Pennsylvania Department of Health
TREMONT HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TREMONT HEALTH & REHABILITATION CENTER
Inspection Results For:

There are 151 surveys for this facility. Please select a date to view the survey results.

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TREMONT HEALTH & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated survey in response to four complaints completed on August 10, 2026, it was determined that Tremont Health and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.\~

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a change in condition for one of 10 sampled residents. (Resident 1)

Findings include:

Review of the facility policy entitled, "Resident Change in Condition Policy," dated May 8, 2026, revealed that nursing staff were to inform the resident's representative of any accident involving the resident which results in injury and had the potential for requiring physician interventions and a need to alter treatment significantly.

Clinical record review revealed that Resident 1 had diagnoses that included protein calorie malnutrition and dementia. Review of the Minimum Data Set (MDS) assessment dated August 5, 2026, revealed the resident had moderate cognitive impairment. Review of the resident's clinical record revealed on May 3, 2026, Resident 1 had slid himself down in his chair and developed multiple skin tears on both of his arms and a therapy screen was initiated for wheelchair positioning. In further review of the clinical record and facility documentation, on May 29, 2026, nursing had discovered a superficial moisture wound on Resident 1's left inner buttocks and the physician ordered a treatment for it. There was no documented evidence that Resident 1's representative was notified of the incident on May 3, 2026, and the skin issue reported on May 29, 2026.

In an interview on August 10, 2026, at 5:56 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1's representative was notified of the incident and skin issue noted previously, and they should have been.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 08/28/2026

1. Resident # 1, RP was updated on current skin condition.

2. To identify those residents that have the potential to be affected the DON/designee audited current residents nursing notes X 72 hours to ensure RP notified on new skin issues.

3. To prevent this from reoccurring the DON/designee educated the licensed nursing staff on when to notify RPs.

4. To monitor and maintain ongoing compliance the DON/designee will audit nursing notes to ensure RP notification is completed weekly X 4 and monthly X 2 or until a period of compliance has been reached as identified by QAPI.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services to improve or maintain functional abilities on a consistent basis for one of 10 sampled residents. (Resident 4)

Findings include:

Clinical record review revealed that Resident 4 had diagnoses that included generalized muscle weakness, displaced fracture of first cervical vertebra, and unsteadiness on feet. The Minimum Data Set assessment dated July 1, 2026, indicated that the resident was cognitively impaired, required substantial assistance from staff for activities of daily living, and had range of motion impairment in both lower extremities. On July 24, 2026, the physical therapist had recommended a Restorative Nursing Program (RNP) for bilateral lower extremity active range of motion exercises for functional muscle strengthening. In further review of the clinical record, it was revealed that on July 24, 2026, the occupational therapist had recommended a RNP program for passive range of motion for both sides of the upper and lower extremities to increase the resident's functional abilities. Per Resident 4's ongoing care plan, both RNP programs were to be offered daily. There was a lack of documentation to support that the resident was offered both RNP programs on two of ten days between August 1 through 10, 2026.

In an interview on August 10, 2026, at 5:54 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 4 was offered both restorative nursing programs daily and she should have been.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 08/28/2026

1. Resident #4 was assessed to ensure no negative effects from missed RNPs on identified 2 days. MD and RP updated.

2. To identify those residents that have the potential to be affected the DON/designee audited current residents with RNPs to ensure no missed programs. Negative findings had assessments completed to ensure no adverse effects with MD/RP updated.

3. To prevent this from reoccurring the DON/designee educated nursing staff on completion of programs and associated charting.

4. To monitor and maintain ongoing compliance the DON/designee will audit 5 residents weekly X 4 and monthly X 2 who participate in RNPs to ensure documentation is completed or until a period of compliance has been reached as determined by QAPI.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that as needed pain medication was administered per the physician's order for one of 10 sampled residents. (Resident 7)

Findings include:

Clinical record review revealed that Resident 7 had diagnoses that included Alzheimer's disease, Parkinson's disease, and end stage renal disease (kidney failure). A physician's order dated June 27, 2025, directed staff to administer acetaminophen (pain medication) every six hours as needed. Review of Resident 7's care plan revealed he was at risk of experiencing pain with an intervention for staff to anticipate the resident's need for pain relief and respond to any complaints of pain. Nursing documentation dated July 4, 2026, at 5:45 p.m., revealed Resident 7 was found lying on the floor in front of the sink on his left side. The resident complained of wrist pain and was unable to move his wrist. Review of Resident's 7 medication administration record revealed no documented evidence that staff had offered or administered the as needed pain medication on July 4, 2026, to relieve the resident's wrist pain and there was no evidence that he had refused the medication.

In a statement submitted on August 11, 2026, at 11:22 a.m., the Director of Nursing confirmed the as needed pain medication was not administered to Resident 7 on July 4, 2026, per the physician's order.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 08/28/2026

1. Resident #7 no longer resides in community.

2. To identify residents who have the potential to be affected the DON/designee completed a 3 day look-back of the nursing notes to determine if pain was not addressed with current residents.

3. To prevent this from reoccurring the DON/designee educated licensed nursing staff on administering PRN pain medication when residents c/o pain.

4. To monitor and maintain ongoing compliance the DON/designee will audit the nursing notes weekly X 4 and monthly X 2 to ensure residents are being treated for acute c/o pain or until a period of compliance has been reached as determined by QAPI.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 12 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from July 20, 2026, through August 9, 2026, revealed the following total nursing care hours below minimum requirements:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on July 25, and 26, 2026, and August 4, 8, and 9, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on July 28, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on July 23, 24, 25, 27, and 31, 2026, and August 3, 6, 8, and 9, 2026.

Plan of Correction - To be completed: 09/08/2026

1) The facility cannot retroactively correct the past C.N.A Ratios

2) The facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will continue to make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Community will continue to use developed Recruitment Plan which includes updating hiring advertisements on community websites, facebook and other media outlets. Community will continue to increase submission of hiring needs and wages on social media posts. Administrator/HR personnel to attend area job/career fairs. Community has contacted Nursing schools to offer internship opportunities. Community continues to sponsor NA training classes. Scheduling Coordinator has received education to improve ability to monitor staffing ratios, PPD and overall efficiency.

3)To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings and one NA to 15 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies.

4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed daily. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 14 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from July 20, 2026, through August 9, 2026, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on July 24, 25, and 26, 2026.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on July 24 and 26, 2026.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on July 20, 21, 23, 24, 25, 26, 27, 30, and 31, 2026, and August 1, 3, 6, 7, and 8, 2026.

Plan of Correction - To be completed: 09/08/2026

1) The facility cannot retroactively correct the past LPN Ratios.

2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to continue to utilize both internal and external resources to meet or exceed the staffing ratios. Community will continue to use developed Recruitment Plan which includes updating hiring advertisements on community websites, facebook and other media outlets. Community will increase submission of hiring needs and wages on social media posts. Administrator/HR personnel will continue to attend area job/career fairs. Community has contacted local Nursing schools to offer internship opportunities and community has tuition reimbursement programs. Scheduling Coordinator has received education to improve ability to monitor staffing ratios, PPD and overall efficiency.

3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for staff to pick up extra shifts.

4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN ratios. Audits will be completed daily. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 09/08/2026

1)The facility cannot retroactively correct the staffing PPD issues.

2)Community continues to use developed Recruitment Plan which includes updating hiring advertisements on community websites, facebook and other media outlets. Community will increase submission of hiring needs and wages on social media posts. Administrator/HR personnel will continue to attend area job/career fairs. Community continues to offer internship opportunities and also offers tuition reimbursement program. Scheduling Coordinator has received education to improve ability to monitor staffing ratios, PPD and overall efficiency.

3)To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on staffing regulations in relation to the daily PPD of 3.2 hours. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum PPD. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. The deployment sheets are developed in advance so staffing challenges can be addressed. A good faith effort is made to achieve the mandated staffing requirements. Supervisors are educated on the importance of filling call offs to meet requirements.

4)To monitor and maintain ongoing compliance the DON/designee will audit schedules daily. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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