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Inspection visit

Health inspection

TREMONT HEALTH & REHABILITATION CENTERCMS #3954993 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to four of six sampled residents. (Residents 1, 2, 3, 4) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension and chronic obstructive pulmonary disease . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident needed staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. Review of documentation in the clinical record revealed that the resident only received two showers since admission to the facility on July 4, 2024. Clinical record review revealed that Resident 2 had diagnoses that included congestive heart failure and hypertension. The MDS assessment dated [DATE], indicated the resident needed staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. Review of documentation in the clinical record revealed that the resident was not offered a shower eight of 18 scheduled times in the past 90 days. Clinical record review revealed that Resident 3 had diagnoses that included diabetes mellitus and chronic obstructive pulmonary disease. The MDS assessment dated [DATE], indicated that the resident was oriented and needed staff assistance for bathing. The resident was to receive a shower twice per week on Wednesday and Saturday. In an interview on September 11, 2024, at 12:05 p.m. the resident stated that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 3 stated that she would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower 14 of 17 scheduled times in the past 90 days. Clinical record review revealed that Resident 4 had diagnoses that included hypertension and depression. The MDS assessment dated [DATE], indicated that the resident was oriented and was dependent on staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. In an interview on September 11, 2024, at 12:30 p.m. the resident stated that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 4 stated that she would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower eight of 18 scheduled times in the past 90 days. (continued on next page) 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 4 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 09/11/2024 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 0550 28 Pa. Code 211.12(d)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Previously cited 10/28/23 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395499 If continuation sheet Page 2 of 4 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 09/11/2024 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 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 provide care and services to meet each resident's needs for one of six sampled residents. (Resident 1) Residents Affected - Few Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension and chronic obstructive pulmonary disease. Review of the current care plan revealed that the resident had hearing loss and wore hearing aides. Review of a progress note dated August 15, 2024, revealed that Resident 1 had an appointment for the physician to clean his ears on September 6, 2024, and that the physician was to clean his ears in the facility. Review of a physician's progress note dated August 22, 2024, revealed that there was no evidence that the physician addressed or cleaned Resident 1's ears. On August 28, 2024, the physician ordered for staff to administer ear drops to both the resident's ears for seven days and then the physician would flush. There was no documented evidence that the physician cleaned or flushed Resident 1's ears or that the resident went to his scheduled appointment on September 6, 2024. In an interview on September 11, 2024, at 2:25 p.m., the Administrator and Director of Nursing confirmed there was no evidence that the physician cleaned Resident 1's ears and that Resident did not attend the September 6, 2024 appointment to have his ears cleaned. 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 4 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 09/11/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on two of three nursing units (B and C unit) and the main dining room. Findings include: Observation on the B nursing unit on September 11, 2024, from 10:30 a.m. through 2:00 p.m. revealed the following: The wall paper was peeling and hanging off the wall in multiple areas in the common area across from the nurses' station. The floor outside the door to the janitor's closet had a large accummulation of black dirt. In rooms 101, 102, 104, 105, 106, and 107, the floors were sticky and the tiles had a dull black/brown coating of dirt accummulation. In room [ROOM NUMBER] the heating unit contained peeling paint and cobwebs near the controls. The wall to the right of the closet was heavily marred. In the shared bathroom there was a brown/black ring of dirt on floor around the bottom of the toilet, the right side toilet grab bar was loose, the wall around the soap dispenser was peeling, and the bathroom door was heavily marred. In room [ROOM NUMBER] near the doorway, the floor was cracked and missing a piece of tile. In room [ROOM NUMBER], bed 2's top drawer to the night stand was broken and crooked, the bottom drawer near the sink did not close and was misaligned, and the closet doors did not close and were misaligned. Obersvations on the C nursing unit on September 11, 2024, from 10:30 a.m. through 2:30 p.m. revealed the following: In room [ROOM NUMBER] the front cover to the heating unit was broke and sticking out exposing a sharp edge. In room [ROOM NUMBER] there was a chair for resident use that the cushion was peeling and flaking off. In the main dining room there was a missing ceiling tile in the middle of the room. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395499 If continuation sheet Page 4 of 4

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Citations

3 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0550GeneralS&S Epotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0921GeneralS&S Epotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the September 11, 2024 survey of TREMONT HEALTH & REHABILITATION CENTER?

This was a inspection survey of TREMONT HEALTH & REHABILITATION CENTER on September 11, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at TREMONT HEALTH & REHABILITATION CENTER on September 11, 2024?

Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.