Hermitage Nursing: Shower Neglect for MS Resident - PA
Inspectors visiting Hermitage Nursing and Rehabilitation on September 18, 2025, found that the facility had failed to provide scheduled showers to a resident identified in records as Resident R1, a person with multiple sclerosis who required full staff assistance and a Hoyer lift just to get out of bed. The resident's care plan called for showers on Wednesday and Sunday evenings. What the records showed instead was a gap stretching from July 30 through September 2 with almost nothing to account for it.
During that five-week stretch, the bathing detail report showed a single partial bath, given on August 27 at 9:02 p.m. No documented showers. No documented refusals that would explain why bed baths were substituted. The July 30 entry noted that a shower had been refused and a bed bath given instead, with nails cleaned and lotion applied. The next shower sheet on record wasn't filled out until September 2.
When inspectors sat down with the resident on September 16, the account was direct. The last shower had been the previous Wednesday, September 10. Sunday, September 14, came and went without one. Nobody offered. The resident said showers didn't always happen on schedule and that bed baths were usually given instead. Asked whether a real shower would be preferred over a bed bath, the answer was yes, without hesitation.
That preference mattered because getting a shower wasn't simple. The resident needed a Hoyer lift to transfer out of bed, full staff assistance to reach the shower room, and full assistance again once there. It wasn't something that could happen without planning and enough staff willing to do the work. A bed bath required less coordination. It also wasn't what the resident wanted or what the care plan required.
The facility's own quarterly assessment, completed in July 2025, had already documented that the resident needed substantial to maximal assistance with bathing. The care plan, updated in August, noted the same. The shower schedule was written into the resident's task list. None of it translated into consistent care.
The Assistant Director of Nursing and the Nursing Home Administrator, interviewed together on September 5, confirmed what the records showed. There was no documented evidence that the resident had received showers as scheduled between July 30 and September 2, and no documented evidence that the resident had refused them during that period. The refusal box, which would have explained a bed bath substitution, had not been filled in. The showers simply weren't there.
Inspectors cited the facility under F0677, which covers the obligation to assist residents with activities of daily living when they cannot perform those activities themselves. The level of harm was assessed as minimal harm or potential for actual harm. One resident was identified as affected.
What the citation doesn't capture is the arithmetic of it. Two showers a week, Wednesday and Sunday. Over the five weeks between July 30 and September 2, that would have meant roughly ten scheduled showers. The record documented one partial bath. The resident, who could not get out of bed without mechanical assistance and a staff team, had no way to close that gap independently.
The facility's own policy stated that residents would be bathed or assisted to shower routinely and as needed, per their preference. The resident's preference had been stated clearly to inspectors: a shower over a bed bath, every time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hermitage Nursing and Rehabilitation from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
HERMITAGE NURSING AND REHABILITATION in HERMITAGE, PA was cited for neglect violations during a health inspection on September 18, 2025.
The resident's care plan called for showers on Wednesday and Sunday evenings.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.