Deficiency Records for Trego Co-Lemke Memorial Hospital Ltcu
Updated as of March 01, 2024
A list of the most recent deficiencies for Trego Co-Lemke Memorial Hospital Ltcu. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-20 | 2023-10-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-20 | 2023-10-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-20 | 2023-10-05 | N |
| Post nurse staffing information every day. | Health | 2023-09-20 | 2023-10-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-20 | 2023-10-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-20 | 2023-10-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-20 | 2023-10-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-20 | 2023-10-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-15 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-15 | 2022-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-15 | 2022-08-11 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-07-15 | 2022-07-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-15 | 2022-07-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-15 | 2022-07-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-15 | 2022-07-25 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2022-07-15 | 2022-07-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-07-15 | 2022-07-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-15 | 2022-07-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-15 | 2022-07-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-15 | 2022-07-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-15 | 2022-07-16 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-07-15 | 2022-07-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-15 | 2022-07-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-06-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-01-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-13 | 2021-04-23 | Y |
| Install proper backup exit lighting. | Fire Safety | 2020-03-11 | 2020-04-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-11 | 2020-04-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-03-11 | 2020-04-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-11 | 2020-04-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-11 | 2020-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-11 | 2020-04-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-11 | 2020-04-09 | N |
