Hermitage Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hermitage Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 6, 2022

  Based on review of facility policies, clinical records, and facility investigation and staff interviews, it was determined that the facility failed to implement adequate safeguards to protect one resident (Resident R2) from physical assault resulting in injury requiring transport to the emergency room for treatment. The facility failed to implement interventions after the assault to ensure that further physical assaults did not occur, placing 15 of 16 residents in the locked memory care unit in an Immediate Jeopardy situation. […]

• Actual harm, isolatedF806Mar 9, 2021

  Based on review of clinical records, facility documentation, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that one of four residents reviewed with food allergies (Resident R10) was free from exposure to a food allergen resulting in actual harm of an allergic reaction. This deficiency is cited as past non-compliance. Findings include: The facility policy entitled, Food Allergies and Intolerances, dated July 29, 2020, indicated that residents with food allergies would be identified upon admission and steps would be taken to prevent the resident's exposure to the allergen(s). The policy further indicated that all resident reported food allergies are documented in the assessment notes and incorporated into the resident's care plan. […]

• No harm, potential for more than minimal, patternF584Aug 28, 2026

  Based on observations, and resident and staff interviews, it was determined that the facility failed to prevent flying insects and maintain a clean, comfortable, home like environment for three of three resident care areas (Units 1, 2, and 3 hallways and shower rooms, room [ROOM NUMBER] and 16 on unit 2 room [ROOM NUMBER] on unit 1, activity area. Findings include:Observations on 8/24/26, at approximately 1:30-1:45 p.m. of the shower room areas on Unit 1, Unit 2, and Unit 3 with the Director of Environmental Services revealed that small flying gnats were observed in the shower areas on walls and flying around the room.During an interview on 8/24/26, at the time of the observations, the Director of Environmental Services confirmed the gnats in all three shower rooms on Units 1, 2 and… […]

• No harm, potential for more than minimal, patternF812Dec 4, 2025

  Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two resident refrigerators (Nursing Unit Two); failed to label food brought into the facility with the resident's name and use by date in one of two resident refrigerators ( Nursing Unit Two); failed to maintain sanitary conditions in one of two resident refrigerators (Nursing Unit One); failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher; and failed to prepare food items in accordance with professional standards in the facility's main kitchen. […]

• No harm, potential for more than minimal, patternF689Feb 7, 2024

  Based on observations and staff interviews, it was determined that the facility failed to ensure a safe environment for residents residing on two of three units regarding a soiled utility room area (Unit 1 and Unit 2). Findings include: Observations on 2/7/24, at 9:51 a.m. of the soiled utility rooms on Unit 1 with the Housekeeping/Laundry Director, revealed the following: To enter the soiled utility room, observed above the key number entry mechanism were two separate strips of tape with a four digit key code identified on each strip. The numbers were located at a level that any resident could visualize and open the soiled utility room door. The Housekeeping/Laundry Manager utilized the numbers identified on the strip to enter the soiled utility room. […]