, to implement recommendations from the wound consultant physician including medications and treatments, to provide wound care treatments as ordered to a pressure injury of the sacral area, to implement a physician ordered setting for an air mattress, to identify and assess changes to the sacral wound, resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) with osteomyelitis (infection of the bone) and sepsis (infection… […]

• Immediate jeopardy, isolatedF686Oct 26, 2023

  Based on observations, interviews, policy review, and record review, the facility failed to ensure three Residents (#141, #87, #21), out of a total sample of 20 residents, received care and treatment to prevent and to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #141, to implement recommendations from the wound consultant physician including medications, treatments, and evaluation of an off-loading cushion, to provide wound care treatments as ordered to a pressure injury of the sacral area, to follow physician orders for settings of a pressure relieving air mattress, to identify and assess changes to the sacral wound, resulting in a Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle,… […]

• Actual harm, patternF690Oct 20, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure proper care and treatment for 4 Residents (#83, #15, #68, and #25) out of 6 residents with catheters. Specifically, the facility failed to ensure: - Residents (#83 and #15) with indwelling catheters were assessed for removal of the catheter as soon as possible; - Residents (#83 and #15) were provided catheter care in accordance with standards of practice; - Residents (#25 and #68) urology consults were reviewed and reflected in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident #68, with a catheter, was assessed for infection per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Residents (#83, #15, #68) urinary output was monitored per the plan of care. Findings include: 1A. […]