Health inspection·March 21, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on a review of facility policy, facility grievances, and resident representative and staff interviews, it was determined that the facility failed to resolve a resident representative's grievance concerns related to care/treatment for one of 31 residents reviewed (Resident R1). Findings include: The Concerns-Grievances policy, dated 12/28/23, revealed the facility will honor the resident's right to voice concerns and/or grievances without discrimination or reprisal. Such concerns and/or grievances will include, but not limited to, treatment which has been furnished as well as that which has not been furnished and instances of behavior of other residents. Other forms of grievances could include management of funds, lost items and/or violation of rights. This process will provide a method of documenting Concerns/Grievances and resolutions. These processes combined will promote customer satisfaction with the facility care and services and identify areas of improvement. Social Services will be responsible for coordinating orientation and in-service training to ensure all facility staff are knowledgeable of the facility's Concern process and that they understand their role in providing responsive customer service to residents and their families in concern resolutions. Social Services Director will coordinate the facility system for collecting concerns and tracking concerns for timely and appropriate response. Social Services will instruct facility staff to submit to the Social Service Director that all concerns received will be investigated within seventy-two hours (72 hours) following receipt of the concern. Within seven (7) days following the receipt of the concern, the facility will inform the complainant with the results of the investigation. A review of facility grievances from the months of January through March 2024, revealed no grievances from Resident R1's family member. During an interview with Resident R1's resident family member on 3/19/24, at 6:00 p.m. it was indicated that a letter of concern was written by Resident R1's family member in February 2024, and provided to Employee E1 regarding care and treatment concerns for Resident R1. During an interview with Employee E1 on 3/20/24, at approximately 4:55 p.m. it was revealed that he/she did receive a letter of concern from Resident R1's family member in February 2024, but failed to provide it to any further facility staff to address the concerns. An interview with the Director of Nursing on 3/20/24, at approximately 6:00 p.m. confirmed that he/she was unaware of Resident R1 family member's care and treatment concerns and further confirmed that the above noted letter of concern regarding the care and treatment concerns were not addressed timely as per the facility grievance policy as stated above. Page 1 of 2 395231 395231 03/21/2024 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

F 0585 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.29(a) Resident rights Residents Affected - Few 395231 Page 2 of 2