Health inspection·November 15, 2024

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to send copies of notice of emergency transfer to the representative of the Office of State Long-Term Care (LTC) Ombudsman for four of four residents reviewed (Residents R18, R37, R56, and R88). Findings include: A facility policy entitled Transfer and Discharge (including AMA-[against medical advice]) dated 1/5/24, indicated the facility will provide copies of notices for emergency transfers to the Ombudsman, when practicable, such as in a list of residents on a monthly basis. Policy also indicated the facility will maintain evidence that the notice was sent to the Ombudsman. Resident R18's clinical record revealed an admission date of 12/16/19, with diagnoses that included stroke, dementia (loss of cognitive functioning affecting a persons memory and behaviors), chronic kidney disease (a gradual loss of kidney function). Departmental notes indicated that Resident R18 was transferred to the hospital on 2/11/24, and returned to the facility on 2/19/24. There was no evidence that the Office of the State LTC Ombudsman was notified. Resident R37's clinical record revealed an admission date of 9/26/23, with diagnoses that included Parkinson's disease (a chronic and progressive movement disorder resulting in tremors, stiffness, and slowing of movement), high blood pressure, and obstructive uropathy (urine cannot flow due to an obstruction). Departmental notes indicated that Resident R37 was transferred to the hospital on 4/30/24, and returned to the facility on 5/03/24. Resident R37 was again transferred to the hospital on 5/10/24, and returned to the facility 5/14/24. Resident R37 was again transferred to the hospital on [DATE], and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified. Resident R56's clinical record revealed an admission date of 1/16/24, with diagnoses that included chronic kidney disease, high blood pressure, and stroke. Departmental notes indicated that Resident R56 was transferred to the hospital on 3/29/24, and returned to the facility on 4/03/24. There was no evidence that the Office of the State LTC Ombudsman was notified. Resident R88's clinical record revealed an admission date of 7/23/24, with diagnoses that included cancer of the prostate, bladder, and glottis (opening between the vocal cords), tracheostomy (a hole is made through the neck into the windpipe and then a tube is place to allow for breathing), and high blood pressure. Departmental notes indicated that Resident R88 was transferred to the hospital on 8/03/24, and returned to the facility on 8/05/24. There was no evidence that the Office of the (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 11/15/2024 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)