Deficiency Records for Somerset Healthcare and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Somerset Healthcare and Rehabilitation 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-17 | 2023-12-07 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-11-17 | 2023-12-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2023-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-28 | 2023-07-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-28 | 2023-07-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-28 | 2023-07-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-25 | 2023-06-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-25 | 2023-06-26 | 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 | 2023-05-18 | 2023-06-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-18 | 2023-06-09 | 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 | 2023-05-18 | 2023-06-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-18 | 2023-06-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-18 | 2023-06-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-18 | 2023-06-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-18 | 2023-06-09 | 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 | 2023-05-18 | 2023-06-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-18 | 2023-06-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-18 | 2023-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-18 | 2023-06-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-18 | 2023-06-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | 2023-06-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-18 | 2023-06-09 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-09-19 | 2022-10-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-19 | 2022-09-15 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Meet other general requirements. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-26 | 2022-07-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-26 | 2022-07-19 | 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 | 2022-05-25 | 2022-07-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-25 | 2022-07-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-25 | 2022-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-07-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-25 | 2022-07-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-25 | 2022-07-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-05-25 | 2022-07-06 | 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 | 2022-05-25 | 2022-07-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-25 | 2022-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-25 | 2022-07-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-25 | 2022-07-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-25 | 2022-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-25 | 2022-07-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-25 | 2022-07-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-25 | 2022-07-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-25 | 2022-07-06 | Y |
| 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 | 2022-01-28 | 2022-03-01 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-28 | 2022-03-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-20 | 2022-02-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-20 | 2022-02-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-14 | 2021-11-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-11-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-15 | 2021-08-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-15 | 2021-08-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-07-15 | 2021-08-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-15 | 2021-08-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-15 | 2021-08-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-15 | 2021-08-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-07-15 | 2021-08-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-07-15 | 2021-08-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-15 | 2021-08-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-15 | 2021-08-12 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-13 | 2021-06-11 | Y |
