A list of the most recent deficiencies for The Hermitage Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-19 | 2023-02-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-19 | 2023-02-17 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-19 | 2023-02-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-19 | 2023-02-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-19 | 2023-02-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-19 | 2023-02-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-19 | 2023-02-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-01-19 | 2023-02-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-19 | 2023-02-17 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-19 | 2023-02-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-02-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-19 | 2023-02-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-19 | 2023-02-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-19 | 2023-02-17 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-19 | 2023-02-17 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-19 | 2023-02-17 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-19 | 2023-02-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-27 | 2023-02-17 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-01-27 | 2023-02-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-27 | 2023-02-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-28 | 2021-05-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-28 | 2021-05-15 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-04-28 | 2021-05-15 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-04-14 | 2021-05-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-14 | 2021-05-14 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-04-14 | 2021-05-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-14 | 2021-05-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-14 | 2021-05-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-14 | 2021-05-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-14 | 2021-05-14 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-04-14 | 2021-05-14 | N |
| Provide or obtain dental services for each resident. | Health | 2021-04-14 | 2021-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-14 | 2021-05-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-14 | 2021-05-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-02 | 2019-05-16 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-04-02 | 2019-05-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-02 | 2019-05-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-02 | 2019-05-16 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-02 | 2019-05-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-02 | 2019-05-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-02 | 2019-05-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-02 | 2019-05-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-02 | 2019-05-16 | N |
