Inspection Reports for The Hermitage

The facility failed to serve a therapeutic diet as ordered by the primary care provider for one resident who had an order for a mechanical soft, ground meats diet with no added table salt. Observations and interviews revealed the resident was served a regular bologna and cheese sandwich instead of the prescribed diet, indicating a staff error despite the presence of a diet order list and labeling procedures.

The facility was found to have deficiencies related to exhaust ventilation, specifically that exhaust fans in the Hall 400-Spa/Bath and Kitchen Hall-Laundry areas were not working, leading to inadequate ventilation and potential buildup of humidity, mildew, slick areas, and odors.

The visit was triggered by a complaint investigation related to failure to meet health care needs for Resident #3, specifically regarding urinary catheter follow-up and changes.

The facility failed to meet the health care needs of one sampled resident (#3) by not ensuring monthly urinary catheter changes, resulting in increased risk of infection and physical harm. The resident's catheter was not changed for over two months, despite hospitalizations and scheduled appointments.

Complaint investigation initiated by Jackson County Department of Social Services on 03/16/22 related to Resident #1's care and injury follow-up.

The facility failed to provide adequate personal care, specifically toenail care, for Resident #1. Additionally, the facility failed to ensure appropriate and timely follow-up for acute shoulder, wrist, and hip injuries due to falls for Resident #1, resulting in severe pain and delayed treatment. The facility also failed to ensure that Resident #6 had physician orders to self-administer medication observed in his room.

The visit was complaint-related, focusing on infection control practices during the COVID-19 pandemic. The facility was found noncompliant with infection prevention guidelines, including improper PPE use and hand hygiene, increasing risk of COVID-19 transmission.

The facility failed to ensure implementation of CDC, NCDHHS, and facility infection control policies related to proper use of PPE, hand hygiene, and precautions to reduce COVID-19 transmission. Observations revealed staff reusing disposable isolation gowns without proper cleaning, not practicing hand hygiene between resident contacts, improper gown use, and extended use of surgical masks beyond recommended guidelines, increasing risk of virus spread.

Multiple deficiencies were cited including failure to maintain proper operation of special locking arrangement doors, lack of current sanitation and fire safety inspection reports, absence of functioning wanderer alarms on exit doors, poor housekeeping with plumbing and odor issues, hazards from maintenance neglect, missing bedroom furnishings, improperly maintained fire extinguishers, and unsafe or non-operating building equipment such as emergency lighting, fire sprinkler obstructions, and electrical hazards.

The facility failed to assure a physician's order for laboratory work was implemented for one resident (#3) and failed to assure medication (potassium chloride) was administered as ordered and accurately documented for the same resident. Discrepancies were found between medication administration records and actual medication supply.

Some deficiencies were not corrected, including issues with housekeeping hazards and fire safety. Specific findings included a missing sprinkler escutcheon, fire doors being propped open or removed, and compromised fire-rated walls and ceilings sealed with unapproved materials.

Multiple deficiencies were cited including lack of current fire safety inspection reports, unsafe storage of portable medical oxygen cylinders, missing hardware on smoke barrier doors, incomplete fire safety rehearsals, and compromised fire-rated walls and doors that do not close or latch properly.