The Hermitage

The facility failed to serve a therapeutic diet as ordered by the primary care provider for one resident. Specifically, a resident prescribed a mechanical soft, ground meats diet with no added table salt was served a bologna and cheese sandwich on white bread with tomato and onion. Staff members, including a personal care aide and a medication aide, were unaware of the resident's specific dietary requirements.

The facility failed to serve a therapeutic diet as ordered by the physician for one resident. Specifically, the resident was prescribed a mechanical soft, ground meats diet with no added salt, but was observed being served a bologna and cheese sandwich with solid meat and vegetables. Staff interviews also indicated a lack of awareness regarding the resident's specific dietary requirements.

The facility failed to ensure the resident's health care needs were met by failing to follow up with monthly urology visits for urinary catheter exchanges. Specifically, a resident with an indwelling catheter was found with a flip valve in place instead of a drainage bag, and the facility failed to facilitate a scheduled follow-up appointment with the urologist.

The facility failed to ensure the health care needs of a resident were met by failing to follow up with monthly urology visits for urinary catheter exchanges. Specifically, a resident's catheter had not been changed since July 19, 2022, despite a hospital stay and subsequent orders for follow-up care. This lack of follow-up resulted in a foul odor in the resident's room and the use of an improper catheter setup.

The facility failed to provide necessary personal care to a resident as required by their care plan. Specifically, staff failed to ensure adequate toenail care was provided, resulting in thick, yellowed, and overgrown toenails on both feet of Resident #1.

The facility failed to provide necessary toenail care for a resident. Observations revealed thickened, yellow, and protruding toenails on both feet, and staff interviews indicated that while the need for podiatry was noted, the resident was not properly scheduled for follow-up care.

The facility failed to ensure appropriate and timely follow-up for acute injuries resulting from a fall. Specifically, the facility did not provide necessary follow-up care for a resident's shoulder, wrist, and hip injuries following an incident on 02/10/22.

The facility failed to implement and maintain its infection prevention and control program as required by CDC and NCDHHS guidelines. Specifically, staff were observed using personal protective equipment (PPE) improperly and failing to practice proper hand hygiene. These failures increased the risk of COVID-19 transmission among residents and staff.

The facility failed to implement and maintain an infection prevention and control program consistent with CDC and NCDHHS guidance during the COVID-19 pandemic. Specific failures included improper use of personal protective equipment (PPE), staff not practicing proper hand hygiene, and inadequate monitoring of infection control protocols.