Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trego Co-lemke Memorial Hospital Ltcu during CMS and state inspections, most recent first.
Failure to Report Witnessed Staff-to-Resident Abuse: Multiple staff witnessed an aide yelling at, flicking, yanking, and forcefully restraining cognitively impaired residents, including a resident with severe dementia and another with PTSD and dementia, but did not report the abuse to administration. Witnesses said they feared retaliation or believed the aide could be mean, and the DON stated administration was unaware until an anonymous complaint was received.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for its residents. Instead, a dietary staff member without certification was responsible for meal preparation and supervision, and both the staff member and an administrative nurse confirmed the lack of certification. The facility also could not provide a policy regarding the employment of a certified dietary manager.
The facility did not follow its water management policy to prevent Legionella, as maintenance staff were unaware of routine checks and administrative staff confirmed the absence of a system to monitor and mitigate risks. Required temperature monitoring and flushing of outlets were not consistently performed, placing residents at risk for waterborne pathogens.
The facility did not ensure RN coverage for eight consecutive hours daily as required, with PBJ records and administrative staff confirming multiple days without an RN present. Staff believed hospital RNs could be used for LTC coverage, and no PBJ policy was available when requested.
A resident with cognitive impairment was subjected to abuse by another resident, resulting in physical redness to the knee. Although staff intervened and assessed the resident, required documentation, administrative notification, and follow-up with the physician and family were not completed according to facility policy. Key staff were unaware of the incident until after the fact, demonstrating a failure to follow established abuse reporting and investigation protocols.
A resident with cognitive impairment was grabbed on the knee by another resident, resulting in redness but no bruising. Although the incident was assessed by a nurse and documented in the medical record, required notifications to administration, the physician, and the family were not completed, and no incident report was filed. Key staff were unaware of the event until much later, indicating a failure to follow established abuse and neglect reporting protocols.
A resident with a urinary catheter and history of UTIs received catheter care from a CNA who failed to change gloves after providing care, subsequently touching the resident, medical equipment, and furniture with soiled gloves. The CNA acknowledged not changing gloves, and the facility could not provide a policy on glove changes during catheter care.
A resident with a history of constipation and multiple chronic conditions did not receive required bowel management interventions after six days without a bowel movement, despite care plan directives and physician orders. Staff failed to document or provide interventions as outlined in the facility's protocols, resulting in the resident being found with fecal incontinence and requiring assistance for hygiene.
A review of records and staff interviews revealed that the facility did not have an antibiotic stewardship policy in place. An administrative nurse confirmed that a cyberattack had erased all policies, and the antibiotic stewardship policy had not yet been restored, leaving the facility unable to provide it when requested.
Failure to Report Witnessed Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure staff reported witnessed staff-to-resident alleged abuse incidents to facility administration. Multiple staff members observed Certified Nurse's Aide M allegedly flicking, yelling at, yanking, and forcefully restraining cognitively impaired residents over an approximately 3-month period, but those staff did not report the incidents when they occurred. The report states that the failure to report these allegations placed all residents in immediate jeopardy. Resident 1 had diagnoses of dementia, Alzheimer's disease, mood disturbance, and anxiety, and had a BIMS score of 00, indicating severely impaired cognition. Resident 1 was dependent on staff for toileting and required moderate assistance with other ADLs. Witness statements described CNA M flicking Resident 1 in the cheek and forehead, yelling at Resident 1 to be quiet, and yanking Resident 1 by the wrist and arm to pull the resident off the toilet. Staff who witnessed these events stated they did not report them to administration, with one stating fear of retaliation and another stating CNA M could be mean and retaliatory. Resident 2 had vascular dementia, anxiety, major depressive disorder, and a history of other mental health disorders, with a BIMS score of 7 and a care plan calling for staff assistance with all ADLs and observation for changes in mood and behavior. A witness stated CNA M was verbally aggressive with Resident 2 in the hallway and leaned down in the resident's face, causing the resident to respond, 'Don't talk to me like that.' Resident 3 had PTSD, vascular dementia, major depressive disorder, and anxiety, with a BIMS score of 00 and dependence on staff for all ADLs except ambulation, bed mobility, and transfers. Witness statements described CNA M telling Resident 3 she had to stay seated, holding her down in a chair, and restraining her hands so she could not eat or drink. Staff who observed these incidents stated they had been trained on abuse and neglect but did not report the events to administration.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) for its 35 residents who received meals from the facility kitchen. Observations showed that a dietary staff member was overseeing meal preparation but was not a CDM, as confirmed by both the staff member and an administrative nurse. The staff member had only recently enrolled in dietary certification classes and had not yet obtained certification. Additionally, the facility was unable to provide a policy regarding the employment of a certified dietary manager when requested by surveyors. These findings were based on direct observation of meal preparation, staff interviews, and review of facility records, with no evidence provided that a qualified CDM was employed at the time of the survey.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement its water management program as outlined in its policy, specifically regarding the prevention of Legionella and other waterborne pathogens. Maintenance staff reported having a log for weekly flushing of certain outlets but were unaware of any routine facility-wide water management checks. Administrative staff confirmed that there was no system in place to monitor for standing water or to mitigate the risk of Legionella growth within the facility. The facility's policy required regular monitoring and recording of water temperatures at both hot and cold outlets, with specific temperature thresholds to prevent bacterial growth, and mandated that sporadically used outlets be flushed weekly. However, the required monitoring, recording, and mitigation activities were not being performed as specified. This lack of adherence to the water management policy placed the facility's residents at risk for exposure to Legionella and other waterborne pathogens.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. Payroll Based Journal (PBJ) records submitted to CMS showed that there was no RN coverage for eight hours on several specific dates. Administrative staff confirmed that on these dates, there was not an RN present in the long-term care area. Both the administrative nurse and staff responsible for PBJ reporting stated they believed that RNs from the attached hospital could be used to fulfill the RN coverage requirement for the long-term care facility. Additionally, the facility was unable to provide a policy regarding PBJ reporting when requested.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and multiple diagnoses, including anxiety, dementia, and major depressive disorder, was subjected to resident-to-resident abuse. The incident involved another resident with severely impaired cognition who grabbed the first resident's knee, causing redness but no bruising. The event was witnessed by a CNA, who intervened to separate the residents and reported the incident to a nurse for assessment. Despite the facility's policies requiring immediate reporting, investigation, and notification of administration, physician, and family, there was a lack of proper documentation and follow-up. The electronic medical record did not include further assessment or documentation of follow-up after the altercation, nor did it show that nursing administration, family, or physician were notified. The nurse involved admitted to not completing an incident report or notifying administration as required, and only verbally informed the family without documentation. Key staff members, including the administrative nurse and social services, were unaware of the incident until much later, indicating a breakdown in communication and protocol adherence. The facility's policies clearly outlined the steps to be taken in the event of resident-to-resident abuse, but these were not followed, resulting in a failure to protect the resident from abuse and to ensure appropriate post-incident actions were taken.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when staff failed to report a resident-to-resident altercation to administration, as required by facility policy. The incident involved a resident with moderately impaired cognition, anxiety, dementia, and major depressive disorder, who was grabbed above the right knee by another resident with severely impaired cognition. The altercation resulted in redness to the knee but no bruising or further injury. The event was documented in the nurse's notes, and the resident was assessed and removed from the situation, but there was no further documentation or follow-up regarding the incident. The electronic medical record lacked evidence of additional assessment, follow-up, or notification to nursing administration, the resident's family, or the physician after the altercation. Interviews revealed that key staff members, including the administrative nurse and social services, were unaware of the incident until much later. The nurse involved acknowledged that an incident report should have been completed and administration notified, but this was not done. The facility's policies require immediate reporting and investigation of such incidents, as well as notification of families and physicians. Staff interviews confirmed that training on abuse and behavior management was provided, and that the expected protocol was to separate residents and notify the nurse for assessment. However, the required steps for reporting and investigating the altercation were not followed, resulting in a failure to comply with the facility's abuse and neglect policies. This lapse placed the resident at risk for further injury and unaddressed abuse or mistreatment.
Failure to Change Gloves During Catheter Care
Penalty
Summary
A deficiency was identified when staff failed to follow proper infection control procedures during catheter care for a resident with a history of benign prostatic hyperplasia, recurrent urinary tract infections, and severe cognitive impairment. The resident's care plan required catheter care twice daily and as needed, including cleansing the urinary meatus, and specified the use of Enhanced Barrier Precautions. During an observed episode of catheter care, a certified nurse aide provided care to the resident but did not change gloves after performing catheter care. The aide continued to touch the resident, medical equipment, furniture, and retrieved a new incontinent brief, all while wearing the same soiled gloves. The aide then assisted with transferring the resident and continued to touch various surfaces and the resident before finally removing and discarding the gloves. The aide later confirmed that gloves had not been changed after providing catheter care, acknowledging this was not in line with expected practice. The facility was unable to provide a policy regarding glove changes during catheter care when requested by surveyors.
Failure to Implement Bowel Management Interventions for a Resident with Constipation
Penalty
Summary
A deficiency occurred when staff failed to monitor and provide appropriate interventions for bowel management for a resident with a history of constipation and multiple comorbidities, including vascular dementia, diabetes mellitus type 2, and hypertension. The resident required substantial assistance with activities of daily living and was always continent of bowel. The care plan directed staff to notify a nurse and implement bowel management protocols if the resident had no bowel movement for three days. Physician orders included several laxatives to be administered as needed for constipation, and the facility's standing orders outlined a stepwise approach for intervention after three days without a bowel movement. Despite these protocols, the resident did not have a bowel movement for six consecutive days, and there was no documentation that staff provided any interventions during this period. Observations revealed the resident was found with fecal incontinence and required assistance to be cleaned. Interviews with staff confirmed that interventions were not implemented as required by the care plan and standing orders, and the nurse was unable to find evidence of any action taken during the period of constipation.
Failure to Implement Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship policy to ensure the appropriate and effective use of antibiotics. During a review of records and interviews, it was confirmed that the facility did not have an antibiotic stewardship policy in place, as verified by the Administrative Nurse. The nurse explained that a cyberattack on the facility's computer system had erased all policies, and although efforts were being made to restore them, the antibiotic stewardship policy had not yet been recreated. As a result, the facility was unable to provide the requested policy when asked.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Ellis | 18.2 mi | ★★★★★ | 12 | 0 |
| Dawson Place | 23.9 mi | ★★★★★ | 17 | 0 |
| Sheridan County Hospital Ltcu | 27.3 mi | ★★★★★ | 21 | 0 |
| Good Samaritan Society - Hays | 30.5 mi | ★★★★★ | 0 | 0 |
| Via Christi Village Hays Ks Llc | 32.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.