Hermitage Healthcare (the)

Based on observation, interview, and policy review the facility failed to maintain a clean and homelike environment for one Resident (#81) on one unit out of three units observed. Specifically, for Resident #81 who resided on the Sunburst Unit the facility failed to ensure that the Resident's enteral tube feeding (nutritional supplement through a tube to the stomach) equipment consisting of a pump and a pole was maintained in a clean manner. Findings include: Review of the facility policy for Cleaning and Disinfection of Environmental Surfaces, last revised 4/2018, indicated the following: -semi-critical items consist of items that come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms . -housekeeping surfaces will be cleaned on a regular basis, when spills occur and when the surfaces are visibly soiled -environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. On 5/30/24 at 11:13 A.M., the surveyor observed multiple stains and splattered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and records reviewed, the facility failed to arrange services according to professional standards of practice for one Resident (#42) out of a total sample of 20 residents. Specifically, facility staff failed to arrange services with the Hand Surgeon for Resident #42 to undergo surgery when the Hand Surgeon diagnosed the Resident with Carpal Tunnel Syndrome (CTS: occurs when the median nerve, which runs from your forearm, through your wrist, into the palm of your hand, becomes pressed or squeezed at the wrist) and a trigger finger (condition in which fingers remain in a bent position due to inflammation of tendons that bend the fingers) and recommended surgical intervention. Findings include: Review of the American Society for Surgery of the Hand's document titled Trigger Finger, dated 2020, indicated the following relative to a trigger finger: - Trigger finger is a common and treatable problem. - Trigger finger is diagnosed through review of one's history, symptoms, and by physical exam. - Risk factors for trigger finger include Diabetes. - Trigger…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent and trauma-informed care for one Resident (#86) out of a total sample of 20 residents. Specifically, the facility staff failed to develop and implement a trauma informed care plan for Resident #86's past history of trauma and/or triggers which may cause re-traumatization. Findings include: Review of the facility policy for Trauma Informed Care last revised October 2019, indicated: -to implement universal screening of residents for trauma -as part of the comprehensive assessment, identify history of trauma or interpersonal violence when such information is provided to the facility. Resident #86 was admitted to the facility in February 2024 with diagnoses including unspecified adult maltreatment (used for confirmed cases of adult maltreatment when clinical information is unknown or not available about a particular condition. It falls under the range of injury, poisoning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and records reviewed, the facility failed to provide two Residents (#49 and #48), who were diagnosed with Dementia, with appropriate treatment to attain or maintain their highest practicable mental and psychosocial well-being, out of a total sample of 20 residents. Specifically, facility staff failed to adequately monitor Resident #48's verbal behaviors and implement effective behavior interventions to prevent Resident #48 from directing verbal behaviors towards Resident #49 when Resident #49 was receiving personal care from facility staff, which resulted in an undignified experience for both Residents. Findings include: Review of the facility's policy, titled Resident Rights, dated November 2017 and last revised January 2024, indicated Federal and State laws guarantee certain basic rights to all residents of the facility, including the resident's right to: - a dignified existence. - be treated with respect, kindness, and dignity . a. Resident #49 was admitted to the facility in October 2017 with diagnoses including: left knee pain, left elbow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. During a review of several infection control policies titled: -Isolation - Categories of Transmission Based Precaution, last revised July 2021 -Covid Testing, last revised July 2021 -Coronavirus Disease (COVID-19) Prevention and Control, last Revised May 2020 -Interim Infection Prevention for COVID-19, revised May 2020 there was no evidence that they were reviewed annually. During an interview on 1/19/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.

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.

Based on document review, and interview, the facility failed to ensure that its staff notified Residents, families, and/or Resident Representatives of COVID-19 positive staff and resident cases in the facility by 5:00 P.M., the next calendar day during the recent COVID-19 outbreak in January 2023, as required. Findings include: Review of the Centers for Medicare and Medicaid Services Interim Final Rule Updating Requirements for Notification of Confirmed or Suspected COVID-19 cases of Residents and staff in nursing homes, Reference: QSO-20-29-NH dated May 6, 2022, indicated: -(3) Inform residents, their representatives, and families of those residing in facilities by 5 P.M., the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . Review of the facility's Confirmed Positive Staff list, dated 1/17/2023, indicated: three positive COVID-19 cases among staff from 1/13/23-1/17/2023. Review of the Hermitage Healthcare Daily Census,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility and its staff failed to ensure weekly surveillance testing for COVID-19 was implemented for staff and also failed to conduct COVID-19 outbreak testing on staff and residents in a timely manner. Specifically, the facility failed to: 1) ensure weekly COVID-19 surveillance testing was done for three staff (Dietary staff #1, CNA#1, and CNA#5) out of a sample of three staff, 2) ensure COVID-19 outbreak testing was done every 48 hours after a COVID positive staff or resident was identified, for two staff (CNA #2 and CNA #5), out of three sampled staff, and 3) ensure COVID-19 outbreak testing was done every 48 hours after a COVID-19 positive staff or resident was identified, for two Residents (#14 and #41) out of a sample of three Residents, to stop the spread of infection. Findings include: Review of the Massachusetts Department of Public Health guidance titled Updates to Long-Term Care Surveillance Testing dated 12/1/22 indicated the following: - All Long-Term Care (LTC) staff who are up to date with COVID-19 vaccines must conduct weekly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure that its staff provided an ongoing program of group and independent activities designed to meet the interests and support the well-being for five Residents (#6, #81, #1, #14, and #27) out of a total sample of 20 residents. Specifically, the facility staff failed to provide independent activities for Residents #6, #81, #1, #14, and #27, and group activities on the Sunburst unit. Findings include: 1) Resident #6 was admitted to the facility in October 2019 with diagnoses including Alzheimer's (a progressive disease that destroys memory and other important mental functions), Major Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), and cognitive communication deficit (difficulty with thinking and how someone uses language). Review of the Care Plan Meeting notes dated 1/11/22 and 4/14/22 indicated that Resident #6 enjoyed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the Center for Disease Control and Prevention (CDC's) Pneumococcal and Influenza Vaccine guidance, record review, and interview, the facility failed to ensure that its staff provided the appropriate Pneumococcal and Influenza vaccines for four Residents (#17, #22, #41 and #89) out of a sample of five applicable residents, putting them at risk for developing facility acquired Pneumonia and Influenza. Findings include: Review of the CDC's Pneumococcal Vaccine Timing for Adults, dated 4/1/22, indicated the following: CDC recommends Pneumococcal vaccination for the following: -Adults 19 through [AGE] years old with no underlying medical conditions- vaccine is not recommended. -Adults 19 through [AGE] years old with certain underlying medical conditions or other risk factors including: Diabetes Mellitus, Congenital or Acquired Immunodeficiencies, Chronic heart/liver/lung disease . administer 1 dose of PCV20, or 1 dose of PCV 15 followed by 1 dose of PPSV23 at least one year later. -For adults 65 years or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, record review, and interview, the facility and its staff failed to provide COVID-19 vaccines as indicated by the Centers for Disease Control and Prevention (CDC) for three Residents (#22, #41 and #89), out of a sample of five applicable Residents. Specifically, facility staff failed to ensure: 1) that Resident #22 received the COVID-19 vaccinations in sequence and with a signed consent, 2) that Resident's #41 and #89 received COVID-19 vaccinations in the proper sequence. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled, Stay Up to Date with your COVID-19 Vaccines Including Boosters, updated September 2022, indicated but was not limited to the following: When are you up to date (UTD)? -You are up to date with your COVID-19 vaccines if you have completed a COVID-19 vaccine primary series and received the most recent booster recommended for you by the CDC. - If you have completed your primary series-but are not yet eligible for a booster-you are also considered up to date. On 1/19/23, the surveyor reviewed the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that its staff implemented the plan of care for two Residents (#4, #58), out of a total sample of 20 residents. Specifically, the facility staff: 1) failed to notify the Physician for one Resident (#1) when the Resident's blood sugar measurement was greater than 250 mg/dl (milligrams per deciliter), and 2) failed to implement the use of multipodus boots (used to aid in the treatment of injuries to the foot and ankle including foot drop and pressure ulcers) for one Resident (#58). Findings include: 1) Resident #4 was admitted to the facility in August of 2010 with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of the current Physician orders, dated January 2023, indicated the following order initiated on 4/20/2021: -Check FSBS (finger stick blood sugar) three times daily prior to meals .please call MD (Medical Doctor) if BS (blood sugar measurement) is greater than 250 mg/dl. Review of the December 2022 Medication Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, policy review, and interview the facility failed to ensure that its staff included one Resident (#74) out of a total sample of 20 residents in the care planning process. Specifically, the facility failed to provide evidence that Resident #74 and the Resident's Representative had been invited to and participated in their care plan meetings. Findings include: Review of the facility policy for Care Plans, last revised November 2017, indicated: -the Resident will be informed of his/her right to participate in his/her treatment. -an explanation will be included in a Resident's medical record if the participation of the Resident .is determined not to be practicable. -the care planning process will facilitate Resident and/or Representative involvement. Resident #74 was admitted to the facility in September 2020. During an interview on 1/17/23 at 10:26 A.M., Resident #74 said that he/she had not been involved in his/her care planning meetings recently. Review of the medical record did not indicate that either the Resident or their Representative were invited to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility and its staff failed to ensure one Resident (#48) received the care and services, based on their assessment, to maintain an acceptable nutritional status. Specifically, the facility failed to: 1) ensure a nutritional supplement was accepted and administered as ordered, 2) revise the care plan to include new interventions to arrest weight loss, and 3) provide the required assistance at meal times. Findings include: Resident #48 was admitted to the facility in April 2022 with a diagnosis of unspecified Dementia. 1) The facility staff failed to ensure documentation of the acceptance/refusal and intake amount, of a nutritional supplement to allow for evaluation of the supplemnt's effectiveness. Review of a Nutrition Therapy Assessment, dated 7/28/22, indicated the Resident's meal intake was 50-100% with most being 75% or more. Weight was stable at 114-118 pounds (lbs.) for the last three months. Review of a Nutrition Therapy Assessment, dated 8/25/22, indicated the Resident had a decline with a weight loss trend of 4 lbs.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and policy review the facility failed to ensure that its staff provided care and services consistent with professional standards for Resident (#60), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), for one out of a total sample of 20 residents. Specifically, the facility staff failed to ensure complete and accurate communication and documentation with the dialysis facility as required. Findings include: Review of the facility policy titled, Skilled Nursing Facility (SNF) Outpatient Dialysis Services Agreement, dated March 1, 2021, indicated the following: -both parties shall ensure that there is documented evidence of collaboration of care and communication between the nursing facility and End Stage Renal Disease (ESRD) Dialysis Unit. Resident #60 was admitted to the facility in December 2022 with diagnoses including ESRD (End Stage Renal Disease - Renal/Kidney failure). Review of the signed Physician orders dated January 2023, indicated the following: -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, record review, and interview, the facility failed to ensure that its staff provided pharmaceutical services for two Residents (#41 and #14) out of a sample of 20 residents. Specifically, the facility staff failed to ensure: 1) Resident #41 had a diagnosis that indicated the need for an anti-psychotic medication (Abilify), and 2) that Resident #14 had monthly pharmacy reviews completed as required. Findings include: Review of the facility policy titled, Psychoactive Medication, dated, April 2018 indicated the following: -Obtain a Physician's order (a Physician's order and an appropriate diagnosis are required for all psychotropic medications.) -A Consultant Pharmacist reviews the appropriateness of the psychotropic medication order as part of each drug regimen review and monitors for: appropriateness of psychotropic administration based on diagnoses . 1) Resident #41 was admitted to the facility in October 2022, with diagnoses including Depression and anxiety disorder. Review of the January 2023, Physician's Order Summary Report indicated the following orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record review, and policy review the facility and its staff failed to ensure that each Resident's drug regimen was free of unnecessary psychotropic medications. Specifically, the facility staff failed to ensure anti-psychotic psychotropic consents were obtained for two Residents (#22 and #41's), out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Psychoactive Medication, dated 4/2018, indicated the following: -An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administrations of psychotropic medication. 1) Resident #22 was admitted to the facility in October 2022 with diagnoses including Schizophrenia and Depression. Review of the Physician Order Summary Report dated January 2023, indicated the following orders for psychotropic medication: Abilify 15mg one tablet by mouth - one time a day (daily). Review of Resident #22's MAR, dated January 2023, indicated: Abilify 15mg was administered as ordered. During an interview and record review on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility and its staff failed to ensure laboratory services were provided for one Resident (#14), out of a sample of 20 residents. Specifically, the facility staff failed to ensure weekly laboratory tests were obtained, as ordered by the Physician, while the Resident was being treated for an infection. Findings include: Resident #14 was admitted to the facility in August 2022. Review of the January 2023 Physician's orders indicated: -an order (initiated 12/13/22) to administer Doxycycline Monohydrate Capsule (antibiotic) 100 milligrams (mg) by mouth every 12 hours for Methicillin-resistant Staphylococcus Aureus (MRSA-an infection caused by a bacteria that is resistant to many antibiotics) and Osteomyelitis (bone infection) -administer for 6-12 weeks. Review of the Physician's order, dated 12/15/22, indicated to check the following laboratory tests weekly on Mondays due to diagnoses of MRSA and Osteomyelitis: -Complete Blood Count with differential (CBC-used to help diagnose and monitor different conditions, including infections), -Basal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and interview, the facility and its staff failed to adhere to food safety requirements to prevent foodborne illnesses. Specifically, the facility staff failed to: 1) perform hand hygiene for sanitary distribution of food, and 2) store food in accordance with professional standards in the kitchenette located on the Sunburst Unit. Findings include: 1) Review of the Department of Public Health (DPH) Memorandum for Comprehensive Personal Protective Equipment Guidance, dated January 21, 2022, indicated that health care personnel should perform hand hygiene prior to donning (putting on) and after doffing (removing) gloves. During an observation on 1/18/23 at 11:26 A.M., during the lunch meal preparation, the surveyor observed the Food Service Director (FSD) distributing food for service. The FSD was observed removing her gloves after taking an item from the oven and putting on a new pair of disposable gloves. The FSD did not perform hand hygiene as required between taking off the old gloves and putting on a new pair of gloves. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.