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 And Rehabilitation during CMS and state inspections, most recent first.
Food storage and monitoring practices were not maintained in resident refrigerators and the kitchen. A resident refrigerator contained unlabeled opened food items and another had visible buildup in the freezer, while kitchen logs showed missed dish machine and food temp recordings and multiple dish machine readings below required wash and rinse temps. The DON and Dietary Manager confirmed the expected labeling, cleaning, and temp standards.
The facility failed to document completion of the required annual 12 hours of in-service training for five of five NA records reviewed. Record review showed no evidence that the required training was completed, and the DON confirmed there was no process in place to track NA in-service training as required.
A resident with immobility and multiple sclerosis, requiring substantial staff assistance and a mechanical lift, did not consistently receive scheduled showers as outlined in their care plan. Documentation and staff interviews confirmed that showers were missed or replaced with bed baths without proper documentation or offering the resident a choice, contrary to facility policy and the resident's expressed preferences.
Hermitage Nursing and Rehabilitation failed to meet the required nurse aide (NA) to resident ratios on several occasions. The facility did not have enough NAs during the day, evening, and overnight shifts over a two-week period. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on five occasions, with care hours falling below the threshold on specific dates. This was confirmed by the Nursing Home Administrator.
Hermitage Nursing and Rehabilitation failed to meet the required nurse aide staffing ratios over a 14-day period, with shortages noted during day, evening, and overnight shifts. The facility consistently fell short of the mandated number of NAs per resident, as confirmed by staffing documents and the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for ten days within a two-week period. The nursing care hours per patient day (PPD) were below the minimum on several occasions, with the lowest being 2.81 PPD. This was confirmed by the Nursing Home Administrator.
The facility failed to store Schedule II-V medications in a permanently affixed compartment in the Unit 1 medication room. Controlled medications were kept in a removable locked box in the refrigerator, contrary to the facility's policy. A registered nurse confirmed the non-compliance during an interview.
The facility failed to notify the State LTC Ombudsman of emergency hospital transfers for four residents, as required by policy. These residents, with various serious medical conditions, were transferred multiple times without the necessary notifications. The Regional Clinician confirmed the facility's non-compliance during an interview.
The facility failed to provide written notice of its bed-hold policy to residents or their representatives within twenty-four hours of hospital transfers. This deficiency affected four residents with various medical conditions, and the lack of documentation was confirmed by the DON.
A facility failed to address a resident's care and treatment grievance in a timely manner. An employee received a letter of concern from the resident's family member but did not forward it for investigation, resulting in the grievance being unresolved. The Director of Nursing was unaware of the issue, confirming the facility's failure to follow its grievance policy.
Food Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, label, and maintain food in accordance with food safety standards in resident refrigerators and in the main kitchen. In Nursing Unit Two, a refrigerator used for residents contained an opened jar of pickled beets without a resident name or date, two extra cheesy pizza Lunchables without a resident name or date, a bag of cherries labeled with a resident name and dated 8/16/25, and a Walmart bag labeled with a resident name and dated 8/22/25 that contained opened bags of cheese cubes, turkey breast slices, and ham slices. The freezer in that same unit also contained one opened bag of frozen strawberries without a name or date and four frozen microwave meals without resident names or dates. The Assistant DON confirmed that food items in the resident refrigerator/freezer should have a resident name and opened date and should be discarded before or by their use-by date. In Nursing Unit One, the refrigerator used for residents had a brown icy-like substance on the shelves and walls of the freezer, and the Dietary Manager confirmed it was not clean. In the kitchen, dishwasher temperature logs for August and September 2025 showed 183 opportunities to record temperatures, but only 163 entries were documented, with 20 missed recordings; three wash temperatures were below the required 150 degrees F and 60 rinse temperatures were below the required 180 degrees F. Food temperature logs for the same period showed 183 opportunities to record meal temperatures, but only 168 entries were documented, leaving 15 missed recordings. The Dietary Manager confirmed that dishwashing machine temperatures are supposed to meet 150 degrees F during the wash cycle and 180 degrees during the rinse cycle, and that food temperatures are to be checked and recorded for each meal.
Missing Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to assure that nurse aides completed the required yearly 12 hours of mandatory in-service training for five of five NA records reviewed. Review of NA in-service records dated from 10/2024 through 10/2025 showed that the facility did not have evidence documenting completion of the required 12 hours of in-service training for the NA employees reviewed. During an interview on 10/15/25 at 2:30 p.m., the DON confirmed that there was no process in place to track in-service training for NAs as required.
Failure to Provide Scheduled Showers and Document Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide scheduled showers to a resident who required substantial to maximal assistance with activities of daily living due to immobility and multiple sclerosis. According to the resident's care plan and facility policy, the resident was to receive showers on Wednesdays and Sundays during the evening shift, with full staff assistance and use of a mechanical lift. Documentation and interviews revealed that the resident did not consistently receive showers as scheduled, and there was no evidence that showers were offered or refused on several occasions. Instead, the resident was often given a bed bath without being offered a shower, despite expressing a preference for a shower over a bed bath. Review of clinical records, shower schedules, and staff interviews confirmed gaps in documentation and delivery of care. There was no documented evidence that the resident received or refused showers according to their care plan and preferences for a period of over a month. Facility leadership confirmed the lack of documentation and adherence to the resident's scheduled showers, which was not in accordance with facility policy or the resident's care plan.
Staffing Deficiencies at Hermitage Nursing and Rehabilitation
Penalty
Summary
Hermitage Nursing and Rehabilitation was found to be non-compliant with the Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions between January 22, 2025, and February 4, 2025. During the day shift, the facility did not meet the minimum requirement of one NA per 10 residents on two days. On the evening shift, the facility failed to meet the minimum requirement of one NA per 11 residents on four days. Additionally, the overnight shift did not meet the minimum requirement of one NA per 15 residents on four days. The staffing shortages were confirmed through a review of the facility's nursing staffing documents and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required NA ratios on the specified dates and shifts. The report does not provide any information about the impact of these staffing shortages on the residents or any specific incidents that occurred as a result of the deficiencies.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain one Nurse Aide for ten residents on day shift, one nurse aide for eleven residents for evening shifts, and one nurse aide to fifteen residents for night shift to meet minimum state regulation, as required and calculated by PA DOH Minimum Staffing Ratios. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure proper staff to resident ratios meet shift requirements according to current censuses. The Census will be reviewed each business day morning to ensure the staff to resident ratio. Every weekend the Director of Nursing and Assistant Director of Nursing alternate to assure compliance. 2. We are going to educate all Clinical Managers on the call off practice. Immediately notify scheduler/Director of Nursing and call staff with the provided phone numbers of employed staff. Failure to find coverage must notify Director of Nursing immediately. The facility will utilize administration staff that have a certified nurse aide certification to maintain the required ratios for the certified nursing assistants, in the event of unforeseen shortage of certified nursing assistants. 3. Daily staffing sheets completed Monday through Friday. Human Resources and Scheduler meet to discuss PPD and ratios. Scheduler, Director of Nursing, Administrator, and Human Resources meet to review staffing schedules five times a week. The Facility will utilize On-shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Director of Nursing and Assistant Director of Nursing oversees the admission process to determine the appropriate level of care regarding ratios and PPD. 5. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 6. Referral bonus will be offered to employees to encourage candidates to apply. 7. The Administrator or designee will review the staffing concerns monthly in the Quality Assurance and Performance Improvement meeting. The scheduler and nursing supervisor will be educated on the requirements of staff in order to meet mandatory resident to staff ratios. 8. Active recruitment of employees at local medical facilities that are closing will be documented. 9. All auditing of the above process will be completed by the Nursing Home Administrator and Director of Nursing, or designee and documented five times weekly at a minimum to achieve compliance.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for five out of fourteen days reviewed. Specifically, on the dates of 1/25/25, 1/26/25, 1/27/25, 2/01/25, and 2/02/25, the facility's nursing staffing documents showed that the provided hours of care were below the required threshold, with recorded hours of 3.16, 2.93, 2.93, 3.06, and 3.11 respectively. This deficiency was confirmed during an interview with the Nursing Home Administrator on 2/07/25, who acknowledged that the facility did not meet the mandated minimum direct nursing care hours on the specified dates.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain a minimum of 3.2 hours of direct resident care for each resident in a 24-hour period. The administrator, Director of Nursing, Assistant Director of Nursing, and scheduler will meet each business day, each morning, for four weeks to ensure the proper staffing is scheduled to meet required PPD according to the current censuses. Census will be reviewed in each morning meeting during the weekday to ensure the resident ratio and PPD is met. The facility will utilize open shifts on the OnShift mobile app available for all staff to access. The facility will utilize administrative staff that has Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant to maintain 3.2 hours of direct patient care in the event of unforeseen staff shortage. Human Resources and Director of Nursing will continue to post ads on social media, Indeed, and community-based efforts to obtain staff. Offer a referral bonus to employees that recruit staff to apply and become hired. The administrator, Director of Nursing, and interdisciplinary team will meet monthly at the Quality Assurance Improvement Program meetings as needed. Scheduler and Nursing supervisors all will be educated on the requirements of staffing needs to meet mandatory minimum 3.2 hours of direct resident care for each resident in each 24-hour period. All the above processes will be completed by the administrator and Director of Nursing or designee and documented five times weekly at a minimum. Nursing supervisors are educated to notify the Director of Nursing and Assistant Director of Nursing as soon as possible of the staff shortage needs to cover needs as soon as possible. All admissions reviewed with Director of Nursing and Assistant Director of Nursing to ensure the ratio and PPD are being met prior to being admitted to the facility. Nursing schedule reviewed and audited each weekday for four weeks to ensure all shifts are properly covered. Director of Nursing and Assistant Director of Nursing alternate weekends with scheduler to audit. It is being audited before and after the schedule is out to ensure we meet regulations.
Nurse Aide Staffing Deficiency
Penalty
Summary
Hermitage Nursing and Rehabilitation failed to meet the required nurse aide (NA) staffing ratios as mandated by the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations. The facility was unable to provide the minimum number of NAs per resident during various shifts over a 14-day period. Specifically, the facility did not meet the required ratio of one NA per 10 residents during the day shift on five occasions, one NA per 11 residents during the evening shift on six occasions, and one NA per 15 residents during the overnight shift on four occasions. This deficiency was identified through a review of the facility's nursing staffing documents and confirmed by the Nursing Home Administrator during a telephone interview. The staffing shortages were documented on specific dates, with the facility consistently falling short of the required number of NAs needed to meet the resident census. For instance, on certain days, the facility had a census of 92 residents but only staffed 8.78 NAs instead of the required 9.20 during the day shift. Similar shortages were noted during the evening and overnight shifts, with the facility failing to meet the required NA ratios, thereby not complying with the state regulations. These findings indicate a pattern of insufficient staffing that persisted over the observed period.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain 1 nurse aide for 10 residents on day shift, 1 nurse aide for 11 residents for evening shifts, and 1 nurse aide to 15 residents for night shift to meet minimum state regulation, as required and calculated by PA DOH Minimum Staffing Ratios. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staff to resident ratios meet shift requirements according to current censuses. Census will be reviewed to ensure staff to resident ratio. 2. The facility will utilize administrative staff that have certified Nurse Aide certification to maintain the required ratios for the CNA, in the event of unforeseen shortage of CNA. 3. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 5. Referral bonus will be offered to employees to encourage candidates to apply. 6. The Administrator or designee will review the staffing concerns in monthly QAPI meetings as needed. 7. Scheduler and Nursing Supervisors will be re-educated on requirements of staff in order to meet mandatory resident to staff ratios. 8. Nursing Supervisors will notify DON/ADON as soon as possible, of staff shortage needs in order to cover needs as possible. 9. Active recruitment of employees at local medical facilities that are closing will be documented. 10. All auditing of above process will be completed by NHA/DON, or designee, and documented 5 times weekly at a minimum.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for ten out of fourteen days reviewed. The deficiency was identified through a review of the facility's nursing staffing documents for the period from November 20, 2024, to December 3, 2024. On specific dates, the facility's nursing care hours per patient day (PPD) fell below the required minimum, with the lowest being 2.81 PPD on December 1, 2024. This shortfall was confirmed by the Nursing Home Administrator during a telephone interview on December 13, 2024.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain a minimum of 3.2 hours of direct resident care for each resident in each 24-hour period. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staffing is scheduled to meet required PPD according to current censuses. Census will be reviewed to ensure staff to resident ratio and PPD. 2. The facility will utilize administrative staff that have RN, LPN licensure and/or CNA in good standing to maintain the required 3.2 hours of direct patient care, in the event of unforeseen staff shortage. 3. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 5. Offer a referral bonus to employees that encourage candidates to apply. 6. The Administrator and his designees will review the staffing concerns in Monthly QAPI meetings as needed. 7. Scheduler and Nursing Supervisors will be educated on requirements of staffing needs in order to meet mandatory minimum of 3.2 hours of direct resident care for each resident in each 24-hour period. 8. Nursing Supervisors will notify DON/ADON as soon as possible, of staff shortage needs in order to cover needs as possible. 9. Active recruitment of potential employees of expected medical facility closings will be documented by Human Resource Director. 10. All auditing of above process will be completed by NHA/DON, or designee, and documented 5 times weekly at a minimum.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to comply with regulations regarding the storage of Schedule II-V medications in one of its medication rooms. Specifically, the deficiency was identified in the Unit 1 medication room, where controlled medications were stored in a white locked box within the refrigerator door. However, this locked box was not permanently affixed to the refrigerator, allowing it to be removed entirely, which is against the facility's policy and regulatory requirements. This was confirmed during an interview with a registered nurse, who acknowledged that the controlled medications were not stored as required by the facility's policy dated 1/05/24.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman of emergency transfers for four residents, as required by their policy. The policy, dated January 5, 2024, mandates that the facility provide copies of notices for emergency transfers to the Ombudsman, when practicable, and maintain evidence of such notifications. However, upon review of clinical records and staff interviews, it was found that the facility did not send these notifications for Residents R18, R37, R56, and R88, who were transferred to the hospital on various occasions. Resident R18, diagnosed with stroke, dementia, and chronic kidney disease, was transferred to the hospital on February 11, 2024, without notification to the Ombudsman. Similarly, Resident R37, with Parkinson's disease and other conditions, was transferred multiple times without notification. Resident R56, with chronic kidney disease and high blood pressure, and Resident R88, with cancer and other serious conditions, were also transferred without the required notifications. The Regional Clinician confirmed these omissions during an interview, acknowledging the facility's failure to comply with the notification requirement.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives within twenty-four hours of their transfer to a hospital. This deficiency was identified for four residents who were transferred to the hospital for various medical conditions, including stroke, dementia, chronic kidney disease, Parkinson's disease, high blood pressure, obstructive uropathy, cancer, and tracheostomy. The facility's policy requires that in the event of an emergency transfer, a written notice of the bed-hold policy should be provided to the resident or their representative within twenty-four hours. The clinical records for the residents in question lacked evidence that such notices were provided, as confirmed by the Director of Nursing during an interview. The residents involved had multiple hospital transfers, yet there was no documentation indicating compliance with the facility's policy regarding bed-hold notifications. This oversight was noted for residents who were transferred on several occasions, highlighting a systemic issue in adhering to the policy requirements.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to resolve a grievance related to the care and treatment of a resident, as reported by the resident's family member. The facility's Concerns-Grievances policy mandates that all grievances be investigated within 72 hours and the complainant be informed of the results within seven days. However, a letter of concern written by the resident's family member in February 2024 was received by an employee but was not forwarded to the appropriate staff for investigation and resolution. This resulted in the grievance not being addressed in a timely manner as per the facility's policy. Interviews with the resident's family member and the employee who received the letter confirmed that the grievance was not processed according to the established procedures. The Director of Nursing was unaware of the grievance and confirmed that the concerns were not addressed promptly. The facility's failure to follow its grievance policy led to the resident's care and treatment concerns being unresolved, violating the resident's rights and the facility's own policies.
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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 Hermitage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clepper Manor | 1.3 mi | ★★★★★ | 0 | 0 |
| Saint John Xxiii Home | 1.6 mi | ★★★★★ | 1 | 0 |
| O'brien Memorial Health Care C | 3.1 mi | ★★★★★ | 6 | 0 |
| Addison Healthcare Center | 3.9 mi | ★★★★★ | 7 | 0 |
| Meadowbrook Manor | 7.2 mi | ★★★★★ | 8 | 0 |
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