A list of the most recent deficiencies for Somerset Ridge Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-01-30 | 2024-01-29 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-08 | 2023-11-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-08 | 2023-09-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-02 | 2023-09-12 | N |
| 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. | Health | 2023-08-02 | 2023-09-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-02 | 2023-09-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-02 | 2023-09-12 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-02 | 2023-09-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-02 | 2023-09-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-02 | 2023-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-02 | 2023-09-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-02 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-09-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-02 | 2023-09-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-02 | 2023-09-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-02 | 2023-09-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-02 | 2023-09-12 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-02 | 2023-09-12 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2023-08-02 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-02 | 2023-09-12 | N |
| Dispose of garbage and refuse properly. | Health | 2023-08-02 | 2023-09-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-02 | 2023-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-09-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-17 | 2023-06-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-21 | 2023-03-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-14 | 2023-03-14 | N |
| 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. | Health | 2023-02-14 | 2023-03-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-14 | 2023-03-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-02-14 | 2023-03-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-14 | 2023-03-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-14 | 2023-03-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-14 | 2023-03-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-14 | 2023-03-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-14 | 2023-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-14 | 2023-03-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-14 | 2023-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-14 | 2023-03-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-21 | 2022-10-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-21 | 2022-10-11 | N |
| 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. | Health | 2022-04-21 | 2022-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-21 | 2022-10-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-21 | 2022-10-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-21 | 2022-10-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-21 | 2022-10-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-21 | 2022-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-10-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-21 | 2022-10-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-04-21 | 2022-10-11 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-04-21 | 2022-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-21 | 2022-10-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-21 | 2022-10-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-04-21 | 2022-09-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-21 | 2022-09-07 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-04-21 | 2022-09-07 | N |
| 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. | Health | 2022-04-21 | 2022-09-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-21 | 2022-09-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-21 | 2022-09-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-21 | 2022-09-07 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-21 | 2022-09-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-21 | 2022-09-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-21 | 2022-09-07 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-21 | 2022-09-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-21 | 2022-09-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-21 | 2022-09-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-21 | 2022-09-07 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-21 | 2022-09-07 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-21 | 2022-09-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-21 | 2022-09-07 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-04-21 | 2022-09-07 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-04-21 | 2022-09-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-21 | 2022-09-07 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-04-21 | 2022-09-07 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-21 | 2022-09-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-21 | 2022-07-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-21 | 2022-07-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-21 | 2022-07-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-21 | 2022-07-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-21 | 2022-07-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-21 | 2022-07-03 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-04-21 | 2022-07-03 | N |
| Provide activities to meet all resident's needs. | Health | 2022-04-21 | 2022-07-03 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-04-21 | 2022-07-03 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-04-21 | 2022-07-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-04-21 | 2022-07-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-21 | 2022-07-03 | N |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2022-04-21 | 2022-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-07-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-26 | 2022-05-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-04-26 | 2022-05-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-04-26 | 2022-05-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-26 | 2022-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-26 | 2022-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-09 | N |
| Report COVID19 data to residents and families. | Health | 2022-01-27 | 2022-02-09 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-27 | 2022-02-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-29 | 2021-05-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-29 | 2021-05-17 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-29 | 2021-05-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-29 | 2021-05-17 | Y |
