Herman Health Care Center

In the surveyor’s words

From the most serious findings on record at Herman Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 25, 2025

  Based on observation, interview and record review the facility failed to prevent one of 17 sampled residents (Resident 82) from multiple falls from August 2024 to May 2025 when:1. Resident 82 had a total of nine fall incidents as follows: a. Unwitnessed fall on 8/20/24 at 10:00 a.m. with no injuryb. Unwitnessed fall on 11/11/24 at 1:34 p.m. resulting to injury (abrasion-a superficial scrape or wound to the skin or other body tissue, caused by rubbing or friction against the surface) to right knee.c. Unwitnessed fall on 12/5/24 at around 11:00 a.m. with no injuryd. Unwitnessed fall on 4/12/25 at 12:30 a.m., with low spine back pain and swelling on the [NAME]. Two unwitnessed falls on 4/24/25 at 7:30 a.m. and 3:30 p.m. with no injuries notedf. Unwitnessed fall on 5/1/25 at 12:59 p.m. […]

• Actual harm, isolatedF627Jun 26, 2025

  Based on interview and record review the facility failed to implement their discharge planning process in including residents for their preparation to effectively transition them to post-discharge care for two of three sampled residents (Residents 1 and 2). Resident 1 and 2's records did not contain discharge care plans, interdisciplinary team (IDT, members of healthcare team that meets to discuss and plan resident care) meeting note addressing discharge planning, and referrals being sent to and accepted from shelters (temporary housing) and home health agencies (organization that provides skilled nursing and other therapeutic services to individuals in their homes). This failure resulted in unsafe discharges and placed residents at health and safety risks. […]

• Actual harm, isolatedF600Jun 4, 2025

  Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was free from sexual abuse (sexual act that is committed or attempted by another person who is incapable of appraising the nature of the act or unable to give consent) when certified nursing assistant E (CNA E) did not separate female Resident 1 from male Resident 2. As a result of above failure, Resident 1's naked waist down body and Resident 1's private area were exposed to Resident 2. Findings: Review of Resident 1's undated face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 6/13/2023. […]

• No harm, potential for more than minimal, widespreadF700Feb 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 40 (Residents 3, 6, 8, 10, 12, 14, 18, 20, 22, 24, 27, 28, 32, 41, 42, 45, 49, 50, 52, 55, 56, 58, 59, 64, 67, 69, 70, 74, 78, 91, 96, 98, 100, 103, 105, 113, 319, 320, 321, and 369) of 40 sampled residents (residents who used bed or side rails) when: 1. There was no documentation that indicated the facility conducted consistent routine maintenance of the facility's beds and side rails for 40 of 40 sampled residents; 2. […]

• No harm, potential for more than minimal, widespreadF812Feb 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. The kitchen refrigerator door has ice buildup in the rubber gasket (a flexible elastic strip attached to the outer edge of a refrigerator); 2. Three pieces of colored chopping board are stained and two cloudy and one cracked blender container in the kitchen sink; and 3 The snacks /nourishment in the unit refrigerator were outdated. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. […]