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

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TREMONT HEALTH & REHABILITATION CENTER
Inspection Results For:

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

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey completed February 23, 2024, 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.

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents in two of four dining rooms. (Residents 9, 91, 205)

Findings include:

Clinical record review revealed that Resident 9 had diagnoses that included Alzheimer's dementia, unspecified protein-calorie malnutrition, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated November 28, 2023, revealed that the resident had cognitive impairment. Review of Resident 9's care plan revealed the resident was to be seated upright in a chair with the assistance of one staff member while eating. On February 21, 2024, from 8:32 a.m. until 8:54 a.m., Nurse Aide (NA) 1 was observed standing while assisting Resident 9 with breakfast.

Clinical record review revealed that Resident 91 had diagnoses that included diabetes mellitius. Review of the MDS assessment, dated February 20, 2024, revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of Resident 91's care plan revealed that staff was to assist him with self-feeding and provide verbal cueing with meals. On February 21, 2024, from 8:30 a.m. through 8:45 a.m., NA 2 was observed standing while assisting Resident 91 with breakfast.

Clinical record review revealed that Resident 205 had diagnoses that included heart failure and chronic kidney disease. Review of the MDS assessment, dated November 28, 2023, revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of the Therapy Staff Education form revealed that staff was to assist Resident 205 with meals. On February 21, 2024, from 8:30 a.m. through 8:45 p.m. and from 11:45 a.m. through 12:00 p.m., NA 3 was observed standing while assisting Resident 205 with breakfast and lunch.

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

Plan of Correction - To be completed: 03/12/2024

1) Residents 9, 91, 205 did not have any adverse effects.

2)To identify other residents that have the potential to be affected, the DON/designee completed an audit of all three meals to ensure all staff assisting resident's dependent on feeding were seated during task.

3)To prevent this from reoccurring, the DON/designee educated nursing staff on residents' rights and dignity including sitting to feed dependent residents.

4)To monitor and maintain ongoing compliance, the DON/designee audited 1 meal a day/5x a week x 4 weeks then monthly x 2 to ensure all staff assisting resident's dependent on feeding are seated during task.

5)The results of the audit will be forwarded to the facility QAPI committee for further review and recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to meet each resident's needs as related to a diagnosis of post traumatic stress disorder and as identified in the comprehensive assessment for two of 31 sampled residents. (Residents 8, 21)

Findings include:

Clinical record review revealed that Resident 8 had diagnoses that included post traumatic stress disorder (PTSD), depression, and Fourier's gangrene (tissue death). Review of a psychiatric consultation dated December 20, 2023, revealed Resident 8 was a combat veteran with PTSD. Review of the Resident Centered Care/All About Me Information Form dated February 3, 2024, revealed the resident had triggers from past trauma that included loud noises, fireworks, and cars backfiring. Resident 8's care plan did not include interventions to address the resident's PTSD diagnosis and related triggers to prevent re-traumatization.

Clinical record review revealed that Resident 21 was admitted to the facility on December 4, 2023, with diagnoses that included major depressive disorder and anxiety disorder. The Minimum Data Set assessment Care Area Assessment summary dated December 11, 2023, noted that the resident's psychotropic drug use was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 21's psychotropic drug use were included in the care plan.

In an interview on February 23, 2024, at 9:34 a.m., the social worker (SW1) confirmed the identified areas were not addressed in Residents 8 or 21's care plans.

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/12/2024

1) Resident 8 had a care plan placed for PTSD. Resident 21 has had a care plan placed for psychotropics.

2) To identify other residents that have the potential to be affected, the DON/designee completed an audit of residents who have a history of PTSD to ensure care plan is present.
To prevent this from reoccurring, the DON/designee reviewed MDS completed in past week to ensure any CAA areas triggered have care plans to reflect.

3) To prevent this from reoccurring, the DON/designee educated social services to ensure care plans are in place for residents with a history of PTSD
To prevent this from reoccurring, the regional reimbursement nurse/designee educated the MDS nurses on ensuring when a CAA is triggered, there is a corresponding care plan.

4) To monitor and maintain compliance, the DON/designee will review residents with history of PTSD weekly x4 then monthly x 2 to ensure a care plan is in place.
To monitor and maintain ongoing compliance, the MDS nurse/designee will review MDS completed weekly x 4 then monthly x 2 to ensure a CAA that is triggered has a corresponding care plan.

5) The results of the audits will be forwarded to the facility QAPI committee for further recommendations and review.

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 resident interview, it was determined that the facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility on a consistent basis for one of 31 sampled residents. (Resident 147)

Findings include:

Clinical record review revealed that Resident 147 had diagnoses that included repeated falls and colon cancer. The Minimum Data Set assessment dated January 2, 2024, indicated that the resident was not cognitively impaired and required staff assistance for activities of daily living. Review of the physical therapy discharge summary dated January 25, 2024, revealed that the resident required staff assistance for transfers and walking. The physical therapist recommended a restorative nursing program for Resident 147. Staff was to assist the resident to walk 150 feet daily with a walker while staff followed with a wheelchair. Review of Resident 147's current care plan revealed that he was dependent on staff assistance for transfers and that he was to walk 150 feet with staff assistance. In an interview on February 20, 2024, at 12:00 p.m., Resident 147 stated that staff did not offer to walk him consistently, he desired to walk daily, and that he would not refuse an offer to walk. Review of nursing documentation from January 27, 2024, through February 22, 2024, revealed there was a lack of documentation to support that the resident received restorative nursing services on February 4, 9, 11, 20, and 22, 2024.

CFR 483.25(c)(2) Mobility
Previously cited 3/10/23

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/12/2024

1) Resident 147 was screened by PT and no decline noted. Resident recently had a medical decline and will be Hospice effective 3/5/2024. Restorative program will be re-evaluated to meet current condition.

2) To identify other residents that have the potential to be affected, the DON/designee reviewed residents on restorative programs to ensure they are being completed as recommended.

3) To prevent this from reoccurring, the DON/designee educated the nursing staff on restorative program completion and documentation

4) To monitor and maintain ongoing compliance, the DON/designee reviewed 5 residents on restorative programs weekly x 4 then monthly x 2 to ensure they were completed and documented as ordered

5) The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for one of 16 days reviewed.

Findings include:

Review of nursing schedules for 16 days from February 7 through 22, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratios of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on February 13, 2024.

In an interview on February 23, 2024, at 10:55 a.m., the Director of Nursing confirmed the facility did not meet the minimum nurse aide to resident ratio for the above mentioned date.

Plan of Correction - To be completed: 03/12/2024

1)The facility cannot correct past staffing issues.

2) The facility cannot retroactively correct past staffing issues. The facility utilizes staffing agencies and own staff to cover call offs which resulted in deficient hours.

3) The NHA/ DON meets daily with the scheduler to review PPD and staffing requirements to ensure compliance. The supervisors have been educated on the staffing requirements and the importance of securing coverage when call offs occur to prevent re-occurrence.

4) Audits of the schedules to maintain compliance will occur 5x a week x 4weeks,3x a week x 1 month.
Results of the audits will be forwarded to the QAPI committee for review and recommendations..,

§ 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 and staff interview, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for six of 16 days reviewed.

Findings include:

Review of nursing schedules for 16 days from February 7 through 22, 2024, revealed the following:

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 February 10, February 12 through 14, February 16, and February 19.

In an interview on February 23, 2024, at 10:55 a.m., the Director of Nursing confirmed the facility did not meet the minimum LPN to resident ratio for the above mentioned dates.

Plan of Correction - To be completed: 03/12/2024

1) The facility cannot correct past staffing issues.
2) The facility cannot retroactively correct past staffing issues. The facility utilizes staffing agencies and own staff to cover call offs which resulted in deficient hours.

3) The NHA/ DON meets daily with the scheduler to review PPD and staffing requirements to ensure compliance. The supervisors have been educated on the staffing requirements and the importance of securing coverage when call offs occur to prevent re-occurrence.

4) Audits of the schedules to maintain compliance will occur 5x a week x 4weeks,3x a week x 1 month.

Results of the audits will be forwarded to the QAPI committee for review and recommendations.

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