Hermitage Nursing And Rehabilitation

Based on review of facility policies, clinical records, and shower schedules, and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 13 residents reviewed (Resident R1).

Findings include: The current facility policy entitled Resident Care, indicated that facility staff will provide general care as necessary for each resident per their preferences when able, and per physician orders.

Residents will be given nursing care and supervision based upon individual needs.

Facility policies and procedures, and nursing and other discipline's standards of practice will be utilized to promote physical, mental, spiritual, nutritional, and emotional status of the resident.

Residents will be bathed or assisted to shower or bathe routinely and as needed per their preference with foot care given per order/need. A quarterly Minimum Data Set (MDS- periodic assessment of resident's abilities and care needs) Assessment for Resident R1, dated 7/15/25, revealed for Section GG area 0130E self care, ability to shower bathe self was documented as the resident needed substantial/maximal assistance. A care plan for Resident R1, dated 8/4/25, revealed that Resident R1 required assistance for ADL's (Activities of Daily living) related to immobility and multiple sclerosis.

Review of resident tasks (tasks completed by staff related to resident care) revealed Resident R1 was to have bathing/showering on Wednesdays and Sundays on 3:00 p.m. to 11:00 p.m. shift. An interview with Resident R1 on 9/16/25, at approximately 11:30 a.m. revealed that Resident R1 identified that his/her shower schedule was Wednesdays and Sundays on evening shift and does not always get a shower and is usually given a bed bath.

Resident R1 stated that the last shower given was last Wednesday (9/10/25) but was not given a shower on Sunday (9/14/25) and was not offered to get one.

Resident R1 identified that if he/she was offered to get a shower in the shower room, they would prefer a real shower over a bed bath.

Resident R1 revealed that he/she required full assist of staff and a hoyer lift (mechanical lift) to get out of bed to a chair and set up in shower room and full assist of staff was needed for a shower. A review of the bathing detail report and shower sheets for Resident R1 revealed that from 8/16/25 to 9/16/25, one partial bath was given on 8/27/25 at 9:02 p.m.

Review of shower sheets revealed that on 7/30/25, it was documented that a shower was refused but the staff person provided a bed bath, nails cleaned, and lotion applied.

The next documented shower sheet was 9/2/25. A shower sheet was also filled out 9/7/25, and on 9/10/25.

Review of this documentation revealed that there was no documented evidence that the resident received a shower per his/her preference, order, or care plan, and there was no documented evidence that the resident refused her showers, requiring that a bed bath be given.

During an interview on 9/5/25, at approximately 3:15 p.m. the Assistant Director of Nursing and Nursing Home Administrator confirmed that there was no documented evidence that Resident R1 received and/or refused showers from 7/30/25, through 9/2/25, as per the resident's preferences and shower schedule.28 Pa.

Code 211.10(d) Resident care policies28 Pa.

Code 211.12(d)(5) Nursing services

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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