Health inspection·August 8, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and staff interviews, it was determined that the facility failed to provide a clean, comfortable and homelike environment for seven of 53 rooms (Rooms 51, 33, 34, 35, 37, 39, and 40.) Finding include: Review of facility policy entitiled, The 5 Step Daily Patient Room Cleaning dated 1/01/23, revealed the entire floor must be dust mopped . Observations conducted between 10:06 a.m. through 10:40 a.m. revealed the following: room [ROOM NUMBER] had loose debris under resident beds room [ROOM NUMBER] had loose debris under the bed by the door room [ROOM NUMBER] had loose debris noted on the resident floors room [ROOM NUMBER] had loose debris noted on the floor room [ROOM NUMBER] had a Kleenex box wedged under the window bed room [ROOM NUMBER] had debris on the floor and under the door bed Observations of rooms on Unit Three on 8/08/23 at 10:43 a.m. revealed that Housekeeper Employee E2 was cleaning resident rooms. During an interview at that time, Housekeeper Employee E2 stated that he/she had finished cleaning room [ROOM NUMBER]. During observation of room [ROOM NUMBER], loose debris was observed under the bed in the room by the window. During an interview with Housekeeper Employee E2 on 8/08/23 at 10:45 a.m he/she stated they had completed cleaning the room but had forgotten to clean under the resident's beds. Observations with the Housekeeping Assistant Manager on 8/08/23, at 12:33 p.m. revealed the prior morning observations were still present in Rooms 33, 34, 35, 37, 39 and 40 including the loose debris noted under beds, on the floors and the Kleenex box still under the bed in room [ROOM NUMBER]. During an inteview on 8/08/23, at 12:43 p.m. Housekeeper Employee E3 stated all rooms were (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 395231 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)