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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TREMONT HEALTH & REHABILITATION CENTER
Inspection Results For:

There are  137 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
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 two complaints, completed on May 17, 2025, at Tremont Health and Rehabilitation Center it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 ten of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from April 25 through May 15, 2025, revealed the following:

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 April 25, 27, 28, and May 2, 3, 4, 10, and 13, 2025.

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 April 26, 2025.

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 April 26, 27, and May 3, 4, and 11, 2025.



 Plan of Correction - To be completed: 07/07/2025

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

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 has increased wages for certified nurse aides and LPNs. 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 will sponsor career fair. Community will contact local Nursing schools to offer internship opportunities. Community has been certified to sponsor Certified Nurse Aide training courses. Under TLC sponsorship, community has held one certified nurse aide training class which yielded 2 staff members. Community has hired Nurse Aide Educator and first community class will start June 2, 2025 and continue with classes every 5 weeks. Community has contracts with 5 outside nursing agencies to provide additional staffing and has contracted with traveling nurse agencies that provide block schedules with LPN & RN positions. Community has hired Scheduling Coordinator 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 recommendations.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 20 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from April 25 through May 15, 2025, 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 April 27, and May 3, 4, and 12, 2025.

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 April 25 and 28, and May 3, 4, and 7, 2025.

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 April 26 and 30, and May 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 15, 2025.



 Plan of Correction - To be completed: 07/07/2025

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

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 has increased wages for certified nurse aides and LPNs. 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 will sponsor career fair. Community will contact local Nursing schools to offer internship opportunities. Community has contracts with 5 outside nursing agencies to provide additional staffing and has contracted with traveling nurse agencies that provide block schedules with LPN & RN positions. Community has hired Scheduling Coordinator to monitor staffing ratios, PPD and overall efficiency. Community has hired and retained 5 LPNs since last POC and continues to recruit.

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 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 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.:State only Deficiency.
(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.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for 13 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from April 15 through May 15, 2025, revealed the following total nursing care hours below minimum requirements:

April 25, 2025: 3.06 care hours per resident.
April 26, 2025: 2.73 care hours per resident.
April 27, 2025: 2.79 care hours per resident.
April 28, 2025: 3.08 care hours per resident.
May 2, 2025: 3.19 care hours per resident.
May 3, 2025: 2.96 care hours per resident.
May 4, 2025: 2.69 care hours per resident.
May 6, 2025: 3.16 care hours per resident.
May 9, 2025: 3.09 care hours per resident.
May 10, 2025: 2.98 care hours per resident.
May 11, 2025: 2.88 care hours per resident.
May 12, 2025: 3.12 care hours per resident.
May 15, 2025: 3.16 care hours per resident.



 Plan of Correction - To be completed: 07/07/2025

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

2) The facility continues to utilize staffing agencies and bonuses for staff. Community continues to use developed Recruitment Plan which includes updating hiring advertisements on community websites, facebook and other media outlets. Community has increased wages for certified nurse aides and LPNs. 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 will sponsor career fair. Community will contact local Nursing schools to offer internship opportunities. Community has contracts with 5 outside nursing agencies to provide additional staffing and has contracted with traveling nurse agencies that provide block schedules with LPN & RN positions. Community has received certification to run Nursing Assistant classes and has hired Certified Nurse Aide Educator. Community has hired Scheduling Coordinator to monitor staffing ratios, PPD and overall efficiency. Community has hired 14+ nurse aides, 5 LPNs and 3 RNs since last POC and continues to recruit.

3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated 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.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port