F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to ensure that a
physician's order was implemented for one of 31 sampled residents. (Resident 97)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 97 was admitted to the facility on [DATE], with diagnoses that
included diabetes and end stage renal disease. Review of the clinical record revealed the resident was
transported to another location for hemodialysis at 9:00 a.m. on Mondays, Wednesdays, and Fridays.
Review of a physician order, dated June 26, 2022, revealed that the resident was to have an insulin
injection of 7 units of Humalog insulin solution twice a day with the first dose scheduled at 11 a.m. Review
of the Medication Administration Records for January 2023, revealed that the medication was not given
eight times, February 2023, the medication was not given six times and March 2023, the medication was
not given three times.
In an interview on March 10, 2023, at 10:21 a.m., the Director of Nursing stated the physician order was not
followed and there was no documentation to support the physician was notified the resident was missing
the 11 a.m. doses due to dialysis.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395499
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tremont Health & Rehabilitation Center
44 Donaldson Road
Tremont, PA 17981
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, observation, and staff interview, it was determined that the facility failed to implement
interventions to prevent contractures for one of six sampled residents with limited range of motion.
(Resident 147)
Findings include:
Clinical record review revealed that Resident 147 had diagnoses that included Parkinson's disease and
aphasia (loss of ability to understand or express speech). Review of the Minimum Data Set assessment
dated [DATE], revealed that Resident 147 had cognitive impairments, and had functional limitation in range
of motion on one side of the upper and lower extremities, and required extensive assistance from staff for
most activities of daily living. On January 26, 2023, a physician ordered that staff apply a left palm guard
during morning care and remove it with evening care. Observations on March 7, 2023, at 12:21 p.m., March
8, 2023 at 11:40 a.m., and 12:21 p.m., and March 9, 2023 at 10:45 a.m., revealed that Resident 147 did not
have the left palm guard in the left hand and the hand was clenched in a fist.
In an interview on March 10, 2023, at 11:30 a.m., the Rehabilitation Director, confirmed the left palm guard
was ordered due to Resident 147's muscle contracture of the left hand.
In an interview on March 10, 2023 at 11:12 a.m., the Director of Nursing confirmed that Resident 147
should have been wearing the left palm guard.
CFR 483.25(c)(2) Mobility
Previously cited 5/21/21
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395499
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tremont Health & Rehabilitation Center
44 Donaldson Road
Tremont, PA 17981
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy review, clinical record review, and staff interview, it was determined that the facility failed to
provide services to restore function to residents identified with a decline in bladder and bowel continence
for one of 31 sampled residents. (Resident 67)
Findings include:
Review of the facility policy entitled, Continence Management Program, dated October 20, 2022, revealed
that based on the resident's comprehensive assessment, all residents who were incontinent would receive
appropriate treatment and services to restore continence to the extent possible.
Clinical record review revealed that Resident 67 had diagnoses that included lack of coordination and
abnormalities of gait and mobility. The Minimum Data Set (MDS) assessment dated [DATE], indicated that
the resident was always continent of bladder and bowel. Review of the MDS assessments dated November
5, 2022, and February 5, 2023, revealed that Resident 67 had a decline in continence and had become
occasionally incontinent of bladder and frequently incontinent of bowel. Evaluations for continence and
retraining dated November 17, 2022, and February 17, 2023, failed to identify the resident's decline in
continence. Nurse Aide documentation for 30 days prior to March 10, 2023, reflected that the resident
continued to experience occasional episodes of urinary incontinence and frequent episodes of bowel
incontinence. There was a lack of documentation to support that services were provided to address
Resident 67's decline in bladder and bowel function.
During an interview on March 10, 2023, at 10:21 a.m., the Director of Nursing confirmed that a decline in
continence should have been evaluated and resulting interventions implemented.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395499
If continuation sheet
Page 3 of 3
