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Deficiency Records for Hermitage Nursing and Rehabilitation
A list of the most recent deficiencies for Hermitage Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Hermitage Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-21 | 2024-04-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-07 | 2024-03-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-29 | 2024-02-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-29 | 2024-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-29 | 2024-02-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-29 | 2024-02-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-29 | 2024-02-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-21 | 2024-01-30 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-21 | 2024-01-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-21 | 2024-01-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-21 | 2024-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-01-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-21 | 2024-01-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-10 | 2023-05-01 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-04-10 | 2023-05-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-20 | 2023-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-20 | 2023-02-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-23 | 2023-02-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-23 | 2023-02-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-01-23 | 2023-02-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-23 | 2023-02-04 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-01-23 | 2023-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-23 | 2023-02-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-23 | 2023-02-04 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-23 | 2023-01-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-06 | 2022-06-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-06 | 2022-06-28 | Y |
| Report COVID19 data to residents and families. | Health | 2022-06-06 | 2022-06-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-08 | 2022-06-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-08 | 2022-06-01 | Y |
| Meet other general requirements. | Fire Safety | 2022-02-16 | 2022-04-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-11 | 2022-03-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-11 | 2022-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-11 | 2022-03-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-11 | 2022-03-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-08 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-08 | Not Fixed | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-08 | Not Fixed | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-02 | Not Fixed | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-14 | Not Fixed | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-29 | Not Fixed | Y |
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