Pennsylvania Department of Health
HERMITAGE NURSING AND REHABILITATION
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HERMITAGE NURSING AND REHABILITATION
Inspection Results For:

There are  152 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
HERMITAGE NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Follow-up Survey completed on December 13, 2024, it was determined that Hermitage Nursing and Rehabilitation failed to correct all the deficiencies cited during the follow-up survey of September 20, 2024, and continued to be out of compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:


Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios for one NA per 10 residents during the day shift for five of 14 days (11/23/24, 11/24/24, 11/29/24, 12/01/24, and 12/03/24); failed to meet one NA per 11 residents on the evening shift for six of 14 days (11/22/24, 11/23/24, 11/24/24, 11/28/24, 12/01/24, and 12/02/24); and failed to meet one NA per 15 residents on the overnight shift for four of 14 days (11/26/24, 11/28/24, 11/29/24, and 11/30/24).

Findings include:

Review of facility nursing staffing documents for the time period from 11/20/24, through 12/03/24, revealed the following NA staffing shortage for the day shift where the NA ratio was not met.

11/23/24 census of 92 residents8.78 NAs worked and 9.20 were required
11/24/24 census of 92 residents8.07 NAs worked and 9.20 were required
11/29/24 census of 92 residents8.58 NAs worked and 9.20 were required
12/01/24 census of 93 residents7.58 NAs worked and 9.30 were required
12/03/24 census of 93 residents7.51 NAs worked and 8.45 were required

Review of facility nursing staffing documents for the time period from 11/20/24, through 12/03/24, revealed the following NA staffing shortage for the evening shift where the NA ratio was not met.

11/22/24 census of 92 residents6.33 NAs worked and 8.36 were required
11/23/24 census of 92 residents6.87 NAs worked and 8.36 were required
11/24/24 census of 92 residents8.33 NAs worked and 8.36 were required
11/28/24 census of 90 residents6.39 NAs worked and 8.18 were required
12/01/24 census of 93 residents5.47 NAs worked and 8.45 were required
12/02/24 census of 95 residents8.07 NAs worked and 9.50 were required

Review of facility nursing staffing documents for the time period from 11/20/24, through 12/03/24, revealed the following NA staffing shortage for the overnight shift where the NA ratio was not met.

11/26/24 census of 88 residents5.08 NAs worked and 5.87 were required
11/28/24 census of 90 residents5.28 NAs worked and 6.99 were required
11/29/24 census of 93 residents6.19 NAs worked and 6.20 were required
11/30/24 census of 92 residents4.16 NAs worked and 6.20 were required

During a telephone interview on 12/13/24, at 9:26 a.m. the Nursing Home Administrator confirmed that the facility did not meet the NA ratio for the above dates and shifts.



 Plan of Correction - To be completed: 01/22/2025

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.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:


Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet 3.2 minimum number of general nursing care hours for each 24-hour period for ten of 14 days reviewed (11/22/24, 11/23/24, 11/24/24 11/26/24, 11/28/24, 11/29/24, 11/30/24, 12/01/24, 12/02/24, and 12/03/24)

Findings include:

Review of facility nursing staffing documents for the time period of 11/20/24, through 12/03/24, revealed the following general nursing care hours was below the minimum 3.2 per patient day (PPD) on the following days:

11/22/24 2.96 PPD
11/23/24 3.05 PPD
11/24/24 3.12 PPD
11/26/24 3.17 PPD
11/28/24 3.07 PPD
11/29/24 3.14 PPD
11/30/24 3.05 PPD
12/01/24 2.81 PPD
12/02/24 2.99 PPD
12/03/24 3.08 PPD

During a telephone interview on 12/13/24, at 9:26 a.m. the Nursing Home Administrator confirmed that the facility did not meet the 3.2 minimum direct nursing care hours on the above dates.



 Plan of Correction - To be completed: 01/22/2025

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 QAPImeetings 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 Recourse Director.

10. All auditing of above process will be completed by NHA/DON, or designee, and documented 5 times weekly at a minimum.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port