Hermitage Nursing & Rehab

Inspectors wroteThis citation is uncorrected. For prior example, please see 1F1B06-H1, exit date 03/05/26. Please refer to event ID 1F1B06-H2, exit date 05/11/26, for details.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse when one staff member (Certified Nurse Assistant (CNA) A) yelled at and physically forced one resident (Resident #1), with a diagnosis of dementia, back into his/her room twice while the resident was resisting and trying to exit his/her room. The resident received multiple bruises on their hands and forearms and exited their room visibly upset after the altercation and stating he/she wanted the staff member arrested. The CNA was later arrested and charged with assault. The facility census was 65. The Administrator was notified on 02/26/26, at 12:30 P.M., of an Immediate Jeopardy (IJ) which began on 02/20/26. The IJ was removed on 02/27/26, as confirmed by surveyor on-site verification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, obtain and document treatment orders, and care plan wounds for three residents. Resident #4 had a head laceration and right wrist splint, Resident #8 had open leg ulcers, and Resident #5 a skin tear and multiple scabbed areas to left arm. The facility census was 65. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive assessment, including a review of the clinical rationale and approved indication for use of psychotropic medications (prescription drugs that manage mental health conditions by affecting brain activity, mood, thoughts, and behavior), for one resident (Resident #3) with a diagnosis of dementia, prior to utilizing anti-psychotic medications (a class of medications primarily used to manage psychosis) to treat the resident's behaviors. The facility failed to consistently monitor, identify, and implement nonpharmacological interventions to address the resident's behaviors and failed to care plan use of antipsychotic medication. The facility census was 65. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse were reported immediately to facility management and within two hours of staff being aware of the allegation, when staff did not report two allegations of abuse involving two residents (Resident #1 and #2) to administration and the Department of Health and Senior Services (DHSS) in a timely fashion. The facility census was 65. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure after an allegation of abuse, an immediate investigation was completed with steps implemented to protect all residents during the investigation, when staff failed to complete timely investigations of two allegations of abuse involving two residents (Resident #1 and #2). The facility census was 65. Review of the facility's policy titled, Abuse Policy, undated, showed the following-It is the policy of the facility that each resident will be free from abuse;-Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion;-All employees who have been alleged to commit abuse will be suspended immediately pending investigation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete skin assessments, document accurate wound assessments, obtain and update orders timely, provide treatment as ordered, and care plan for one resident (Resident # 2) with a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 65. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services per standards of practice when the facility staff did not obtain an ordered urinalysis (UA) timely, did not follow-up to obtain timely results of a UA/culture and sensitivity result (a urine sample grown in a lab to identify bacteria or other pathogen and then tested against various bacteria to determine how effective different antibiotics are at killing the bacteria), and did not document follow-up or delays related to the UA for one resident (Resident #3) with an untreated urinary tract infection (UTI). The facility census was 65. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to implement a complaint infection prevention and control program when the facility failed to review and update their infection prevention and control program policies and procedures manual annually as required. The facility also failed to ensure all staff were trained regarding the use of Enhanced Barrier Precautions (EBP - refers to an infection control method using gowns and gloves for high-contact care of residents with or at risk for MDROs) and failed to follow EBP guidelines as indicate for three residents (Resident #5, #69, #40). Staff failed to follow standard infection control practices when providing cigarettes to two residents (Resident #49 and #68) who smoke when staff touched the filters with the bare hands without performing hand hygiene or donning gloves. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) level one was retained in the resident's medical record and accessible for one resident (Resident #38) of four residents reviewed for PASARR. The facility census was 63. Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) level one was retained in the resident's medical record and accessible for one resident (Resident #38) of four residents reviewed for PASARR. The facility census was 63. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to provide wound care per physician orders for one resident (Resident #40's). The facility had a census of 63. Review of the facility provided policy, Wound Care and Treatment, undated, showed the following:-It is the purpose of this facility to prevent and treat all wounds;-There must be a specific order for the treatment. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to change oxygen tubing per professional standards, failed to document the change of oxygen tubing, failed to ensure appropriate storage of oxygen tubing that was not in use, failed to document pulse ox readings, failed to follow oxygen orders, and failed to ensure that the facility oxygen orders and the Hospice oxygen orders matched for one resident (Resident #5). The facility census was 63. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep food safe from potential contamination or bacterial growth when staff stacked wet dishware inside one another, trapping moisture, which could potentially contaminate food served from those items. The facility census was 60. Review of the facility's policy titled General Dish Room Sanitation, by Nutrition and Dining Services Manual, dated April 2011, showed the following information: -All items are to be air dried; -No moisture can be found on any stacked item. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity when staff left two residents (Residents #42 and #27) exposed during transfer and/or incontinent care, stood over two residents (Residents #15 and #8) while assisting the residents to eat, and cursed at one resident (Resident #43). The facility census was 60. Review of a facility policy entitled Resident Rights, undated, showed the following: -It is the purpose of this facility to meet the Federal and State mandate in respect to resident rights. The resident has a right to a dignified existence. A facility must protect the rights of each resident; -Rights include privacy and respect. Review of a facility policy entitled Perineal Care, undated, showed to provide privacy for the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when staff administered medication to one resident (Resident #2) after touching the medication with bare hands and placing the medication directly on top of the medication cart, and when staff failed to complete routine hand hygiene during and after wound care for three residents (Resident #8, Resident #37, and Resident #11). The facility census was 60. Review of the Centers for Disease Control and Prevention's (CDC) Hand Hygiene Guidance, dated 01/30/20, showed the following in reference to healthcare settings: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure one resident's (Resident #36) code status (if the resident wished to received cardiopulmonary resuscitation (CPR - a lifesaving technique that is used when someone's breathing or heartbeat has stopped) was consistent and accurate throughout the resident's medical record. The facility census was 60. Review showed the facility did not provide a policy regarding code status. 1. Review of Resident #36's face sheet showed the following information: -admission date of [DATE]; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff attempted to provide one resident (Resident #27) with a double dose of medication during a random medication pass observation. The facility had a census of 60. Review of the facility policy titled Medication Administration, undated, showed the following: -Staff should read the label three times before administering medication: -First when comparing the label top the medication sheet; -Second when setting up the medication; -Third when preparing to administer the medication to the resident. 1. Review of Resident #27's face sheet showed the following: -admission date of 10/18/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse (RN), other than the Director of Nursing, for at least eight consecutive hours per day seven days per week with the facility average daily occupancy over 60 residents. The facility census was 70. Record review showed the facility did not provide a policy regarding RN coverage. 1. Record review of the facility Daily Nurse Staffing Form (posted staffing sheets), dated December 2021 and January 2022, showed no RN was scheduled from 6:00 A.M.-2:00 P.M., 2:00 P.M.-10:00 P.M., and 10:00 P.M.-6:00 A.M. shifts on the following days: -On 12/6/21, with a census of 72. -On 12/10/21, with a census of 73; -On 12/11/21, with a census of 72; -On 1/10/22, with a census of 70. During interview on 1/13/22, at 11:05 A.M., the Director of Nursing (DON) said the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a side rail evaluation form, to include a risk/benefit review and alternatives attempted prior to use of side rails, failed to document an ongoing evaluation of side rails, failed to obtain a physician order for side rails, failed to obtain informed consent for side rails, failed to complete a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment, and failed to develop care plan interventions and approaches for side rails for ten residents, (Resident #5, Resident #11, Resident #17, Resident #31, Resident #41, Resident #47, Resident #54, Resident #64, Resident #65, and Resident #221) The facility census was 70. Record review of the facility's policy, titled Restraints, Use of, dated March 2015, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants when staff failed to use appropriate hand hygiene after performing incontinent care for four residents (Resident #7, Resident #64, Resident #69, and Resident #221), and failed to maintain an infection control program that provided a safe and sanitary environment for all residents during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic when staff failed to follow their policy and standards of practice when staff failed to wear personal protective equipment (PPE) facemasks appropriately in a home with a COVID outbreak. The facility census was 70. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure recommended interventions for weight loss, including weekly weights and supplemental nutritional shakes, were implemented and care planned and failed to ensure meal intake was properly documented for one resident (Resident #29). The census was 70. Record review of the facility's policy titled Nutrition, dated March 2012, showed the following information: -Residents will be provided meals three times a day at facility-determined times; -Diet ordered by physician will be followed; -Residents will be offered bed time snacks unless contraindicated; -At no time will this facility withhold nutrition to promote or hasten death; -Examples of Nutritional Interventions without a physician's order: whole milk, juice, supercereal, extra butter, extra desserts, snacks; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff administered medications with an error rate of less than 5% when a nurse failed to prime the insulin pen needle per the manufacturer's guidelines before administering rapid acting insulin to two residents (Resident #32 and Resident #307). The medication error rate was 8% based on two medication errors out of 25 opportunities. The facility census was 70. Record review of the Novolog (a type of fast-acting insulin) website guidance, dated May 2018, showed the following information: -The Novolog FlexPen (a prefilled insulin pen): [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent a significant medication errors when a nurse failed to prime the insulin pen needle per the manufacturer's guidelines before administering rapid acting insulin to two residents (Resident #32 and Resident #307). The facility census was 70. Record review of the Novolog (a type of fast-acting insulin) website guidance, dated May, 2018, showed the following information: -The Novolog FlexPen (a prefilled insulin pen): the method of administration may affect glycemic control (a medical term referring to the typical levels of blood sugar in person with diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose)) and predispose the person to hypoglycemia (abnormally low blood sugar) or hyperglycemia (abnormally high blood sugar). [...]