Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hermitage Healthcare (the) during CMS and state inspections, most recent first.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as observed by surveyors.
A facility did not update its Facility Assessment after admitting a resident with a laryngectomy tube, failing to identify the need for specialized care, staff training, and equipment for airway management. The assessment did not reflect the new care requirements, despite documentation in the resident's medical records and acknowledgment by facility leadership.
A resident with severe dementia, anxiety, and vision impairment was repeatedly left unsupervised during meals, despite requiring continuous supervision and assistance. The resident was observed eating with a comb and fork, spilling food and drink on themselves and their surroundings, and not receiving the appropriate utensils or support. Staff were unclear about the resident's care needs, and the DON confirmed these incidents were dignity concerns.
A resident with a history of falls and muscle weakness was repeatedly observed without access to a functioning call light, as the device was left hanging behind the bed and out of reach. Staff interviews confirmed the call light's clip was broken and that the resident was unable to call for assistance, contrary to facility policy and the resident's care plan.
Two residents did not receive care according to professional standards: one did not have the prescribed wound cleansing solution used for an arterial ulcer, and another had a urinary catheter size changed during a urology consult without the physician's orders being updated to reflect the new size. Nursing staff and the DON confirmed that facility policies and physician orders were not followed in both cases.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A resident with sensorineural hearing loss did not receive a recommended hearing aid due to the facility's lack of follow-up with the audiology office. Despite an evaluation confirming the need for a hearing aid and consent for services, the resident remained without the device, continued to experience hearing difficulties, and expressed a desire for further assistance. Facility staff did not ensure the hearing aid was ordered or received, and no additional follow-up was conducted after the initial appointment.
Nursing staff did not receive training or competency assessments specific to laryngectomy tube care for a resident admitted with this condition. Multiple nurses were unable to distinguish between tracheostomy and laryngectomy care, and the facility lacked policies and documentation addressing the unique needs of residents with laryngectomy tubes.
Surveyors identified that two residents did not receive their prescribed medication doses as ordered, resulting in a medication error rate of 11%. In both cases, nurses administered lower doses than ordered and inaccurately documented the administration in the MAR, contrary to facility policy.
The facility did not ensure that all staff completed mandatory annual Resident Rights training, with 35 staff members found out of compliance. The SDC lacked a tracking system for monitoring education completion, and the facility did not have a policy on the frequency of mandatory education. The DON confirmed the deficiency after reviewing staff education records.
The facility did not provide written transfer and bed-hold notifications or notify the Ombudsman when several residents, including those with cognitive impairment or legal representatives, were transferred to the hospital. Record review and staff interviews confirmed the absence of required documentation for these notifications.
A resident with cataracts and a prescription for eyeglasses was inaccurately coded on the MDS assessment as not using corrective lenses, despite optometry records, resident statements, and direct observation confirming eyeglass use. The error was acknowledged by the MDS nurse, who attributed it to a float staff member completing the assessment.
A resident's enteral tube feeding equipment was found unclean, with multiple stains and dried brown material, despite facility policies requiring regular cleaning. Observations revealed a lack of communication between nursing and housekeeping staff regarding cleaning responsibilities, leading to the deficiency.
A resident diagnosed with Carpal Tunnel Syndrome (CTS) and a trigger finger did not receive recommended surgical intervention due to the facility's failure to arrange follow-up services. Despite being assessed as cognitively intact, the resident's surgical needs were not communicated to the physician or health care proxy. Facility staff were unaware of the surgical recommendation, and the occupational therapist was unable to contact the hand specialist, resulting in the resident not receiving the necessary surgery.
A resident with a history of trauma, including unspecified adult maltreatment and cognitive impairment, was admitted without a trauma-informed care plan. Despite hospital records indicating severe trauma, the facility did not develop or implement a care plan addressing the resident's needs, leading to ineffective management of behaviors such as wandering and care rejection. A social worker admitted the oversight.
Two residents with dementia experienced an undignified situation when one resident verbally abused the other during personal care. The facility staff failed to monitor and document these behaviors, and did not implement effective interventions to prevent the verbal abuse, leading to a deficiency in providing dignified care.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Update Facility Assessment for Laryngectomy Tube Care Needs
Penalty
Summary
The facility failed to update its Facility Assessment following the admission of a resident with a laryngectomy tube, despite this representing a change in the resident population not previously identified in the assessment. The resident was admitted with diagnoses including dementia and a laryngectomy tube, requiring specialized care and equipment for airway management, particularly in the event of cardiopulmonary arrest. The hospital discharge summary and nurse practitioner progress note both documented the presence of a laryngectomy tube and the need for full code status. A review of the Facility Assessment, last updated in July 2025, showed that while it included information on residents with respiratory failure and those requiring oxygen therapy, suctioning, tracheostomy care, ventilator or respirator care, and BIPAP/CPAP, it did not specifically identify residents needing laryngectomy tube care. The assessment also lacked documentation of staff training, competencies, or specialized equipment necessary for managing laryngectomy tubes. During interviews, facility leadership acknowledged that the assessment had not been updated to reflect the needs of residents with laryngectomy tubes after the resident's admission.
Failure to Ensure Dignified Dining Experience for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe unspecified dementia, anxiety, and bilateral cataracts was not treated with respect and dignity during mealtimes. The resident, who had highly impaired vision, severely impaired decision-making, and required supervision or assistance with eating, was observed eating alone in their room during multiple meals. The resident attempted to eat using a comb and a fork, resulting in food being spilled on themselves, the tray, the tray table, and the floor. The resident's care plan and Kardex indicated a need for continuous supervision during meals due to their cognitive and visual impairments, but this supervision was not provided. During one lunch observation, the resident was left alone and used a comb and fork to eat, leading to significant difficulty and mess. The resident was seen stabbing at food with the comb and fork, dropping food on the floor and themselves, and mixing chewed food with other meal items. The Activities Director discovered the resident in this state, located the proper eating utensil, and removed the comb, but the resident had already experienced a lack of dignity and appropriate assistance during the meal. Staff interviews revealed confusion about the resident's care needs, with the assigned CNA unaware of the specific requirements for supervision and the nurse confirming that the Kardex did require continuous supervision. Further observations showed the resident eating breakfast and lunch alone on other occasions, with food and drink being spilled due to lack of assistance. The Director of Nursing acknowledged that such incidents, including eating with a comb and spilling food, would be considered dignity concerns. The failure to provide the required supervision and appropriate utensils during meals resulted in the resident not being treated with the respect and dignity guaranteed by facility policy and federal and state laws.
Failure to Ensure Resident Access to Call Light System
Penalty
Summary
Facility staff failed to provide reasonable accommodation for a resident by not ensuring the call system was within the resident's reach, as required by facility policy and the resident's care plan. Multiple observations over two days showed the call light hanging on the wall behind the resident's bed, inaccessible to the resident both while lying down and sitting up. The resident, who had a history of falls, muscle weakness, and anxiety disorder, confirmed during an interview that they were unable to reach the call light and had to resort to yelling for assistance. Staff interviews revealed awareness of the issue, with a CNA noting that the call light's clip was broken and should be fixed to allow it to be attached to the bed. The CNA acknowledged that the lack of access to the call light would cause the resident distress and prevent them from calling for help. The DON also confirmed that the resident should have access to the call light at all times and that staff are responsible for ensuring it is within reach.
Failure to Follow Physician Orders for Wound Care and Catheter Management
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For one resident with a right heel arterial ulcer, the facility did not implement the wound consultant's recommendation to use a specific wound cleansing solution (Vashe) as ordered by the physician. Instead, a nurse used normal saline to cleanse the wound, despite the physician's order and wound care specialist's notes specifying the use of Vashe. The nurse acknowledged during an interview that the correct solution was not used and that normal saline does not have antibacterial properties, which was contrary to the wound care plan and facility policy. For another resident with a history of urinary retention and a Foley catheter, the facility failed to ensure that physician's orders were updated to reflect a change in catheter size following a urology consult. The resident returned from the consult with a different size catheter (18 Fr Coude) than what was documented in the physician's orders (16 Fr/10 ML). Nursing staff and the DON confirmed during interviews that the orders should have been updated to match the catheter size inserted during the consult, but this was not done. The discrepancy was identified during a review of the resident's medical record and direct observation of the catheter in place. Both deficiencies were identified through observation, record review, and staff interviews. The facility's policies required verification of physician's orders and adherence to specific procedures for wound care and catheter management, but these were not followed in the cases described. The failures involved not following wound care recommendations and not updating medical orders to reflect changes in treatment, as required by professional standards and facility policy.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Recommended Hearing Aid to Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident with sensorineural hearing loss received a recommended hearing aid, as identified through observations, interviews, and record reviews. The resident, who was admitted with left ear hearing loss and had a care plan noting impaired communication, underwent an audiological evaluation that confirmed significant hearing impairment and recommended a hearing aid. Although consent for audiology services was obtained and the process to acquire a hearing aid was initiated, there was no documented follow-up by the facility to confirm the order or ensure the device was received. The resident remained without a hearing aid, continued to experience hearing difficulties, and expressed a desire to see someone about his hearing. Interviews revealed that the facility's staff believed the audiology office would contact them once the hearing aid arrived, but no further contact was made after the initial appointment. The unit manager later discovered that the hearing aid had not been ordered as previously thought, and no additional follow-up occurred. The resident's legal guardian indicated willingness to purchase the hearing aid if needed but noted that the facility did not pursue the audiologist's recommendations. Facility policy required staff to assist residents with appointments and follow-up care, but this was not carried out for this resident.
Lack of Staff Competency for Laryngectomy Tube Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to care for a resident with a laryngectomy tube. Specifically, the facility's assessment did not identify any residents requiring laryngectomy tube care, nor did it indicate that staff had received training or competency evaluations for this type of care. Multiple nurses, including those regularly assigned to the resident, were unable to distinguish between a tracheostomy and a laryngectomy, and reported not receiving any specific training or competency assessment related to laryngectomy tube care. The Assistant Director of Nurses, who also served as the Staff Development Coordinator, confirmed that while tracheostomy care training had been provided, no such training or competency assessment existed for laryngectomy care, and there was no facility policy addressing this need. The resident in question was admitted with a laryngectomy tube and Alzheimer's Dementia. Interviews with nursing staff and the resident's physician revealed a lack of awareness and understanding regarding the resident's specific airway needs. The physician was unaware of the difference in stoma type and expected that staff would have received appropriate training and that necessary equipment would be available. The absence of staff training, competency assessment, and facility policy for laryngectomy care directly contributed to the deficiency identified during the survey.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, resulting in an observed error rate of 11% during the survey. For one resident with asthma, the nurse administered only one puff each of Budesonide-Formoterol Fumarate and Spiriva Respimat inhalers, despite physician orders specifying two puffs of each medication. The nurse also documented in the Medication Administration Record (MAR) that two puffs of each medication were given, which did not match the observed administration. The nurse acknowledged the discrepancy and recognized that the medications were not administered as ordered. In a separate incident, another resident with dysphagia and gastro-esophageal reflux disease was ordered to receive two capsules of Omeprazole DR 20 mg daily. However, the nurse administered only one capsule and documented in the MAR that two capsules were given. The nurse later confirmed that only one capsule was administered and that this did not follow the physician's order. These actions were inconsistent with the facility's medication administration policy, which requires verification and administration of medications as prescribed.
Failure to Ensure Annual Resident Rights Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff members received annual training on Resident Rights, as required. According to the Annual All Employee Course Completion History Report, 35 staff members were not in compliance with the mandatory annual Resident Rights education as of the review date. The Staff Development Coordinator (SDC) acknowledged responsibility for staff education but admitted there was no tracking system in place to monitor compliance with mandatory education requirements. The SDC also confirmed that Resident Rights education should be completed upon hire and annually by all staff. The Director of Nurses (DON) confirmed that many staff were out of compliance with the required training after reviewing the course completion report. The Administrator stated that the facility did not have a policy specifying the frequency of mandatory education. The DON emphasized the importance of Resident Rights education for staff to be properly trained to care for residents. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written documentation and notifications related to transfer, discharge, bed-hold policies, and Ombudsman notification for four residents out of a sample of twenty. Specifically, the facility did not issue written transfer and bed-hold notices to the appropriate resident representatives or notify the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital. This was confirmed through record review and staff interviews, which revealed the absence of documentation for these notifications in the clinical records of the affected residents. For one resident with a legal guardian, there was no evidence that the guardian received written notice of the hospital transfer or bed-hold policy, nor that the Ombudsman was notified. Another resident with a health care proxy also lacked documentation of written transfer and bed-hold notifications to the proxy and notification to the Ombudsman. In a third case, the record did not show that the Ombudsman was notified of the resident's hospital transfer. For a fourth resident, who was severely cognitively impaired, there was no evidence that transfer and bed-hold notifications were provided or that the Ombudsman was informed when the resident was sent to the hospital. Interviews with the social worker responsible for these notifications confirmed that the facility did not have a specific policy for bed-hold, transfer, and Ombudsman notification, and that federal regulations should have been followed. The social worker was unable to provide evidence that the required notifications were sent for any of the four residents involved in the deficiency.
Inaccurate MDS Coding for Corrective Lenses Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident regarding the use of corrective lenses during the observation period. The resident, who had a history of hypertensive chronic kidney disease, essential primary hypertension, and falls, was documented in optometry evaluations as having cataracts and requiring eyeglasses with a specific prescription. Despite this, the MDS assessment indicated that the resident did not use corrective lenses, and that the resident had adequate vision. Interviews and observations confirmed that the resident used eyeglasses, with the resident stating they wore glasses and had been advised by an eye doctor about the need for cataract surgery. The surveyor observed the resident's eyeglasses on the bedside table, and the MDS nurse acknowledged that the assessment was coded in error, attributing the mistake to a float staff member who completed the assessment. The nurse confirmed that the resident could not see without their glasses and that the MDS should have reflected the use of corrective lenses.
Failure to Maintain Clean Enteral Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident residing on the Sunburst Unit. Specifically, the resident's enteral tube feeding equipment, including a pump and a pole, was observed to be unclean. The facility's policy for Cleaning and Disinfection of Environmental Surfaces, last revised in April 2018, requires that semi-critical items, which come in contact with mucous membranes or non-intact skin, should be free from all microorganisms. Additionally, housekeeping surfaces are to be cleaned regularly, when spills occur, and when visibly soiled. Despite these guidelines, the surveyor observed multiple stains and dried brown material on the resident's feeding tube pump and pole on two separate occasions. During an observation and interview, Nurse #1 acknowledged that the resident's tube feeding supplies should not have been soiled and should have been cleaned. Nurse #1 indicated that the housekeeping staff were responsible for cleaning the surfaces in the resident's room. However, Housekeeping Staff #1 stated that she had not been informed about the soiled tube feeding supplies and mentioned that both housekeeping and nursing staff were responsible for keeping these items clean. This lack of communication and adherence to cleaning protocols led to the deficiency in maintaining a clean environment for the resident.
Failure to Arrange Surgical Services for Resident with CTS and Trigger Finger
Penalty
Summary
The facility failed to arrange necessary surgical services for a resident diagnosed with Carpal Tunnel Syndrome (CTS) and a trigger finger, as recommended by a hand surgeon. The resident, who was admitted with Type 2 Diabetes and wrist pain, was diagnosed with moderate right CTS through an electromyography (EMG) test. The hand surgeon recommended surgery for the resident's right carpal tunnel and trigger finger, but the facility did not arrange for the follow-up with the surgeon. The resident, who was initially deemed incapacitated due to moderate progressive dementia, was later assessed as cognitively intact. Despite this, the facility did not communicate the surgical recommendation to the resident's physician or health care proxy (HCP). The resident expressed ongoing pain and difficulty with hand movement, indicating that the problem persisted without resolution. The resident reported that pain medication was provided but did not address the underlying issue, and the resident had not received any updates regarding the surgery. Interviews with facility staff revealed a lack of awareness and communication regarding the surgical recommendation. Nurse #2 was unaware of the surgery recommendation and believed the resident's condition was being managed with medication for arthritis. The occupational therapist, who evaluated the resident, attempted to contact the hand specialist but was unable to obtain necessary information from the nursing staff or the resident's family. This lack of coordination and follow-up resulted in the resident not receiving the recommended surgical intervention.
Failure to Implement Trauma-Informed Care Plan for Resident
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident who was a trauma survivor. The resident, admitted in February 2024, had a history of unspecified adult maltreatment, cognitive impairment, and depression. Hospital discharge paperwork indicated the resident was a victim of nonconsensual sexual intercourse, leading to an Elder At-Risk report. The resident also had a right humerus fracture and multiple rib fractures. Despite these significant trauma indicators, the facility did not develop or implement a trauma-informed care plan for the resident. The resident's care plans did not include trauma-informed care, although there was a behavior care plan addressing wandering, exit-seeking, screaming, anger, disruptive sounds, and care rejection. The facility's attempts to manage these behaviors through interventions were ineffective. A social services evaluation confirmed the resident's trauma history and the absence of a trauma-informed care plan. During an interview, a social worker acknowledged the oversight in not completing the necessary care plan for the resident.
Failure to Address Verbal Behaviors in Dementia Patients
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia, leading to an undignified experience for both. Resident #49, who has a history of traumatic brain injury, major depressive disorder, and dementia, was observed to be agitated and resistant to care, frequently yelling and crying during personal care. Resident #48, also diagnosed with dementia with agitation, exhibited verbal behaviors such as yelling and swearing at Resident #49 during these times, which were not adequately monitored or addressed by the facility staff. On the day of the surveyor's observation, Resident #48 was seen yelling at Resident #49, who was crying out in pain during personal care. Despite being alerted to the situation, Nurse #2 did not address Resident #48's verbal behaviors, and the behavior was not recorded in the facility's records. The staff failed to implement effective behavior interventions to prevent Resident #48 from directing verbal behaviors towards Resident #49, resulting in a lack of dignity and respect for both residents. The facility's process for behavior monitoring was not followed, as staff did not record the observed behaviors and interventions in the electronic health record. The Director of Nursing confirmed that the behaviors should have been documented and discussed in the facility's weekly Risk Meeting, but this did not occur. The lack of documentation and discussion of Resident #48's behaviors indicates a failure in the facility's process for monitoring and addressing resident behaviors, contributing to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Worcester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parsons Hill Rehabilitation & Health Care Center | 1.4 mi | ★★★★★ | 1 | 0 |
| St Mary Health Care Center | 1.9 mi | ★★★★★ | 10 | 0 |
| West Side House Ltc Facility | 2.1 mi | ★★★★★ | 17 | 0 |
| Jewish Healthcare Center | 2.4 mi | ★★★★★ | 9 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
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