The Hermitage HealthCare

The Hermitage HealthCare

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Hermitage HealthCare? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Hermitage HealthCare

Hermitage HealthCare is a for profit, 101-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Worcester, Leicester, Holden, Shrewsbury, Millbury,  Spencer, Grafton, Sutton, Northborough, Oxford, Charlton, Westborough, Clinton, Northbridge, Webster, and the other towns in and surrounding Worcester County, Massachusetts.

Hermitage HealthCare
383 Mill St,
Worcester, MA 01602

Phone: (508) 791-8131
Website: http://www.nextstephc.com/

CMS Star Quality Rating

The Hermitage HealthCareThe Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of July 2018, Hermitage HealthCare in Worcester, Massachusetts received a rating of 2 out of 5 stars.

Performance Area Rating
Overall Rating 2 out of 5 (Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 3 out of 5 (Average)

Fines Against Hermitage HealthCare

The Federal Government fined Hermitage HealthCare $20,703 on 06/12/2015 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Hermitage HealthCare committed the following offenses:

Failed to honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility staff failed to ensure that residents had a safe, comfortable and home-like environment.

Findings include:

On 12/6/17 at 7:30 A.M., the Surveyor conducted an environmental tour on the locked dementia unit. The small kitchen/dining area had a locked refrigerator, a sink and a stove (non-functioning). There were green cabinets with some missing hardware and sharp edges. Surrounding the sink there were countertops that were water damaged and warped. Directly in back of the sink was grout that had turned black. The grout in other areas was yellowish in color. To the left of the sink, the counters and cabinetry was pulling away from the wall. There was a piece of decorative cabinetry below the sink and above the lower cabinets that was being held in place by a large piece of green duct tape. 9 of 9 chairs in the small kitchen/dining area had gouged, peeling and scraped legs.

In room [ROOM NUMBER], the window curtain was unattached from the curtain rod on one side. In room [ROOM NUMBER], the window curtain was torn and pulling off the curtain rod. The nightstand and bureaus were badly chipped, scratched and gouged.

In room [ROOM NUMBER], which had four beds, there were 2 holes in the bathroom wall that were approximately 2 inches in diameter each. Bed B headboard and footboards were badly gouged and scratched. A nightstand next to Bed B had plastic molding that had peeled away from one of the drawers and was hanging off the nightstand creating an accident hazard. This piece measured approximately 15 inches long.

Outside room [ROOM NUMBER], were 2 upholstered arm chairs with torn and wornout areas on the seats and the arms where residents rested their arms. There were two more kitchen chairs with badly scratched and gouged legs. During interview on 12/6/17 at 8:00 A.M., the Surveyor showed the Facility Administrator (FA) the concerns on the unit. He said that a proposal was drawn up on 9/4/17 to do the kitchen over, however, there was no response from the corporate people. The FA showed the Surveyor an e-mail dated 12/5/17 that indicated the Regional Maintenance person offered to do the kitchen over for almost half the price, and that Corporate finally agreed to have the kitchen updated. The FA indicated that he wanted to get this done as soon as possible to avoid having any citations by DPH.

During interview on 12/6/17 at 8:30 A.M., the Environmental Manager said that the grout in the kitchen looked black and moldy. She said that housekeeping tried to clean it, but nothing worked.

Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility staff failed to develop and implement a comprehensive person-centered plan of care for 8 Residents (#5,#6, #24, #32, #56, #67, #68, and #87) out of a total sample of 18 residents.

Findings include:

1-a For Resident #87, the facility staff failed to develop a comprehensive person-centered care plan for incontinence.

Resident #87 was admitted to the facility in 11/2017 with a [DIAGNOSES REDACTED]. Review of the Certified Nursing Assistant (CNA) Kardex, dated 11/9/17, indicated the resident was toileted with assistance of 2 and was incontinent of bladder. Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/16/17, indicated the resident had moderately impaired cognition as evidenced by the staff assessment, needed staff assistance of 2 for toileting and was always incontinent of urine.

Review of the Care Area Assessment (CAA) for incontinence, dated 11/23/17, indicated the resident was incontinent at all times and a plan of care needed to be developed to avoid complications, and had an increased risk for urinary tract infections and skin breakdown. Review of the Medical record indicated there was no plan of care developed for incontinence.

On 12/06/17 8:51 A.M., during an interview, MDS Nurse #1 said she was unable to find the care plan for incontinence.

b. For Resident #87, the facility staffed failed to follow the care plan for grooming. Resident #87 was admitted to the facility 11/2017 with [DIAGNOSES REDACTED]. Review of the Certified Nursing Assistant (CNA) Kardex, dated 11/9/17, indicated the resident needed assistance of 2 for grooming. Review of the Activities of Daily Living care plan, dated 11/10/17, indicated the resident needed assistance of 1 or 2 for grooming. Review of Admission Minimum Data Set (MDS) Assessment, dated 11/16/17, indicated the resident had moderately impaired cognition as evidenced by the staff assessment and needed extensive assistance of 1 for grooming.

On 11/30/17 at 8:20 A.M., the surveyor observed the resident in bed, his/her fingernails were jagged and dirty.

On 12/06/17 at 8:40 A.M. during an observation and interview, CNA #2 said the resident’s nails were dirty and did not look like they were done on bath day like they were supposed to be.

2. For Resident #56, the facility failed to develop and implement a person-centered plan of care for incontinence. Resident #56 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. Review of the (NAME)ual MDS Assessment, dated 4/14/17, indicated the resident had severe cognitive impairment as evidenced by a score of 5 out of 15 on the BIMS (Brief Interview for Mental Status), needed assistance of two for toileting and was always incontinent of urine.

Review of the corresponding CAA, no date, indicated the facility staff should develop a care plan for incontinence to avoid complications. Review of the Bladder Assessment, dated 4/25/17, indicated the resident was incontinent of bladder, toilet 2 to 3 times per shift and provide incontinent care. Review of the CNA Kardex, no date, indicated the resident was occasionally incontinent of urine, he/she needed assistance of one for toileting and wore pull-ups. Review of the Quarterly MDS Assessment, dated 10/11/17, indicated the resident had moderately impaired cognition as evidenced by a score of 8 out of 15 on the BIMS, needed extensive assistance of 2 for toileting and was always incontinent of bladder. Review of the Alteration in (NAME)mination care plan, reviewed on 10/21/17, indicated the goal was to maintain current level of incontinence. The interventions included:

– Discuss medications with doctor, evaluate frequency/timing of incontinence,
– Labs as ordered,
– Monitor changes and report,
– Praise and encourage to be as independent as able, and
– Use briefs for incontinence protection.

On 12/06/17 at 10:15 A.M. during an interview with the Director of Nurses (DON), she said that the incontinence care plan did not have a measurable goal, and there were no interventions in place on how to provide incontinence care for the resident.

3. For Resident #6, facility staff failed to develop a plan of care for side rails per the facility’s policy. Resident #6 was admitted to the facility in 5/2017. [DIAGNOSES REDACTED]. Review of the facility’s Bed Rail Guideline (undated) included:

– If bed rails are being considered, assessment is completed before use, with ongoing reassessment (at least quarterly).

– Care plan interventions implemented when bed rails are utilized and reviewed at least quarterly.

Review of the clinical record had no evidence that a bed rail care plan was developed per facility policy when the facility determined the resident was appropriate for bed rail use. During interview on 12/7/17 1:00 P.M., Unit Manager #3 said there was no care plan developed for the utilization of bed rails per facility policy. Please Refer to F700 and F909.

4. For Resident #67, admitted to the facility in 7/2017 with a [DIAGNOSES REDACTED]. Review of the clinical record, Potential for Bladder and Bowel Retraining form dated 7/21/17 indicated that Resident #67 was continent of bowel and bladder at that time (upon admission).

Review of the Initial Minimum Data Set Assessment (assessment reference date of 7/26/17) indicated the resident: scored a 3 out of 15 points on the Brief Interview for Mental Status (BIMS), was frequently incontinent of urine and had no toileting plan in place. Review of the care plan addressing bowel and bladder incontinence was initiated on 8/9/17. The goal was that the resident would maintain the current level of continence.

Interventions included:

– Praise and encourage to be as independent as able.
– Preventative skin care including barrier cream with am/pm care and any incontinence.
– Provide (1) assist for toileting and incontinence care.
– Use of briefs/pads for incontinence protection.

Review of the Bladder Assessment Form dated 11/5/17, indicated the resident was currently incontinent due to Alzheimer’s dementia, diabetes and back pain. There was no evidence in the clinical record that the facility developed an individualized plan to try and restore as much bladder function as possible after the resident had a decline in bladder function since admission to the facility. During interview on 11/30/17 at 2:00 P.M., the Unit Manager (UM) #3 said that the 3 Day Patterning conducted on admission was not completed per policy and that the resident was mostly dry until Day 3 of the trial. She said that the trial should have been every hour (done every 2 or 3 hours) and then an individualized plan developed. During interview on 12/6/17 at 2:43 P.M., the resident’s family member told the Surveyor the resident was totally continent on admission to the facility, and that the facility had not mentioned the increased incontinent episodes.

5. For Resident #24, the facility staffed failed to follow the care plan for grooming. Resident #24 was admitted to the facility in 6/2014 with a [DIAGNOSES REDACTED]. Review of the Significant (NAME)e in Status MDS Assessment, dated 9/20/17, indicated the resident had severely impaired cognition as evidenced by the staff assessment, and needed assistance of 2 for grooming.

Review of the Self care impairment care plan, dated 10/21/17, indicated the resident needed assistance of 1 or 2 for grooming depending on the resident’s mood. Review of the CNA kardex, no date, indicated the resident needed assistance of 1 for grooming.

On 11/30/17 at 1:15 P.M. the surveyor observed the resident’s fingernails as long, dirty and jagged.

On 12/01/17 at 12:59 P.M. the surveyor observed the resident’s fingernails as long, dirty and jagged.

On 12/5/17 at 9:15 A.M. during an interview with UM #2, he said the resident’s nails needed to be cleaned and cut. He said the CNAs are responsible to provide nail care on the resident’s bath day and apparently the nail care was not done.

6. For Resident #32, the facility staff failed to follow the care plan for grooming. Resident #32 was admitted to the facility in 6/2015 with a [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 9/20/17, indicated the resident had severe cognitive impairment as evidenced by a score of 3 out of 15 on the BIMS (Brief Interview for Mental Status) and needed an extensive assistance of 1 for grooming. Review of the physical function deficit care plan, dated 10/23/17, indicated the resident needed assistance of 1 for grooming.

Review of the CNA kardex, no date, indicated the resident was dependent for grooming. On 11/30/17 at 8:27 A.M., the surveyor observed the resident with numerous long hairs on his/her chin. On 12/05/17 at 9:01 A.M. the surveyor observed the resident with numerous long hairs on his/her chin. During an interview on 12/06/17 at 9:13 A.M. with CNA #2, she said the resident had long hairs on his/her chin. She said it was the CNA’s responsibility to perform any grooming for the resident. She said the resident can be difficult sometimes and refused care but she could try again.

7. For Resident #68, the facility staff failed to follow the care plan for grooming. Resident #68 was admitted to the facility in 1/2017 with a [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 10/25/17, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS, and needed assistance of 1 for grooming. Review of the physical function deficit care plan, dated 11/27/17, indicated the resident needed assistance of 1 for grooming. Review of the CNA kardex, admitted ,[DATE], indicated the resident needed assistance for grooming.

On 11/29/17 at 11:00 A.M., the surveyor observed the resident with numerous long chin hairs.

On 11/30/17 at 7:50 A.M. the surveyor observed the resident with numerous long chin hairs.

On 12/06/17 at 9:16 A.M. during an interview with CNA #2, she said the resident had long hair on his/her chin and it didn’t look good.

Then CNA #2 asked the resident if he/she wanted a good shave to his/her chin. The resident said sure.

8. For Resident #5, the facility staff failed to follow the care plan by providing continuous supervision to prevent 6 out of 7 falls. Resident #5 was admitted to the facility in 6/2013 with [DIAGNOSES REDACTED].

Review of the current fall care plan, dated 7/2013, indicated the following interventions;

– Offer activities program,
– Keep environment free of obstacles,
– Foot wear to prevent slipping,
– Continual supervision with ambulation, needs contact guard for all destinations, initiated 12/10/15,
– Bed alarm, initiated 4/20/16,
– When first out of bed monitor for safe ambulation, initiated 4/20/16,
– If found sleeping in a chair, assist to bed, initiated 1/2/17, and
– Lap buddy to wheelchair for rest periods, initiated 2/2017.

Review of the Quarterly MDS Assessment, dated 12/3/16, indicated the resident had severely impaired cognition as evidenced by the staff assessment, needed supervision for ambulation and had 1 fall since last assessment. Review of the facility event report, dated 12/21/16, indicated the resident had an unwitnessed fall at 10:15 P.M. The resident was found sleeping on the activity room floor.

Review of the facility event report, dated 1/2/17, indicated the resident had an unwitnessed fall at 11:30 A.M. in the hallway. Review of the facility event report, dated 2/5/17, indicated the resident had an unwitnessed fall out of his/her bed at 4:30 A.M The resident was found with feet tangled in the blankets.

Review of the Quarterly MDS Assessment, dated 3/3/17, indicated the resident had severely impaired cognition as evidenced by the staff assessment, needed assistance of 1 for ambulation and had 2 or more falls since last assessment. Review of the facility event report, dated 3/21/17, indicated the resident had an unwitnessed fall at 3:50 P.M. and was found on the hallway floor. The report indicated to increase supervision as necessary, but the resident was already supposed to be continually supervision and should have been in the sunroom while awake.

Review of the event report, dated 3/31/17, indicated the resident had an unwitnessed fall at 11:10 A.M. and was found sitting on the hallway floor. Review of the event report, dated 5/14/17, indicated the resident had an unwitnessed fall at an unknown time and was found on the unit’s kitchen floor. Review of the (NAME)ual MDS Assessment, dated 5/25/17, indicated the resident had severely impaired cognition as evidenced by the staff assessment, needed assistance of 1 for ambulation and had 2 or more falls since last assessment. Review of the event report, dated 11/18/17, indicated the resident had a witnessed fall while a CNA was providing the resident care. On 12/06/17 at a 2:30 P.M. during an interview with the Director of Nurses (DON) she said she was not sure how supervision was provided to prevent falls. The DON was not aware that Resident #5 was supposed to be continually supervised.

Failed to develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to revise the care plan for one (#54) resident, in a sample of 18 residents, when interventions were no longer implemented.

Findings include:

For Resident #54, the facility staff failed to revise the care plan for urinary incontinence when interventions were no longer being implemented.

Resident #54 was admitted to the facility in 2/2012 with [DIAGNOSES REDACTED]. Review of the (NAME)ual Minimum Data Set Assessment, dated 10/11/17, indicated the resident was cognitively intact and always incontinent of bladder.

Review of the care plan for Urinary Incontinence, revised 11/8/17, included the following interventions:

-Contact precautions -ESBL (a multi-drug resistant organism) precautions
-(NAME)luate timing of medications which may cause increased urination.
-(NAME)luate frequency/timing of incontinence episodes
-Refer to therapy for increased incontinence

During an interview with the resident on 11/29/17 at 11:06 A.M., the resident said he/she was not interested in participating in any sort of training program or referrals to improve his/her urinary incontinence.

During an interview with Unit Manager #1 on 12/6/17 at 8:18 A.M., she said the resident was no longer on any type of infection control precautions, they were not timing administration of his medications as it relates to incontinence, not documenting the frequency of urinary incontinence and had no plans to refer the resident to therapy. She said the interventions on the care plan were outdated and were not being implemented.

Failed to ensure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility staff failed to maintain a professional standard of practice relative to the use of an air mattress for one Resident(#10) in a total sample of 18 residents.

Findings include:

For Resident #10, the facility staff failed to follow the manufacturer’s guidelines for correctly setting the comfort level of an air mattress.

Review of the manufacturers guidelines for the resident’s air mattress, provided by the facility, indicated that the comfort control LED displays the patient comfort levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight.

Resident #10 was admitted to the facility in 2/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, dated 8/23/17, indicated the resident had severe cognitive impairment based upon the staff assessment, and was at risk for developing pressure ulcers.

Review of the physician’s orders [REDACTED].

On 11/29/17 at 3:55 P.M., the surveyor observed the resident in bed on an air mattress set for a weight of 210 lbs. Review of the clinical record indicated that on 11/30/17, the resident weighed 176.2 pounds (lbs).

On 12/07/17 at 8:37 A.M. the surveyor, accompanied by Unit Manager (UM) #1, observed the resident in bed with the air mattress still set at 210 lbs. At that time, UM #1 said the air mattress was incorrectly set at 210 lbs.

Failed to provide activities to meet all resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility staff failed to provide ongoing activities based on the comprehensive assessment for 3 Residents (#5, #32 and #68) out of a total sample of 18 residents.

Findings include:

1. For Resident #68 the facility staff failed to offer the resident activities of his/her choice.

Resident #68 was admitted to the facility in 1/2017 with a [DIAGNOSES REDACTED]. Review of an Activities progress note, dated 2/1/17, indicated the resident enjoys current events, reading the newspaper and watching the news. The resident also enjoys classical music and enjoys all animals. It further indicated that staff will encourage the resident to come to activities of his/her choosing.

Review of the Admission Minimum Data Set (MDS) Assessment, dated 2/1/17, indicated the resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS).

The resident indicated the following activities were very important:

– Having the newspaper,
– Listening to music,
– Keeping up with the news,
– Being involved with favorite activity, and
– Going outside.

Review of the Activities care plan, dated 11/27/17, indicated the resident prefers to be independent with his/her activities. The goal was for the resident to continue to participate in independent activities. The interventions included:

– Invite me to sit in during activity programs, and
– Monitor my participation in my independent activities.

Review of the 11/2017 and 12/2017 Individual Resident Daily Activities Log was blank.

On 11/29/17 at 10:46 A.M. during a resident interview, the resident said that he/she is a loner and prefers to stay in her room, but would like to know when there is protestant services and would like to be able to listen to classical music while in his/her room.

On 11/30/17 at 11:00 A.M. the surveyor observed the resident seated in the hallway. The resident was offered by a staff member if he/she would like to attend activities and the resident said no.

On 12/01/17 at 10:20 A.M. the resident was observed in the bedroom, seated in a wheelchair with eyes shut.

On 12/05/17 at 8:52 A.M. during an interview with the Activity Director (AD), she said the care plan for Resident #68 was not individualized. She said she was not aware that the resident liked classical music, although it was documented in an earlier progress note. The surveyor asked what activities were offered to the resident because the participation logs are blank. The Activity Director said that the resident was really independent and that was why the logs were blank. The AD said that she would get the resident a CD player with classical music. She said that she really needed to spend time individualizing residents’ care plans.

2. For Resident #32, the facility staff failed to offer the resident activities of his/her choice.

Resident #32 was admitted to the facility in 6/2015 with a [DIAGNOSES REDACTED]. Review of the (NAME)ual MDS Assessment, dated 6/21/17, indicated the resident had severe cognitive impairment as evidenced by a score of 2 out of 15 on the BIMS. The resident was assessed as the following being very important; keep up with the news and read the newspaper.

Review of the Activities care plan, dated 10/23/17 indicated the resident’s favorite activity was to read the daily paper. Review of the Individual Resident Daily Activities Log for 11/2017 thru 12/5/17 indicated the resident watched television daily and attended entertainment 3 times. On 11/30/17 at 1:19 P.M. the surveyor observed the resident seated in his/her room. The resident did not have the newspaper.

On 12/5/17 at 8:10 A.M. the surveyor observed Resident #32 in his/her bedroom, seated in a wheelchair with eyes closed. The resident did not have a newspaper. On 12/5/17 at 8:00 A.M. during an interview with Unit Manager (UM) #2 he said the resident likes to stay in his/her bedroom and enjoys reading the daily paper. UM #2 said that the resident must not have paid, so the newspaper is no longer coming. UM #2 said that after another resident is done reading the paper he tries to remember to give it to Resident #32. UM #2 said he can’t remember when the resident’s newspaper stopped coming. On 12/5/17 at 8:30 A.M. during and interview with the Activity Director, she said the resident was very private, lived alone and does not like to join groups often. She said the resident had been receiving the paper daily but the Health Care Proxy stopped it. The Activity Director said it was stopped about 1 month go and was not sure why. The Activity Director said that he/she should be given the house paper or magazines to read. The Activity Director said she needed to update the plan of care to reflect the resident’s needs.

3. For Resident #5, the facility staff failed to offer the resident activities of his/her choice.

Resident #5 was admitted to the facility in 7/2013 with a [DIAGNOSES REDACTED]. Review of the (NAME)ual MDS Assessment, dated 5/25/17, indicated the resident had severely impaired cognition as evidenced by the staff assessment. A family representative was interviewed for the resident’s preferred activity. The only area that was identified to be somewhat important was to be engaged in favorite activities, although a favorite activity was not identified.

Review of the Activity care plan, dated 11/12/17, indicated that the resident spoke Spanish. The goal was to be able to enjoy activities in his/her native language and attend activities that do not depend on understanding a language.

The interventions included:

– I enjoy food that I can hold in my hands, and
– Introduce me to other residents, staff or visitors who also speak my native language.

Review of the 11/2017 Individual Resident Daily Activities Log, indicated that the resident was involved with a sensory group 15 out of 30 days and watched television daily. On 11/30/17 at 1:06 P.M., the surveyor observed the resident seated in the activity room in the corner by his/her self while bingo was being played by other residents. The resident was not holding any type of sensory items. Review of the 12/1/17 thru 12/5/17 Individual Resident Daily Activities Log indicated the resident was involved with a sensory group 5 out of 5 days, listened to music 1 time, and a family member visited 1 time. On 12/6/17 at 12:42 A.M. the surveyor observed the resident seated at the table while an activity was held for other residents. The resident was not participating in anyway or holding any type of sensory item. On 12/6/17 at 1:00 P.M. during an interview with CNA #1, she said the resident liked music and liked to play with baby dolls. On 12/06/17 at 1:24 P.M. during an interview with the AD, she said the resident care plan was out dated and didn’t reflect the resident. The AD showed the surveyor the 11/2017 and 12/2017 Individual Resident Daily Activities Log. She said the sensory group included giving the resident something to hold. The surveyor shared the observations of the resident and told the AD that the resident has not been observed holding any type of object. The AD said the resident should have been holding something. The AD then said that she had spoken to the residents son last week and asked him to bring in Spanish music for the resident. The surveyor asked why the facility has not offered and /or supplied the Spanish music. She said we should have. The AD went on to say that although the television was checked off as a daily activity, it really did not make sense because the television was not on a Spanish station.

Failed to provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility staff failed to ensure 1 Resident (#5) out of 18 residents, received appropriate services to maintain or improve mobility.

Findings include:

For Resident #5, the facility staff failed to follow the recommendations of the Physical Therapist (PT).

Resident #5 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, dated 11/15/17, indicated the resident had severely impaired cognition as evidenced by the staff assessment, needed extensive assistance of 1 person to ambulate in the bedroom, ambulated only once or twice in the hallway with an assistance of 1 person.

Review of the Kardex, no date, indicated the resident did not ambulate. Review of the Rehabilitation to Nursing Communication Form, dated 11/21/17, indicated the distance the resident ambulated varied, required hand held assistance of 2 staff members using a gait belt to ambulate.

Review of PT discharge summary, dated 11/27/17, indicated the resident should be ambulated 40 feet with 2 staff daily.

Review of the Certified Nursing Assistant’s (CNA) flow sheets, dated 11/21/17 thru 12/6/17, indicated the resident was not ambulated.

On 12/7/17 at 7:45 A.M. during an interview with CNA #2, she said that she took care of the resident all of the time and did not know he/she ambulated. She then showed the surveyor the ambulation list, which did not include Resident #5’s name. On 12/7/17 at 8:00 A.M. during an interview with the Rehabilitation Director, she said that she had educated the staff on how to ambulate Resident #5 and had printed out a new ambulation list. She said she was not sure why the unit still had the old list, but said the resident should have been ambulated daily.

Failed to provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interview, facility staff failed to ensure that 1 of 18 residents (#67) received appropriate services and assistance to maintain as much urinary continence as possible.

Findings include:

Resident #67 was admitted to the facility in 7/2017 with a [DIAGNOSES REDACTED]. Review of the 3 Day Pattern Assessment indicated that facility staff did not complete the assessment every hour per policy. The voiding assessment began on 7/20/17 at 11:00 A.M., however, review of the assessment indicated the resident was not checked and toileted from 3:00 P.M. on 7/20/17 until 6:00 A.M. on 7/21/17. The resident was then checked every 2 hours until 2:00 P.M. and not again until 12:00 A.M. on 7/22/17, which indicated the resident was wet. The patterning indicated the resident was checked every 2-3 hours and not hourly per policy from 12:00 A.M. until 2:00 P.M. and was found wet four times. Review of the clinical record, Potential for Bladder and Bowel Retraining dated 7/21/17 indicated that Resident #67 was continent of bowel and bladder at that time (upon admission).

Review of the Initial Minimum Data Set Assessment (assessment reference date of 7/26/17) indicated the resident: scored a 3 out of 15 points on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment, was frequently incontinent of urine, and had no toileting plan in place.

Review of the care plan addressing bowel and bladder incontinence was initiated on 8/9/17. The goal was that the resident would maintain the current level of continence. Interventions included:

– Praise and encourage to be as independent as able.
– Preventative skin care including barrier cream with am/pm care and any incontinence.
– Provide (1) assist for toileting and incontinence care.
– Use of briefs/pads for incontinence protection.

Review of the Bladder Assessment Form dated 11/5/17, indicated the resident was currently incontinent due to Alzheimer’s dementia, diabetes and back pain. There was no evidence in the clinical record that the facility developed an individualized plan to try and restore as much bladder function as possible after the resident had a decline in bladder function since admission to the facility.

During interview on 11/30/17 at 2:00 P.M., Unit Manager (UM) #3 said that the 3 Day Patterning conducted on admission was not completed per policy and that the resident was mostly dry until Day 3 of the trial. She said that the trial should have been every hour and then an individualized plan developed.

During interview on 12/6/17 at 2:43 P.M., the resident’s family member told the Surveyor the resident was totally continent on admission to the facility.

Failed to try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy, record review and interview, facility staff failed to attempt other alternatives prior to installing bed rails; review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for one resident # 6 in a total sample of of 18 residents.

Findings include:

Resident #6 was admitted to the facility in 5/2017. [DIAGNOSES REDACTED].

Review of the facility’s Bed Rail Guideline (undated) included:

– If bed rails are being considered, assessment is completed before use, with ongoing reassessment (at least quarterly).
– Care plan interventions implemented when bed rails are utilized and reviewed at least quarterly.
– The assessment and documentation also included: measuring the gaps between the rails themselves and the gaps between the bed rail and the mattress. A visual review is performed to assess that the mattress does not shift/slide allowing for an increased gap between the bed and the bed rail.

The facility’s Bed Rail Guideline also indicated the facility would demonstrate satisfactory compliance with the guide as follows:

– Residents with bed rails have appropriate assessments completed.
– There is evidence of multidisciplinary approach to bed rail utilization.
– There is evidence that risks and benefits were explained to the resident.

Review of the Side Rail Assessment Screen, dated 5/19/17, indicated the resident was ambulatory; not able to get into bed unassisted; able to turn side to side unassisted in bed; did not attempt to get in/out of bed unassisted; was unable to utilize the call bell for assistance; the side rail did not restrict freedom of movement or normal access to his/her body; had alterations in safety awareness due to cognitive decline; able to turn side to side with side rails; currently using side rails for positioning and support. The Assessment Screen indicated the side rail was measured and the gaps between the rails themselves and the gaps between the side rail and mattress were conducive to resident safety; the head of the bed was elevated to conduct a visual review to assess that the mattress and the side rail did not have a gap large enough to impose a resident safety issue/concern; and that a visual review was performed to assess that the mattress does not shift/slide allowing for an increased gap between the bed and the side rail. It was determined by the admitting nurse that 2 quarter rails were appropriate for this resident. The Initial Minimum Data Set (MDS) Assessment of 5/24/17 indicated that Resident #6 had short and long term memory loss and poor decision making skills; required extensive assistance from staff for bed mobility, transfers, ambulation in the corridor, toilet use, hygiene and bathing. The MDS also indicated the resident had delusions, physical and verbal outbursts towards others, rejected care and was receiving an antipsychotic medication.

Review of the clinical record had no evidence that a bed rail care plan was developed per facility policy when the facility determined the resident was appropriate for bed rail use. There was no evidence of informed consent with a review of risks and benefits signed by the resident or representative.

On 12/6/17 at 7:30 A.M., the Surveyor observed the resident lying in bed. The resident was awake and waiting for help getting out of bed. The Surveyor observed that the mattress on the bed was too short and did not go all the way to the foot board.

On 12/7/17 at 10:00 A.M., the Facility Administrator (FA), Unit Manager #3, and 2 surveyors measured the mattress. The thickness measured 5.5 inches and not 6 inches per specifications. The recommended mattress size was 36 x 76 or 36 x 80 inches. The measurements done with the facility were 34.0 x 73.5 inches. The space between the mattress and the foot board measured 2.5 inches, and between the mattress and the headboard was 2.0 inches. If the mattress slid down it would leave a space at the head of the bed of about 4.5 inches which could cause the resident to become entrapped. The FA said that the mattress would be replaced with one that would fit the bed as soon as possible.

During interview on 12/7/17 1:00 P.M., Unit Manager #3 said there was no evidence that the facility policy was followed regarding: – To meet quarterly as an interdisciplinary team to discuss side rail use for the resident, – Review the risks and benefits of bed rails with the resident representative and obtain informed consent prior to installation. – That the gaps around the bed were measured to ensure the resident would not become entrapped prior to utilizing side rails.

Failed to provide or obtain dental services for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to make provisions for routine/follow up dental care for 1 Residents (#68) in a total sample of 18 residents.

Findings include:

1. For Resident #68, the facility staff failed to offer routine dental exams. Resident #68 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the clinical record indicated the facility’s dental service was never offered to the resident, there was a blank form in the resident’s record with the dental service information.

On 11/29/17 at 10:57 A.M. during an interview with the resident the surveyor asked Resident #68 if his/her mouth bothered him/her, and would the resident like to have dental services, the resident answered, no.

On 12/5/17 at 11:10 A.M. during an interview with UM #2 he said that all residents are supposed to be offered dental services upon admission. UM #2 said he did not know why Resident #68 was not, but it was over looked.

Failed to regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, facility staff failed to conduct regular inspections of bed frames, mattresses and bed rails to ensure that 1 of 18 patients (#6) had the correct size mattress per Manufacturer’s Directions for Use (MDFU) and specifications to ensure patients do not become entrapped.

Findings include:

Resident #6 was admitted to the facility in 5/2017. [DIAGNOSES REDACTED]. Review of the facility’s Bed Rail Guideline (undated) included:

– If bed rails are being considered, assessment is completed before use, with ongoing reassessment (at least quarterly).
– Care plan interventions implemented when bed rails are utilized and reviewed at least quarterly.
– The assessment and documentation also includes: measuring the gaps between the rails themselves and the gaps between the bed rail and the mattress.

A visual review is performed to assess that the mattress does not shift/slide allowing for an increased gap between the bed and the bed rail. On 12/6/17 at 7:30 A.M., the Surveyor observed the resident lying in bed holding onto one of the side rails. The resident was awake and waiting for help getting out of bed. The Surveyor observed that the mattress on the bed was too short and did not go all the way to the foot board.

During interview on 12/6/17 at 8:30 A.M., the Environmental/Account Manager said that there is no specific plan in place to regularly inspect bed frames, mattresses and bed rails. On 12/7/17 at 10:00 A.M., the Facility Administrator (FA), Unit Manager #3, and 2 surveyors measured the mattress. The thickness measured 5.5 inches and not 6 inches per specifications. The recommended mattress size was 36 x 76 or 36 x 80 inches. The measurements done with the facility were 34.0 x 73.5 inches. The space between the mattress and the foot board measured 2.5 inches, and between the mattress and the headboard was 2.0 inches.

If the mattress slid down it would leave a space at the head of the bed of about 4.5 inches which could cause the resident to become entrapped. The FA said that the bed was very old, at least 20-[AGE] years old (still has hand cranks at the foot of the bed). He said the mattress was not the correct one for this type of bed, and would be replaced with one that would fit the bed as soon as possible.

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Sources:

Medicare Nursing Home Profiles and Reports – Hermitage HealthCare

Inspection Report for Hermitage HealthCare – 12/07/2017

Page Last Updated: July 18, 2018

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