Hermitage Healthcare (the)

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide effective administration related to necessary care and services for one Resident (#4), out of a total sample of 20 residents when the facility reviewed Resident #4's clinical status of a laryngectomy (surgical procedure in which one's voice box is removed, separating one's airway from the mouth, nose, and esophagus, resulting in the ability to breathe only through an opening in the front of the neck) tube prior to the Resident's admission to the facility and accepted and admitted Resident #4, with a laryngeal tube in place, to the facility. [...]

Inspectors wroteBased on records reviewed and interviews, the facility failed to update the Facility Assessment when the facility had a change in resident population not already identified in the Facility Assessment, increasing the risk for inadequate medical care. Specifically, the facility failed to re-evaluate its resident population and identify the resources needed to provide necessary care and services when Resident #4:-was admitted to the facility with a laryngectomy (surgical procedure in which one's voice box [larynx] is removed, separating one's airway from their mouth, nose, and esophagus, allowing for breathing to occur only through and opening in the front of the neck) tube.-required staff assistance for care of his/her laryngectomy tube.-required specialized equipment to manage his/her airway in the event of cardiopulmonary arrest.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#10) out of a total sample of 20 residents was treated with respect and dignity during dining experiences when the Resident was identified as being dependent on staff assistance for meals. Specifically, for Resident #10, the facility failed to:-provide the Resident with appropriate eating utensils, when the Resident was observed utilizing a comb for eating during a lunch meal.-provide the Resident with the required supervision and intervene as needed when the Resident was left alone in his/her bedroom during breakfast and lunch meals and was observed spilling food items on their person, the meal tray, the tray table and the floor while trying to eat during the meals.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide reasonable accommodations by ensuring appropriate access to the call system for one Resident (#8) out of a total sample size of 20 residents. Specifically, for Resident #8, the facility staff failed to place the call system within reach for the individualized use of the Resident, placing him/her at risk for unmet needs.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide care and services according to accepted standards of clinical practice for two Resident's (#7 and #1) out of a total sample of 20 residents. Specifically, the facility failed to:1. For Resident #7, implement recommendations from the Wound Consultant for the use of a wound cleansing solution for the treatment of a right heel arterial ulcer.2. For Resident #1, ensure that Physician's orders relative to the correct size of the Resident's indwelling urinary catheter were obtained when the urinary catheter size was changed during a Urology Consult visit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance while eating for one Resident (#10) out of a total sample of 20 residents, when the Resident was identified to be dependent on staff assistance to eat. Specifically, the facility failed to provide constant supervision and one-person assistance while eating when Resident #10 was known to lack the ability to initiate or sequence tasks and had impaired vision.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one Resident (#22) out of a total sample of 21 residents, received an assistive device to maintain his/her hearing abilities. Specifically, the facility failed to follow-up with the audiology office to ensure Resident #22 received a hearing aid when the Resident had sensorineural hearing loss and a hearing aid was recommended for the Resident by the Audiologist, increasing the Resident's risk for hearing difficulties.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that nursing staff possessed the competencies required to meet the needs of one Resident (#4) of one applicable resident with a laryngectomy (surgical procedure in which one's voice box [larynx] is removed, separating one's airway from their mouth, nose, and esophagus, allowing for breathing to occur only through and opening in the front of the neck and omitting the mouth and nose as a means of receiving oxygenation and ventilation) tube, out of a total sample of 20 residents. Specifically, for Resident #4, the facility failed to evaluate competencies that demonstrated the knowledge and skills required by the direct care nursing staff to implement proper care and services of the Resident's laryngectomy tube.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication administration error rate of less than five percent (%) for two Residents (#14 and #54), out of two applicable residents, out of 27 medication pass opportunities. The medication error rate was calculated to be 11%. Specifically, 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received annual training on Resident's Rights. Specifically, 35 facility staff members were not in compliance for completion of their mandatory annual Resident's Rights education as of 8/20/25 evidenced by the Annual All Employee Course Completion History Report.

Inspectors wroteBased on record review, and interview, the facility failed to provide written documentation related to transfer discharge notices, and bed-hold policy notice upon hospitalizations, and the Office of the State Long-Term Care Ombudsman notification for four Residents (#2, #3, #1 and #89) out of a total sample of 20 residents. Specifically, the facility failed to: for Resident #2, provide evidence of written documentation relative to hospital transfer notice, bed-hold policy notification upon hospitalization, and Ombudsman notification. [...]

Inspectors wroteBased on record review, and interview, the facility failed to accurately code a Minimum Data Set (MDS) Assessment for one Resident (#8), out of a total sample of 20 residents. Specifically, the facility failed to:-For Resident #8, accurately code for the use of corrective lenses (eyeglasses) during the MDS observation period.

Inspectors wroteBased on observation, interview, and policy review the facility failed to maintain a clean and homelike environment for one Resident (#81) on one unit out of three units observed. Specifically, for Resident #81 who resided on the Sunburst Unit the facility failed to ensure that the Resident's enteral tube feeding (nutritional supplement through a tube to the stomach) equipment consisting of a pump and a pole was maintained in a clean manner.

Inspectors wroteBased on observation, interviews, and records reviewed, the facility failed to arrange services according to professional standards of practice for one Resident (#42) out of a total sample of 20 residents. Specifically, facility staff failed to arrange services with the Hand Surgeon for Resident #42 to undergo surgery when the Hand Surgeon diagnosed the Resident with Carpal Tunnel Syndrome (CTS: occurs when the median nerve, which runs from your forearm, through your wrist, into the palm of your hand, becomes pressed or squeezed at the wrist) and a trigger finger (condition in which fingers remain in a bent position due to inflammation of tendons that bend the fingers) and recommended surgical intervention.

Inspectors wroteBased on interview, policy and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent and trauma-informed care for one Resident (#86) out of a total sample of 20 residents. Specifically, the facility staff failed to develop and implement a trauma informed care plan for Resident #86's past history of trauma and/or triggers which may cause re-traumatization.

Inspectors wroteBased on observation, interviews, and records reviewed, the facility failed to provide two Residents (#49 and #48), who were diagnosed with Dementia, with appropriate treatment to attain or maintain their highest practicable mental and psychosocial well-being, out of a total sample of 20 residents. Specifically, facility staff failed to adequately monitor Resident #48's verbal behaviors and implement effective behavior interventions to prevent Resident #48 from directing verbal behaviors towards Resident #49 when Resident #49 was receiving personal care from facility staff, which resulted in an undignified experience for both Residents.

Inspectors wroteBased on interview and record review, the facility and its staff failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, there was no evidence that the Medical Director attended any of the quarterly QAPI meetings in 2022.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility and its staff failed to: 1) ensure staff at least annually, reviewed and revised the infection control policies, 2) have an implemented system for identifying, investigating, reporting, controlling, and preventing infections and communicable diseases for all residents, staff, and visitors, and 3) use the appropriate Personal Protective Equipment (PPE) during an outbreak of COVID-19 to stop the spread of infection transmission.

Inspectors wroteBased on record review and interview, the facility and its staff failed to ensure an Antibiotic Stewardship Program was in place to monitor antibiotic use.

Inspectors wroteBased on interview and record review, the facility and its staff failed to designate a qualified person to serve as the Infection Preventionist (IP), as required. Review of the key personnel listing indicated that there was no current IP at the facility. During an interview on 1/18/23 at 3:45 P.M., the Regional Clinical Nurse said that that she had been designated to oversee the IP program at the facility as of 1/17/23. She further stated prior to that, the facility did not have a designated qualified person who had undergone specialized training in infection control to oversee the IP program as required.

Inspectors wroteBased on document review, and interview, the facility failed to ensure that its staff notified Residents, families, and/or Resident Representatives of COVID-19 positive staff and resident cases in the facility by 5:00 P.M., the next calendar day during the recent COVID-19 outbreak in January 2023, as required.

Inspectors wroteBased on record review and interview, the facility and its staff failed to ensure weekly surveillance testing for COVID-19 was implemented for staff and also failed to conduct COVID-19 outbreak testing on staff and residents in a timely manner. Specifically, the facility failed to: 1) ensure weekly COVID-19 surveillance testing was done for three staff (Dietary staff #1, CNA#1, and CNA#5) out of a sample of three staff, 2) ensure COVID-19 outbreak testing was done every 48 hours after a COVID positive staff or resident was identified, for two staff (CNA #2 and CNA #5), out of three sampled staff, and 3) ensure COVID-19 outbreak testing was done every 48 hours after a COVID-19 positive staff or resident was identified, for two Residents (#14 and #41) out of a sample of three Residents, to stop the spread of infection.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that its staff provided an ongoing program of group and independent activities designed to meet the interests and support the well-being for five Residents (#6, #81, #1, #14, and #27) out of a total sample of 20 residents. Specifically, the facility staff failed to provide independent activities for Residents #6, #81, #1, #14, and #27, and group activities on the Sunburst unit.

Inspectors wroteBased on the Center for Disease Control and Prevention (CDC's) Pneumococcal and Influenza Vaccine guidance, record review, and interview, the facility failed to ensure that its staff provided the appropriate Pneumococcal and Influenza vaccines for four Residents (#17, #22, #41 and #89) out of a sample of five applicable residents, putting them at risk for developing facility acquired Pneumonia and Influenza.

Inspectors wroteBased on policy review, record review, and interview, the facility and its staff failed to provide COVID-19 vaccines as indicated by the Centers for Disease Control and Prevention (CDC) for three Residents (#22, #41 and #89), out of a sample of five applicable Residents. Specifically, facility staff failed to ensure: 1) that Resident #22 received the COVID-19 vaccinations in sequence and with a signed consent, 2) that Resident's #41 and #89 received COVID-19 vaccinations in the proper sequence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff implemented the plan of care for two Residents (#4, #58), out of a total sample of 20 residents. Specifically, the facility staff: 1) failed to notify the Physician for one Resident (#1) when the Resident's blood sugar measurement was greater than 250 mg/dl (milligrams per deciliter), and 2) failed to implement the use of multipodus boots (used to aid in the treatment of injuries to the foot and ankle including foot drop and pressure ulcers) for one Resident (#58).

Inspectors wroteBased on record review, policy review, and interview the facility failed to ensure that its staff included one Resident (#74) out of a total sample of 20 residents in the care planning process. Specifically, the facility failed to provide evidence that Resident #74 and the Resident's Representative had been invited to and participated in their care plan meetings.

Inspectors wroteBased on observation, record review, and interview, the facility and its staff failed to ensure one Resident (#48) received the care and services, based on their assessment, to maintain an acceptable nutritional status. Specifically, the facility failed to: 1) ensure a nutritional supplement was accepted and administered as ordered, 2) revise the care plan to include new interventions to arrest weight loss, and 3) provide the required assistance at meal times.

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure that its staff provided care and services consistent with professional standards for Resident (#60), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), for one out of a total sample of 20 residents. Specifically, the facility staff failed to ensure complete and accurate communication and documentation with the dialysis facility as required.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure that its staff provided pharmaceutical services for two Residents (#41 and #14) out of a sample of 20 residents. Specifically, the facility staff failed to ensure: 1) Resident #41 had a diagnosis that indicated the need for an anti-psychotic medication (Abilify), and 2) that Resident #14 had monthly pharmacy reviews completed as required.

Inspectors wroteBased on staff interview, record review, and policy review the facility and its staff failed to ensure that each Resident's drug regimen was free of unnecessary psychotropic medications. Specifically, the facility staff failed to ensure anti-psychotic psychotropic consents were obtained for two Residents (#22 and #41's), out of a total sample of 20 residents.

Inspectors wroteBased on record review and interview, the facility and its staff failed to ensure laboratory services were provided for one Resident (#14), out of a sample of 20 residents. Specifically, the facility staff failed to ensure weekly laboratory tests were obtained, as ordered by the Physician, while the Resident was being treated for an infection.

Inspectors wroteBased on observation, policy review, and interview, the facility and its staff failed to adhere to food safety requirements to prevent foodborne illnesses. Specifically, the facility staff failed to: 1) perform hand hygiene for sanitary distribution of food, and 2) store food in accordance with professional standards in the kitchenette located on the Sunburst Unit.