A list of the most recent deficiencies for Somerset Subacute and Care. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-08 | 2023-12-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-26 | 2023-08-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-26 | 2023-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-26 | 2023-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-26 | 2023-08-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-26 | 2023-08-03 | 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 | 2023-05-26 | 2023-07-13 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-26 | 2023-07-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-26 | 2023-07-13 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-26 | 2023-07-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-22 | 2023-06-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-11 | 2022-12-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-23 | 2022-07-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-06-23 | 2022-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-23 | 2022-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-07-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-23 | 2022-07-25 | 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 | 2022-06-23 | 2022-07-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-23 | 2022-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-23 | 2022-07-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-23 | 2022-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-07-25 | 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 | 2022-06-27 | 2022-07-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-27 | 2022-07-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-27 | 2022-07-19 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-06-27 | 2022-07-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-27 | 2022-07-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-27 | 2022-06-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-29 | 2022-05-16 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-29 | 2022-05-16 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-03-01 | 2022-03-18 | Y |
| 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 | 2020-02-06 | 2020-04-02 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2020-02-06 | 2020-04-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-06 | 2020-04-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-30 | 2020-02-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-30 | 2020-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-30 | 2020-02-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-30 | 2020-02-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-30 | 2020-02-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-30 | 2020-02-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-30 | 2020-02-28 | 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 | 2020-01-30 | 2020-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-30 | 2020-02-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-22 | 2019-04-22 | 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 | 2019-02-22 | 2019-04-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-22 | 2019-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-22 | 2019-04-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-10 | 2019-02-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-10 | 2019-02-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-10 | 2019-02-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-10 | 2019-02-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-10 | 2019-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-10 | 2019-02-18 | N |
