Hermitage Healthcare (The)

In the surveyor’s words

From the most serious findings on record at Hermitage Healthcare (The), in the surveyor’s own words.

• Actual harm, isolatedF600Apr 14, 2021

  Based on record review, observation and interviews, the facility staff failed to ensure one sampled resident (#24) was free from physical abuse, out of a total of 19 sampled residents. Findings include: 1. Resident #24 was admitted to the facility in October of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS) Assessment, with reference date of 12/24/20, indicated the resident had long and short term memory impairment and severely impaired decision making ability. Review of the Health Care Facility Reporting System (HCFRS), indicated that on 3/30/21 a resident to resident altercation between Resident #7 and Resident #24 was reported to the Department of Public Health (DPH). 2. […]

• No harm, potential for more than minimal, widespreadF868Jan 19, 2023

  Based 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. Findings include: Review of the attendance sheets for the quarterly QAPI meetings showed no evidence that the Medical Director or his/her designee participated in the QAPI meetings held on the following dates: -2/9/22 -4/14/22 -7/18/22 -10/21/22 During an interview on 1/19/23 at 3:56 P.M., the Administrator said that the Medical Director had not participated in any quarterly QAPI meetings in 2022, but that he should have as required.

• No harm, potential for more than minimal, widespreadF880Jan 19, 2023

  Based 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. Findings include: 1) The facility failed to annually review and/or revise the infection control policies. […]

• No harm, potential for more than minimal, widespreadF881Jan 19, 2023

  Based on record review and interview, the facility and its staff failed to ensure an Antibiotic Stewardship Program was in place to monitor antibiotic use. Findings include: Review of the Antibiotic Stewardship Program Line Listing indicated that there were no completed infection control tracking logs for December 2022 and January 2023. During an interview on 1/19/23 at 2:01 P.M., the Regional Clinical Nurse said that the line listing used to track infections and antibiotic use had not been done for December 2022 and January 2023.

• No harm, potential for more than minimal, widespreadF882Jan 19, 2023

  Based 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.