Deficiency Records for Somerset Woods Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Somerset Woods Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-29 | 2023-10-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-29 | 2023-10-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-29 | 2023-10-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-23 | 2022-06-24 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-23 | 2022-06-24 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-05-23 | 2022-06-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-23 | 2022-06-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-23 | 2022-06-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-23 | 2022-06-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-23 | 2022-06-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-23 | 2022-06-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-23 | 2022-06-24 | 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 | 2022-05-23 | 2022-06-24 | 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 | 2022-05-23 | 2022-06-24 | 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 | 2022-05-23 | 2022-06-24 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-05-23 | 2022-06-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-05-23 | 2022-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-23 | 2022-06-24 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-23 | 2022-06-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-23 | 2022-06-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-19 | 2020-01-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-19 | 2020-01-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-19 | 2020-01-06 | N |
