Hermitage Health Center

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF641Sep 16, 2026

  Based on Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, medical record review, observations, and interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 2 residents (Resident #14 and Resident #5) of 16 residents reviewed for MDS assessment accuracy. The findings include: Review of Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .primary purpose as an assessment instrument is to identify resident care problems .the assessment [MDS] accurately reflects the resident's status .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes… […]

• No harm, potential for more than minimal, isolatedF641May 20, 2025

  Based on Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #23) of 5 residents reviewed for unnecessary medications. The findings include: Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, updated 10/2023, revealed .MEDICATIONS .The intent of the items in this section is to record the number of days, during the last 7 days .that .select medications were received by the resident .Antiplatelet .Check if an antiplatelet medication (e.g., [example] aspirin .) was taken by the resident at any time during 7-day observation period . […]

• No harm, potential for more than minimal, isolatedF842May 20, 2025

  Based on medical record review and interview, the facility failed to ensure the medical record was accurate for 1 resident (Resident #33) of 18 residents reviewed for medical records. The findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Anxiety, Dementia, and Prediabetes. Review of the Comprehensive Admission Skin assessment dated [DATE], revealed .upper denture .natural lower . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF644Aug 10, 2022

  Based on medical record review and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) timely after a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level I Form Pre-Admission Screening and Resident Review dated 7/16/2021, showed .DIAGNOSIS .Psychotic/Delusional Disorder .[CONDITION(S)] Disorder .Anxiety Disorder .Level I Outcome: No Status Change .A Level II evaluation is not required and this Level I is approved with a Level I No Status Change. […]

• No harm, potential for more than minimal, isolatedF842Aug 10, 2022

  Based on medical record review and interview, the facility failed to maintain an accurate medical record for insulin administration for 1 resident (#34) of 4 residents reviewed for insulin administration. The findings include: Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 70-30 [a combination of intermediate acting and short acting insulin] 100 UNIT/ML [milliliters] GIVE 40 UNITS SUBCUTANEOUSLY [a route of medication administration where medication is injected into the skin] TWICE DAILY BEFORE LUNCH AND DINNER; HOLD IF BLOOD GLUCOSE < [less than] 200 . […]