HERMITAGE HEALTHCARE (THE)

Nursing Home Inspector

383 MILL STREET
WORCESTER, MA 01602
Worcester County
Phone: 508-791-8131
Provider Number: 225009
Last Inspection: 09/16/2016

About the Nursing Home

Number of Beds: 101
Number of Residents: 95
Beds Available: 6
Percent Occupancy: 94%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

27

Facility
16

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

27

2016
15

2015
26

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/16/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 10/14/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 10/17/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 10/14/2016
 
Failed To: Put firmly secured handrails on each side of hallways. Isolated : Minimal 3 10/14/2016
 
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 10/18/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 10/17/2016
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 10/17/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 10/17/2016
 

6/12/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 7/31/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 7/10/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 7/10/2015
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 7/31/2015
 

6/10/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 7/25/2014
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 7/25/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 7/25/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 7/25/2014
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 7/25/2014
 
Failed To: Make sure that each residents' abilities in activities of daily living do not decline, unless unavoidable. Isolated : Minimal 3 7/25/2014
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 7/25/2014
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 7/25/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/31/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 10/25/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/25/2017
 

5/4/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Isolated : Minimal 3 7/7/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 95 99.96 96.79
Registered Nurses 0.50 0.88 0.89
Licensed Practical / Vocational Nurses 0.72 1.00 0.84
Certified Nursing Assistants 2.19 2.37 2.30
Total Staff Hours 3.42 4.25 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 2 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 44 93 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 82 96 95
of long-stay residents experiencing one or more falls with major injury 3 3 3
of long-stay residents who have depressive symptoms 1 3 2
of long-stay residents who lose too much weight 9 5 5
of long-stay residents who received an antianxiety or hypnotic medication 22 22 20
of long-stay residents who received an antipsychotic medication 23 18 18
of long-stay residents who self-report moderate to severe pain 2 5 4
of long-stay residents who were physically restrained 3 0 0
of long-stay residents whose ability to move independently worsened 19 16 18
of long-stay residents whose need for help with daily activities has increased 14 14 14
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 63 58 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 17 76 79
of short-stay residents who had an outpatient emergency department visit 7 13 11
of short-stay residents who made improvements in function 44 57 60
of short-stay residents who newly received an antipsychotic medication 5 1 1
of short-stay residents who self-report moderate to severe pain 3 17 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 23 80 82
of short-stay residents who were rehospitalized after a nursing home admission 27 23 22
of short-stay residents with pressure ulcers that are new or worsened 2 57 56