A list of the most recent deficiencies for Tremont Health Care Center. 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2024-01-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-07 | 2023-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-26 | 2023-12-15 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-10-26 | 2023-11-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-26 | 2023-11-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-26 | 2023-11-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-26 | 2023-11-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-26 | 2023-11-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-26 | 2023-11-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-26 | 2023-11-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-26 | 2023-11-29 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-26 | 2023-11-29 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-10-26 | 2023-11-29 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-26 | 2023-11-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-26 | 2023-11-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-26 | 2023-11-29 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-10-26 | 2023-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-11-29 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-10-26 | 2023-11-29 | N |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2023-10-26 | 2023-11-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-26 | 2023-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-11-29 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-10-26 | 2023-11-29 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-10-26 | 2023-11-29 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-10-26 | 2023-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-02-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-19 | 2023-02-15 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-19 | 2023-02-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-19 | 2023-02-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-30 | 2023-01-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-30 | 2023-01-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-21 | 2022-11-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-09-21 | 2022-11-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-21 | 2022-11-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-20 | 2022-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-20 | 2022-04-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-20 | 2022-04-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-20 | 2022-04-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-20 | 2022-03-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-20 | 2022-01-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-20 | 2022-01-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-20 | 2022-01-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-20 | 2022-01-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-20 | 2022-01-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-20 | 2022-01-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-20 | 2022-01-25 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-20 | 2022-01-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-20 | 2021-12-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-20 | 2021-12-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-20 | 2021-12-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-20 | 2021-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-20 | 2021-12-19 | N |
| Provide appropriate foot care. | Health | 2021-10-20 | 2021-12-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-20 | 2021-12-19 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-10-20 | 2021-12-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-20 | 2021-12-19 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-10-20 | 2021-12-19 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-10-20 | 2021-12-19 | 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 | 2021-10-20 | 2021-12-19 | 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 | 2021-10-20 | 2021-12-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-20 | 2021-12-19 | N |
| Dispose of garbage and refuse properly. | Health | 2021-10-20 | 2021-12-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-20 | 2021-12-19 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-10-20 | 2021-12-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-03 | 2021-12-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-03 | 2021-12-19 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-11-03 | 2021-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-18 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-08 | 2021-10-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-08 | 2021-10-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-11 | 2021-05-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-04 | 2021-03-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-11 | 2019-12-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-11 | 2019-12-02 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-11 | 2019-12-02 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-09-11 | 2019-11-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-11 | 2019-11-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-11 | 2019-11-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-11 | 2019-11-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-11 | 2019-11-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-11 | 2019-11-18 | 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 | 2019-09-11 | 2019-11-18 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-09-11 | 2019-11-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-11 | 2019-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-11 | 2019-11-18 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-11 | 2019-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-11 | 2019-11-18 | N |
| Keep all essential equipment working safely. | Health | 2019-09-11 | 2019-11-18 | N |
