Average — CMS composite of the measures below.
The next survey window likely opens 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 Nursing & Rehab during CMS and state inspections, most recent first.
A resident with vascular dementia, who was generally independent and calm, was involved in an altercation with a CNA in the SCU hallway and bedroom doorway. Video showed the CNA grabbing the resident’s forearms and twice forcefully pushing the resident back into the room while the resident appeared to resist and gesture toward the day area. Another CNA reported hearing the CNA repeatedly yell at the resident to get back in bed while the resident refused, and observed the CNA holding and struggling with the resident’s arms. Shortly afterward, the resident exited the room visibly upset, loudly demanding that the CNA be arrested and pointing to a bleeding area on the forearm. Nursing staff and the DON later documented multiple bruises of varying sizes and shapes on both hands and forearms, which staff described as looking like someone had grabbed the resident, and other staff confirmed the resident had no recent falls, was not clumsy, and had no prior bruising.
The facility failed to consistently assess, document, and obtain appropriate treatment orders for wounds and orthotic use for three residents. One resident returned from the hospital with a forehead laceration and a prescribed wrist splint, but the care plan was not updated, a wound assessment was delayed for several days, there were no early orders to monitor the laceration or skin under the splint, and staff were confused about which arm required the splint, with observations showing the splint off and not monitored. Another resident with chronic leg ulcers had an active wound treatment order, yet MARs showed missed treatments, multiple weekly skin assessments documented skin as intact with no treatment in place, no wound assessments were available for an entire month, and observations revealed multiple open areas on the leg being treated under a single order, with dressings applied in a way that left an open area partially uncovered and adhesive on the wound bed. A third resident, care planned as at risk for skin breakdown, had a weekly skin assessment charted as intact and no nurse notes for several days, while CNAs reported a prior skin tear on the forearm that had been treated with steri-strips and bandages and had progressed to multiple scabbed areas with redness; the DON later confirmed there had been no earlier documentation or timely physician notification for treatment or monitoring orders.
A resident with dementia and a history of stroke was admitted without psychotropic medications and initially assessed as alert and pleasant, yet staff quickly obtained and administered IM haloperidol for attempts to ambulate without assistance, followed by multiple PRN and scheduled orders for risperidone, lorazepam, Zoloft, and Seroquel for behaviors such as anxiety, yelling, roaming, and standing up from a wheelchair. The facility did not complete a comprehensive assessment or develop a care plan addressing antipsychotic use, and nursing documentation frequently lacked detailed descriptions of behaviors, nonpharmacological interventions, or behavior monitoring at the time medications were given. Interviews with an RN, DON, NP, physician, and the Administrator confirmed that the indications and dosing for antipsychotics, including high-dose risperidone and IM haloperidol, were not appropriate for the behaviors described and that nonpharmacological approaches should have been attempted first, contrary to facility policy requiring residents to be free from chemical restraints and mandating thorough, interdisciplinary care planning.
Two residents with dementia made separate allegations of abuse that were not reported to facility leadership and DHSS within required timeframes. In one case, a CNA observed another CNA forcefully holding and pushing a resident by the arms while the resident resisted and later noted bruising; the CNA states they informed an LPN and the DON the same day, but the allegation was not reported to the state until several days later. In the other case, a resident repeatedly told a hospice RN and multiple CNAs and nurses that a man was raping them; staff variously "blew off" the statements, attributed them to confusion, or assumed others had reported them, and the allegation was not promptly reported to the DON or to DHSS. Staff interviews showed inconsistent understanding and practice regarding immediate internal reporting and the 2‑hour external reporting requirement for all abuse allegations, including those from cognitively impaired residents.
The facility failed to ensure immediate reporting, investigation, and protective measures for abuse allegations involving two residents. One resident with vascular dementia and severe cognitive impairment was observed by a CNA being grabbed and pushed by a CNA while resisting, later found with scattered bruising on both arms. The witnessing CNA reported the incident informally, but the LPN on duty denied receiving the report, another CNA did not escalate it, and the alleged perpetrator continued working alone on the special care unit. In a separate case, a cognitively impaired resident with dementia and psychiatric diagnoses repeatedly told a hospice RN that a man had raped the resident; the hospice RN did not document or formally report the allegation, attributing it to dementia. These actions and inactions conflicted with facility policy requiring immediate suspension of alleged perpetrators, prompt reporting to leadership and authorities, and timely completion of abuse investigations.
A resident with severe cognitive impairment, diabetes, edema, and dependence for ADLs developed a right heel pressure ulcer that was initially documented as an unstageable, fluid-filled blister and later as 100% eschar. Although the facility’s policy required ongoing and weekly skin and wound assessments with detailed documentation and regular reevaluation of treatment, multiple skin assessments recorded "no skin issues" while the MAR showed ongoing heel protectors and skin prep, and no wound observation reports were completed for an extended period. When an LPN later performed wound care, a notable odor was present and the heel showed a black scabbed area, yet the treatment order for skin prep had never been updated since initiation, and interviews with the DON, NP, hospice RN, and Administrator confirmed that weekly wound assessments had not been done, documentation was incomplete, and treatment had not been reevaluated despite changes in the wound.
Staff failed to timely obtain, track, and act on ordered urine lab tests for a resident with dementia, severe cognitive impairment, and bladder incontinence who had a UA and culture ordered for a suspected UTI. The urine specimen was not collected until four days after the order, and there was no documentation of efforts to obtain the specimen, contact the lab, or follow up on results for several days thereafter. When the culture ultimately showed high counts of Klebsiella aerogenes and Hafnia alvei resistant to nitrofurantoin, the practitioner ordered nitrofurantoin without documented acknowledgment of the resistance. Interviews with an LPN, NP, DON, and the Administrator showed that nurses were not routinely checking the lab website, there was no designated medical records staff monitoring labs, the DON did not call the lab or receive results, and leadership was unaware of expected lab turnaround times.
Infection Control Program and EBP Failures: The facility failed to complete an annual review of its infection prevention and control program and staff showed inconsistent knowledge of EBP. Staff did not use gowns for residents with wounds or a PICC line, did not post EBP signage, and did not have PPE readily available. Staff also handled residents’ unpackaged cigarettes with bare hands, failed to perform hand hygiene, and did not clean the glucometer or perform hand hygiene between resident medication and blood glucose care tasks.
A resident with schizophrenia, bipolar disorder, borderline intellectual functioning, major depressive disorder, and insomnia had no documented PASARR Level 1 screening in the medical record. The chart included psychotropic meds, MDS findings of mild cognitive impairment, and care plan entries for delusions/hallucinations, mood distress, impaired decision making, isolation, and trauma-related needs. Staff stated the Level 1 PASARR should have been obtained from the hospital or initiated through the PCP, but the facility could not produce the screening and had no written PASARR policy.
Failure to Follow Physician-Ordered Wound Care: An LPN did not complete wound care as ordered for a resident with multiple skin wounds and a severe cognitive deficit. During observation, the LPN used non-stick gauze and border tape instead of the ordered island dressing for the buttock wound, did not cleanse or dress the left heel as ordered, and did not apply skin prep to the right outer calf because the area appeared healed. Staff interviews confirmed that wound care should follow the physician’s orders.
A resident with COPD, hypoxemia, heart disease, heart failure, and hospice services had repeated low pulse ox readings and oxygen adjustments, but staff did not consistently document oxygen liters, physician notification, or pulse ox checks as ordered. The record also showed mismatched facility and hospice oxygen orders, no documentation of weekly tubing and humidifier changes, and oxygen tubing observed without dates or initials, including tubing left on the floor and not stored in a bag.
Failure to Protect a Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA. The resident had vascular dementia with agitation, was severely cognitively impaired, but was usually understood and usually understood others. The resident was generally pleasant, mostly independent with walking, dressing, toileting, and hygiene, and typically got up, dressed, and went to the dining/day area each morning. The resident resided on the special care unit (SCU) for safety and had no documented recent behavioral issues, aggression, falls, or injuries prior to the incident. The resident’s care plan included ensuring areas were free of hazards, redirecting the resident when entering unsafe areas, and preventing serious injuries related to memory/recall deficits. On the morning of the incident, video surveillance from the SCU hallway showed the CNA and the resident at the resident’s doorway. The CNA initially grabbed the resident’s right forearm while the resident stood in the doorway and the resident pulled away. Over several minutes, the resident and CNA appeared to gesture back and forth, with the resident pointing toward the day area and the CNA pointing toward the resident’s room. The video then showed the resident raising his or her arms in front of the CNA, the CNA knocking the resident’s arms down, then holding the resident’s forearms and pushing the resident back into the room. The CNA exited, closed the door, and walked toward the day area. The resident reopened the door and stood in the doorway again, at which point the CNA walked quickly back, grabbed the resident’s forearms, and again appeared to forcefully push the resident into the room while holding the resident’s forearms. A CNA who arrived on the unit around that time reported hearing the CNA repeatedly yell at the resident to get back in bed, while the resident yelled that he or she did not want to go back to bed. This CNA stated that upon looking into the room, the CNA had hands on the resident’s forearms and was struggling with the resident, who was trying to get loose, while the CNA continued to hold and push the resident toward the bed. The CNA told the staff member to leave the resident alone and then to leave the SCU. Another CNA reported that shortly afterward, the resident exited the room visibly upset, loudly stating that the person who had done this needed to be arrested, and pointed to a bleeding area on the forearm. This CNA and others described the resident as very upset and angry, and it reportedly took about two hours to calm the resident. Subsequent assessments documented multiple bruises on both of the resident’s hands and forearms in various sizes and shapes, including circular, linear, oblong, and rectangular bruises, as well as a scabbed area. Nursing staff and the DON observed these bruises and described them as appearing consistent with someone having grabbed the resident. Staff who knew the resident stated that the resident did not usually bump into things, was not clumsy, and had no recent falls. The resident’s physician stated that multiple bruises on the arms and hands would not be expected unless the resident was on many blood thinners, and that the only acceptable reason to grab a resident’s arms would be to prevent a fall or injury. The Administrator later confirmed that review of the video showed the CNA grabbing the resident by the arms and pushing the resident back into the room on two occasions, and that the resident’s responsible party reported bruises and an allegation that the CNA had abused the resident.
Failure to Assess, Document, and Care Plan Wounds and Orthotic Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to monitor, obtain, and document treatment orders and to care plan wounds and orthotic use for multiple residents, contrary to its wound care policy. One resident with vascular dementia and severe cognitive impairment sustained an unwitnessed fall in the special care unit dining area, resulting in a forehead laceration, right wrist sprain, closed head injury, and cervical sprain. The hospital discharge summary directed that the resident wear a right wrist splint until cleared by the physician and follow up with the primary physician. Upon return, nursing documentation noted the removable splint and Dermabond-closed laceration, but there was no immediate wound assessment; the first wound assessment was completed six days after the laceration occurred. The care plan was not updated to include the recent fall, laceration, or right wrist sprain, and there were no early physician orders to monitor the head laceration or the skin under the splint. Staff interviews revealed confusion about which arm required the splint, with some CNAs recalling the splint on the right arm and others stating it was always on the left, and observations showed the splint off and lying on the counter without documentation of refusal or monitoring. Another resident with severe cognitive impairment, intracerebral hemorrhage, and chronic leg wounds had an active order to cleanse the right calf wound, apply skin prep, calcium alginate, and cover with border gauze daily and as needed. Medication administration records showed the treatment was not documented as completed on at least two days, and January progress notes contained no documentation related to the right calf wound. Multiple weekly skin assessments in January and February documented skin as intact with no treatment in place, despite the ongoing wound treatment order and a wound management report later identifying an ulcer on the right ankle/lower calf with slough and drainage. Facility records showed missing weekly skin assessments on some dates and no wound assessments for January. Observations of wound care revealed the resident had multiple open areas on the right lower leg, including two wounds on the outer calf and later a total of five shallow open areas, but the nurse performed a single treatment based on one wound order, split a calcium alginate dressing between two wounds, and applied a bordered dressing that did not fully cover one open area and allowed the adhesive border to contact the wound bed. Staff and the nurse practitioner stated that all open areas should be assessed, documented, and have individualized orders, and that adhesive borders should not be placed directly on wound beds. A third resident with severe cognitive impairment, psychotic disorder, dementia, and total dependence for ADLs was care planned as at risk for skin impairment, with interventions including weekly licensed nurse skin checks and reporting any signs of skin breakdown to the charge nurse and physician. A weekly skin assessment documented intact skin with no issues, and there were no nurse progress notes for several days. However, observation showed the resident scratching the left forearm with long fingernails and having four scabbed areas with surrounding redness, including one large scabbed area and three smaller ones, uncovered and without visible ointment. Multiple CNAs reported that the areas began as a skin tear approximately one to two weeks earlier, initially treated with steri-strips, then covered with a bandage and later bordered gauze, and that additional open areas developed from adhesive or scratching. The DON stated not being aware of the areas until the date of surveyor observation and confirmed that nurses should document new skin tears in progress notes, notify the physician and family, and obtain treatment or monitoring orders, but there was no earlier documentation of the skin tear or monitoring in the record. The deficiency centers on the facility’s failure across these residents to consistently assess, document, obtain and follow treatment orders, and incorporate wounds and orthotic use into care plans as required by facility policy.
Failure to Assess, Care Plan, and Justify Antipsychotic Use for a Dementia Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive assessment and establish a care plan before initiating and escalating psychotropic and antipsychotic medications for a resident with dementia. The resident was admitted with diagnoses including dementia, anxiety, and cerebral infarction, and the hospital discharge summary showed no antipsychotic, antianxiety, or antidepressant medications at discharge. The admission physician note documented the resident as alert, oriented to self, pleasant, conversant, and following commands, with no documentation of a need for or orders for antipsychotic medications. The quarterly MDS indicated severe cognitive impairment, behavioral symptoms directed and not directed toward others one to three days a week, and that the resident received antipsychotic medication, but the facility did not provide a comprehensive care plan for the resident. On the evening of admission, nursing staff documented that the resident attempted to ambulate without assistance, did not accept redirection, and was brought to the nurses’ desk for closer monitoring. After the resident refused and spit out melatonin ordered by the NP, staff obtained an order for and administered a 2.5 mg IM haloperidol injection for a diagnosis of dementia, without documentation of a clinical rationale consistent with psychosis or serious harm. Over the following days, staff obtained multiple new and escalating psychotropic and antipsychotic orders, including PRN and then scheduled risperidone, lorazepam four times daily and then PRN, Zoloft, additional IM haloperidol orders (both lactate and decanoate), and later Seroquel, often for behaviors such as crawling on the floor, anxiety, yelling out, restlessness, roaming, and standing up from the wheelchair. The POS frequently listed diagnoses such as dementia without behavioral, psychotic, mood disturbance, and anxiety, or mild dementia with psychotic disturbance, while the record lacked corresponding comprehensive assessments or clear clinical justification for these medication regimens. Throughout this period, the facility failed to consistently monitor, document, and address the resident’s behaviors using nonpharmacological interventions. MAR entries often listed general reasons such as anxiety, yelling, roaming, restlessness, or aggression for PRN antipsychotic and antianxiety administration, but nursing progress notes on multiple dates did not describe the specific behaviors at the time of administration or any nonpharmacological approaches attempted. There was also missing documentation regarding receipt and discontinuation of lorazepam and new antipsychotic orders, and no separate behavior monitoring records or antipsychotic assessments were provided for the month. Interviews with an RN, the DON, the NP, the physician, and the Administrator confirmed that standing up from a wheelchair or similar behaviors were not appropriate indications for antipsychotic use, that risperidone dosing had been increased excessively, that IM haloperidol at the dose given was not appropriate, and that nonpharmacological interventions should have been tried first. The facility’s own policies required residents to be free from chemical restraints and required comprehensive, interdisciplinary care planning based on thorough assessment, but these processes were not followed for this resident. The facility also failed to develop and implement a care plan specifically addressing the use of antipsychotic medications for this resident. Despite repeated behavioral episodes documented in nursing notes—such as attempts to walk unassisted, sliding from the wheelchair, increased confusion, throwing items, yelling, cursing, spitting out medications, grabbing other residents, and multiple falls—there was no evidence of a comprehensive, individualized care plan that incorporated measurable goals, time frames, and nonpharmacological strategies to manage the resident’s dementia-related behaviors. The record did not show an interdisciplinary approach or revisions to a care plan in response to changes in the resident’s condition and medication regimen. Instead, the response to behaviors was largely pharmacologic, with frequent additions and changes to antipsychotic and antianxiety medications without the required assessment, documentation, and care planning to support their use.
Failure to Timely Report Allegations of Physical and Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all allegations of abuse were immediately reported to facility management and to the state agency within required timeframes. Facility policy required any employee or volunteer who became aware of abuse, neglect, exploitation, or misappropriation to immediately report to the Administrator, and required the Administrator or designee to report allegations of abuse or serious bodily injury to the state agency within two hours, including during nights and weekends. Despite this, staff did not promptly report an allegation of physical abuse involving one resident and repeated allegations of sexual abuse involving another resident, and one of the allegations was not reported to the Department of Health and Senior Services (DHSS) at all. For the first resident, who had vascular dementia with agitation and resided on a special care unit, the Administrator learned from the resident’s responsible party that the resident had bruises on the hands and arms and that an unnamed staff member had reported that a CNA had abused the resident. The Administrator’s subsequent interview with a CNA revealed that on a morning shift the CNA had entered the special care unit and observed another CNA in the resident’s room holding the resident’s forearms while the resident resisted and verbally objected to being put back to bed. The CNA reported hearing the other CNA repeatedly yell at the resident to get back in bed while the resident yelled that they did not want to go back to bed. The CNA stated that the two were struggling, that the resident tried to get loose while the CNA continued to hold and push the resident toward the bed, and that the resident later wanted to call the police and was difficult to calm. The CNA reported that shortly after the incident, they called the nurses’ station and told an LPN to come assess the resident’s arms, informed the LPN that the CNA had tried to hold the resident’s arms down and that the arms appeared bruised, and later that same day told other aides and the DON at the nurses’ station that the CNA had bruised the resident’s arms while trying to force the resident back into bed. The DON later documented scattered bruising on both upper extremities in various stages of healing and notified the physician. However, the allegation of abuse was not reported to DHSS until three days after the incident, and the LPN denied being informed of any incident involving the resident and the CNA. For the second resident, who had dementia, depression, anxiety disorder, delusional disorder, and paranoid personality disorder with severe cognitive impairment and dependence on staff for multiple ADLs, multiple staff and a hospice RN were aware that the resident had repeatedly stated that a man was raping them. The hospice RN reported that over approximately two weeks the resident said, "Don’t let that man in here. He’s raped me," and on a couple of occasions was tearful and said a man came in and raped them. The hospice RN stated that they "blew it off," believed they may have told an LPN or the DON, and did not know they had to report the allegation because the resident had dementia. A CNA recalled the resident stating at the nurses’ station that they had been raped, with the charge nurse present, and reported that the resident repeated the rape allegation a few days later during care; the CNA said they told an LPN or another nurse, who responded that the resident was confused. Other CNAs reported hearing that the resident had claimed rape multiple times, some stating they had reported the allegation to a charge nurse over two months earlier. Despite these repeated allegations and staff awareness, the facility did not self-report the rape allegation to DHSS until it was documented later as an allegation of sexual assault, and the DON stated that no one had informed them of any rape allegation, even though the DON considered such comments to be an allegation of abuse. Staff interviews showed inconsistent understanding and application of the requirement to immediately report all abuse allegations, including those made by confused residents, to facility leadership and to DHSS within two hours.
Failure to Immediately Report and Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all allegations of abuse were immediately reported, investigated, and that protective measures were implemented during the investigation for all residents, including two identified residents. Facility policy stated that residents would be free from abuse, that all employees alleged to have committed abuse would be suspended immediately pending investigation, and that accused residents would be isolated and monitored. The policy also required immediate or 24‑hour reporting to the State Survey Agency and law enforcement, and completion of investigations within five working days. Despite this, staff did not promptly report or act on allegations of abuse involving two residents, and the alleged staff perpetrator continued to work with residents after an incident was witnessed. For the first resident, who had vascular dementia with agitation, severe cognitive impairment, and resided on a special care unit, the Administrator learned of possible abuse only after the resident’s responsible party reported bruises on the resident’s hands and arms and relayed that an unnamed staff member had said a CNA abused the resident. A progress note documented scattered bruising on both upper extremities in various stages of healing, with the resident stating he or she woke up that way and denying pain or functional impairment. The Administrator’s subsequent review of video footage from the special care unit hallway showed the CNA grabbing the resident by the arms and pushing the resident back into the room on two occasions. Interviewed staff reported that on the morning of the incident, one CNA heard the alleged perpetrator repeatedly yelling at the resident to get back in bed, observed the CNA holding the resident’s forearms while the resident struggled to get free, and saw the CNA continue to push the resident toward the bed while holding the resident’s arms. That CNA stated he or she told the CNA to leave the room and the unit, and later called the nurse to look at the resident’s arms, expecting an incident report to be made. However, the LPN on duty that morning stated that no one informed him or her of any incident involving the resident and the CNA, and also reported not going to the special care unit to make rounds due to lack of time. Another CNA stated that he or she was told about the abuse by the witnessing CNA but did not report it, believing it had already been reported to the Administrator. The DON and other nursing staff indicated in interviews that grabbing a resident’s arms and causing bruising would be considered physical abuse and that alleged perpetrators should be removed from resident care areas and suspended pending investigation, but the Administrator confirmed that the CNA worked additional overnight shifts on the special care unit after the alleged abuse and before the allegation was brought to his or her attention. This sequence of events shows that the allegation was not immediately reported through the chain of command, the resident’s immediate safety was not ensured, and the alleged perpetrator was not promptly removed from resident care. For the second resident, who had dementia, depression, anxiety disorder, delusional disorder, paranoid personality disorder, severe cognitive impairment, and dependence on staff for multiple ADLs, there was also a failure to recognize and report an allegation of abuse. The resident’s care plan noted mood distress, crying, and cognitive deficits, and a progress note documented episodes of increased confusion and hallucinations, including the resident asking for specific individuals and misidentifying men in the facility as others. The hospice RN who visited weekly reported that during the prior two weeks the resident had said, “Don’t let that man in here. He’s raped me.” The hospice nurse stated that he or she “blew it off,” believed he or she may have mentioned the comments to an LPN or the DON, did not document the allegation in notes, and did not know it had to be reported because the resident had dementia. The DON stated that the hospice nurse and any staff with knowledge of the resident’s comments should have immediately notified the charge nurse and the DON, and that the resident’s statement was considered an allegation of abuse. This demonstrates that the facility did not ensure that all staff, including contracted hospice staff, recognized and immediately reported allegations of abuse, resulting in a failure to initiate an immediate investigation and protective measures for this resident as required by facility policy and regulation.
Failure to Assess, Document, and Reevaluate Treatment for a Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for one resident with a right heel pressure injury, in accordance with its own wound care policy. The resident had multiple diagnoses including diabetes, depression, and edema, severe cognitive impairment, delusions and hallucinations, and was dependent on staff for all ADLs except eating. The facility’s policy required ongoing skin assessments with weekly documentation, thorough wound documentation, reevaluation of dressing and skin integrity every shift, and regular reassessment of the wound’s response to treatment. Despite this, the facility did not consistently complete or document skin and wound assessments, did not accurately reflect the resident’s wound status in routine skin assessments, and did not update treatment orders as the wound evolved. The resident developed a right heel blister/pressure ulcer first documented in early November as an unstageable pressure ulcer measuring 4 cm by 8 cm, with subsequent documentation describing a fluid-filled blister with darkened skin and use of a protective boot and skin prep. Over November and December, wound observation reports and nursing notes showed changes in size and characteristics, including progression to 100% necrotic/eschar tissue, with measurements gradually decreasing to 3.5 cm by 4 cm. The care plan referenced a right heel blister/eschar and ongoing skin prep treatment, and the MAR reflected heel protectors and skin prep as completed. However, multiple skin assessments documented during this period and into January and February stated there were “no skin issues,” despite the ongoing presence of the right heel wound and continued treatment orders. Beginning in January, no wound observation reports were completed for the right heel wound, and there were no progress notes related to the heel wound for that month, even though the MAR continued to show heel protectors and skin prep as administered. In February, repeated skin assessments again documented no skin issues. When surveyors observed wound care in late February, an LPN removed the resident’s sock and noted a notable odor from the foot, stating the treatment should be re-evaluated and that the odor had been present since earlier in the week. A black, round scabbed area was observed on the right heel, and skin prep was applied. A subsequent nursing note described the wound as an unstageable right heel wound with necrotic tissue, borders no longer attached, and surrounding tissue pink and warm. Interviews with nursing staff, hospice staff, the DON, NP, and the Administrator confirmed that weekly wound assessments had not been completed since December, that the wound order for skin prep had not been changed since initiation, that hospice did not share wound assessments with the facility, and that skin assessments should have included the wound but instead repeatedly documented no skin issues. Throughout this period, the facility failed to follow its policy requirements for ongoing and weekly wound assessments, accurate documentation of wound characteristics, and timely communication and reassessment of treatment. The DON acknowledged that the former ADON had been responsible for wound assessments and that there had been no wound assessments since December, and stated he/she did not know why they were not done. The Administrator stated that staffing issues affected nurses’ completion of observations and follow-up for wounds, and that the ADON should complete weekly wound assessments and nurses should stage all wounds correctly and document monitoring of skin areas in progress notes. These actions and inactions resulted in a lack of current, accurate wound documentation, absence of documented reassessment of the wound’s response to treatment, and failure to update or reevaluate treatment orders despite ongoing necrotic tissue and later development of odor noted by staff.
Failure to Timely Obtain, Track, and Act on Urine Lab Results for Suspected UTI
Penalty
Summary
Facility staff failed to provide and follow up on ordered laboratory services for a resident with a suspected UTI. The resident, who had dementia with severe cognitive impairment, required moderate assistance with toileting and other ADLs, was dependent for hygiene, and was incontinent of bladder. A physician ordered a urinalysis (UA) and urine culture on 02/14/26 for diagnosis of UTI, but from 02/14/26 to 02/17/26 there was no documentation that staff obtained the UA, contacted the lab, encountered any difficulty obtaining the specimen, or received any results. The UA specimen was not collected until 02/18/26 at 7:41 p.m., four days after the initial order, despite a lab agreement stating that common tests would be reported the same day and most others within 24 hours, with routine lab days Monday through Friday. After the specimen was collected on 02/18/26, progress notes from 02/19/26 to 02/26/26 contained no documentation regarding the status of the UA, any follow-up with the lab, or any findings. The final UA and culture report, dated 02/27/26, showed growth of >100,000/ml Klebsiella aerogenes and >100,000/ml Hafnia alvei, with susceptibility testing indicating resistance to nitrofurantoin. On 02/27/26, staff documented that the UA with culture and sensitivity results were received and that the physician, who was in the facility, ordered nitrofurantoin 100 mg twice daily for seven days, 13 days after the initial UA order, without documentation of any discussion that the identified organisms were resistant to the prescribed antibiotic. Interviews revealed that nurses were not routinely checking the lab website for results, there was no medical records person monitoring labs, the DON acknowledged not calling the lab or receiving results and stated that no staff had checked on them, and the Administrator was unaware of expected lab turnaround times.
Infection Control Program and EBP Failures
Penalty
Summary
The facility failed to implement its infection prevention and control program as reflected by an outdated and incomplete infection prevention and control policy manual. The manual was initially dated April 2014, the infection prevention and control plan review was last signed by the Medical Director and Administrator on 02/06/24, and the program evaluation did not show signed and dated approval by the Quality Assurance Committee, Administrator, and Medical Director. During interviews, the Administrator said the facility policies were kept electronically and did not think the facility completed an annual review of the infection prevention and control policies and procedures, while the RN/QA Consultant and the MDS Coordinator/Infection Preventionist stated they were aware of the annual review requirement but had not been involved or were not aware of it. The facility also failed to ensure staff were trained and followed Enhanced Barrier Precautions for residents who had wounds or indwelling devices. Resident #5 had pressure ulcers and an order for EBP related to wounds/pressure areas, but during wound care the LPN and CNA did not wear a gown, and the LPN did not perform hand hygiene in the room before exiting. Resident #69 had diagnoses including discitis, osteomyelitis, infective myositis, and a PICC line with an order for EBP related to the PICC line, but during IV antibiotic administration the RN did not place EBP signage on the room door and did not wear a gown. Resident #40 had multiple wounds and care plan documentation for EBP precautions, but during wound care staff did not wear gowns, there was no EBP sign on the door, and no PPE was readily available. Staff interviews showed inconsistent understanding of EBP. One CNA said EBP meant barrier cream in the room and stated no training had been received, while other staff described EBP as requiring gowns and gloves for residents with wounds, catheters, infections, or IV lines. The DON and Administrator stated staff were expected to use gowns, gloves, and hand hygiene for EBP. The report also documented staff failing to follow standard infection control practices during cigarette handling and medication pass. Staff touched residents’ unpackaged cigarettes with bare hands, did not perform hand hygiene or use gloves, and in one instance placed cigarettes in a coat pocket before giving them to residents. During medication administration, an RN did not clean the glucometer between residents and did not perform hand hygiene between resident care tasks, including after handling a syringe that fell on the floor and before moving to another resident. The RN also failed to clean the glucometer between blood glucose checks for different residents.
Missing PASARR Level 1 Screening in Resident Record
Penalty
Summary
The facility failed to ensure a PASARR Level 1 screening was retained in the medical record and accessible for one resident reviewed for PASARR. Resident #38 had been admitted with diagnoses including paranoid schizophrenia, bipolar disorder, borderline intellectual functioning, major depressive disorder, and insomnia. The resident’s quarterly MDS showed mild cognitive impairment, diagnoses of bipolar disorder and schizophrenia, and use of routine antipsychotic, antidepressant, and antianxiety medications. The care plan documented delusions/hallucinations, mood distress, impaired decision making, isolation, and trauma-related concerns, and the current physician orders included Abilify, bupropion hydrochloride, divalproex, Invega Sustenna, sertraline, and trazodone. Review of the medical record showed no copy or documentation of a completed Level 1 PASARR screening. During interviews, the ADON, BOM, DON, and Administrator all stated that a Level 1 PASARR should be obtained from the hospital before admission, or initiated through the resident’s PCP if admitted from home, and that any triggered Level 2 should also be completed and maintained in the record. The BOM stated the state agency was contacted and the original screening was no longer available because it had been completed prior to 2013, and the facility was requesting a replacement screening. The facility also did not provide a written policy pertaining to PASARRs.
Failure to Follow Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care according to physician orders for one resident with multiple skin conditions and diagnoses including nontraumatic intracerebral hemorrhage, MSSA infection, non-pressure chronic ulcer of skin, open wounds of both lower legs, a blister of the left foot, a furuncle of the buttock, and a pressure ulcer. The resident’s quarterly MDS showed severe cognitive deficit, pressure ulcer or injury over a bony prominence, and risk for developing pressure ulcers. The care plan identified the resident as at risk for skin issues related to bilateral lower extremity edema, incontinence, impaired function and mobility, and other disease processes, and directed staff to follow treatment for all areas in place. The resident’s physician orders included daily skin prep to the right outer calf until healed, daily cleansing of the left heel area with wound cleaner, skin prep to the peri-wound, coverage with an island dressing, and daily cleansing of the upper buttock with wound cleaner, skin prep to the peri-wound, calcium alginate to the wound bed, and coverage with an island dressing. During observation, an LPN removed the dressing from the upper right buttock, cleansed the area, applied calcium alginate, and covered it with non-stick gauze and border tape instead of the ordered island dressing. The LPN stated no island dressing was found. During the same observation, the LPN removed the soft boot from the left foot and found no dressing covering the heel; the LPN applied skin prep to a red area approximately 2 cm in diameter and replaced the boot, but did not clean the wound with wound cleanser or cover it with the ordered island dressing. The LPN also observed the right outer calf area, which had a dried scab approximately 1/2 cm in diameter with no drainage or redness, and did not apply the ordered skin prep because the wound was considered healed. Interviews with nursing staff, the MDS Coordinator/Infection Preventionist, DON, and Administrator confirmed that staff should follow physician orders for wound care and obtain a new order if a wound was healed or treatment needed to be discontinued.
Respiratory Care and Oxygen Documentation Failures
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for one resident with a history of atherosclerotic heart disease, COPD, hypoxemia, heart failure, moderate cognitive impairment, and hospice services. The resident’s record included oxygen orders, pulse oximetry monitoring, and a plan of care addressing respiratory distress, but staff did not consistently follow or document those orders. The record showed repeated instances where oxygen saturation was low, oxygen was applied or adjusted, and physician notification was not documented. Staff also did not document oxygen tubing changes, humidifier bottle changes, or the required storage of unused tubing. The resident’s facility physician order sheet included oxygen 2 liters per nasal cannula as needed for shortness of breath or oxygen saturation below 92% on room air, an order to check oxygen saturation as needed and notify the physician if less than 90%, and an order to change oxygen tubing and humidifier bottle weekly and as needed, placing the tubing in a plastic bag when not in use. Hospice documentation also showed oxygen orders that differed from the facility record, including an order for oxygen at 2 to 4 liters per nasal cannula as needed for comfort. Staff progress notes documented multiple low oxygen saturation readings, including readings of 45%, 60%, 74%, 78%, and 70%, with oxygen applied afterward, but the notes often did not include the liters delivered, room air status, or physician notification. The treatment administration records for October, November, and December did not document the oxygen tubing and humidifier changes, pulse ox checks as needed, physician notification for oxygen saturation below 90%, or oxygen administration as ordered. On observation, the resident was seen with oxygen tubing that had no date or staff initials. On one occasion, the tubing attached to the portable oxygen tank had no date or initials, and the tubing attached to the concentrator was lying on the floor under the bed with no bag present for storage. Interviews with CNA, CMT, LPNs, the DON, and the Administrator showed inconsistent understanding of the resident’s oxygen orders, who was responsible for reconciling hospice and facility orders, who checked and documented pulse oximetry, and how often oxygen tubing should be changed and labeled. Staff stated that tubing should be dated and initialed when changed and stored in a bag when not in use, but the resident’s record and observations did not reflect that these practices were followed.
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What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hermitage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northwood Hills Care Center | 17.4 mi | ★★★★★ | 0 | 0 |
| Big Spring Care Center For Rehab And Healthcare | 17.7 mi | ★★★★★ | 3 | 0 |
| Camdenton Windsor Estates | 19 mi | ★★★★★ | 1 | 0 |
| Aspire Senior Living Warsaw | 21.8 mi | ★★★★★ | 9 | 0 |
| Parkview Health Care Facility | 22.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.