Altercare Somerset Inc.

Inspectors wroteBased on interview and closed record review, the facility failed to ensure a resident received showers or bed baths at least twice weekly. This affected one resident (#70) of six residents sampled for showering. The facility census was 68.

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to ensure resident equipment was maintained in a clean and sanitary manner. This affected three residents (#9, #44 and #54) of 25 sampled residents. The facility census was 69. Findings Include:1. Review of the medical record for Resident #44 revealed an initial admission date of 08/20/23 with the latest readmission of 05/21/24 diagnoses included the protein calorie malnutrition, urinary tract infection (UTI), depression, mood disorder, hypothyroidism, anemia, metabolic encephalopathy, solitary pulmonary nodule, chronic pain, atrial fibrillation, anorexia, osteoarthritis, dementia, macular degeneration and cerebral atherosclerosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. [...]

Inspectors wroteBased on observation, record review, staff and family interview, the facility failed to honor a resident's stated beverage preference. This affected one, (Resident #22) of two residents reviewed for choices. The facility census was 69.

Inspectors wroteBased on medical record review, interview, and review of facility policy review, the facility failed to ensure the baseline care plan was timely reviewed and provided to one ((Resident #74) of 24 residents reviewed. The census was 69.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan for one, (Resident #22) of 24 residents reviewed. The facility census was 69.

Inspectors wroteBased on observation, medical record review, interviews and facility policy review, the facility failed to ensure residents who were dependent on staff were provided routine bathing. This affected two residents (#10 and #36) of six residents reviewed for activities of daily living (ADL). The facility census was 69. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 08/14/24 with the latest readmission date of 07/15/25. Diagnoses included but were not limited to spinal stenosis lumbar region, dementia, chronic obstructive pulmonary disease, palliative care, chronic respiratory failure, chronic pain, hyperlipidemia, hypertension, myasthenia gravis, diabetes mellitus, depression, anxiety, migraine, atrial fibrillation, congestive heart failure, cardiomyopathy, arthritis, candidiasis and anemia. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure fall prevention interventions were implemented as indicated. This affected one resident (#47) of three residents reviewed for falls. The facility census was 69.

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure a resident who required an indwelling foley catheter for bladder elimination was monitored for appropriate daily urine output as well as documenting urine output each shift. This affected one (Resident #46) of the three residents reviewed for bladder elimination. The facility census was 69.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure meal intakes were monitored and documented for three (Resident #44, #46, and #74), and the facility failed to ensure an order supplement was documented for one, (Resident #44). This affected three of six reviewed for nutrition and hydration. The facility census was 69.

Inspectors wroteBased on observation, record review, facility staff interview, and facility policy review, the facility failed to follow physician 's order for oxygen administration. This affected one resident (#9) of one resident reviewed for respiratory care. The facility census was 69.

Inspectors wroteBased on medical record review and staff interview the facility failed to follow up with psychiatric recommendations in a timely manner. This affected one resident (#8) of two residents reviewed for mood and behavior. The facility census was 69.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident, who required assistance with personal care, received assistance with activities of daily living (ADLs). This affected one resident (#11) of six residents reviewed for ADL assistance. The facility census was 71.

Inspectors wroteBased on record review, observation, and interview, the facility failed to protect residents' confidential information. This affected three residents (#66, #88, and #99) of seven residents reviewed for HIPAA. The facility census was 71.

Inspectors wroteBased on record review, review of the facility's shower schedules, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, received the assistance needed to receive showers as scheduled. This affected three (Resident #3, #9, and #30) of three residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure residents had the right to a safe, clean, and sanitary environment. This affected 42 of 67 residents (25 residents were identified to not use the facility's two shower rooms (Residents #3, #4, #6, #17, #21, #22, #36, #37, #38, #39, #42, #44, #47, #48, #50, #52, #53, #54, #55, #59, #63, #64, #65, and #66). The facility's census was 67.

Inspectors wroteBased on review of a facility self-reporting incident (SRI), it's related investigation, staff interview, and policy review, the facility failed to ensure resident's personal money was not misappropriated by facility staff. This affected one resident (#36) of one residents reviewed for misappropriation and one of two SRI's reviewed.

Inspectors wroteBased on record review, review of shower schedules, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, received the assistance they needed for bathing/ showers. This affected three residents (#8, #14, and #20) of four residents reviewed for showers.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's nutritional status was adequately monitored by recording meal percentages and fluid intake amounts that were consumed during her stay in the facility. This affected one resident (#69) of three residents reviewed for nutrition.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's medical record was complete and accurate to reflect activities of daily living (ADL) care that was provided to the resident while in the facility. This affected one resident (#69) of four residents reviewed for accuracy of medical records.

Inspectors wroteBased on medical record review, interview, and review of facility policy, the facility failed to develop and implement a comprehensive, effective and individualized nutritional program to ensure nutritional recommendations were implemented timely, weights and assessments were completed timely, care plans were updated appropriately, and significant/severe weight changes were addressed for Resident #264. Actual harm occurred when Resident #264 who was cognitively impaired and weighed 104 pounds on 05/19/24 experienced a gradual weight loss until 06/24/24 when she experienced a severe 8.5% (9 pounds) weight loss. The nutritional recommendations for Resident #264 that were made on 05/19/24 were not put in place until they were recommended again on 06/09/24. [...]

Inspectors wroteBased on record review, observations, resident, family and staff interviews, and policy review, the facility failed to ensure residents, who required assistance from staff for personal care, received the assistance they needed to complete activities of daily living per the residents' preferences. This affected five (#7, #20, #40, #55, and #264) of six residents reviewed for activities of daily living (ADL). The facility's census was 62.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide spend down notification for a resident who received Medicaid benefits. This affected one (#15) of five residents reviewed for funds. The facility census was 62.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure care plans were implemented for all residents. This affected two (Residents #55 and #28) of 20 resident care plans reviewed. The census was 62. Findings Include: 1. Resident #55 was admitted to the facility on [DATE]. His diagnoses were unspecified fracture of T5-T6 vertebra, difficulty walking, muscle weakness, hyperlipidemia, acute respiratory failure, dysphagia, anemia, type II diabetes, atherosclerotic heart disease, hypertension, atrial fibrillation, acute embolism and thrombosis, bipolar disorder, heart failure, Parkinson's disease, acute kidney failure, anxiety disorder, sleep apnea, insomnia, polyneuropathy, conjunctivitis, and altered mental status. Review of facility Minimum Data Set (MDS) assessment, dated 06/15/24, revealed he was cognitively intact. [...]

Inspectors wroteBased on observations, medical record review, and staff interview, the facility failed to ensure a resident was properly positioned in a wheelchair. This affected one (Resident #25) of three residents reviewed for positioning. The facility census was 62.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. This affected two of two residents reviewed for urinary tract infections (Residents #8 and #20) in a sample of 24. The facility census was 62.

Inspectors wroteBased on record review and interview the facility failed to provide evidence that urostomy care was completed as care planned and ordered for Resident #47. This affected one resident (#47) of one resident reviewed for urostomy care. The facility census was 62.

Inspectors wroteBased on observations, medical record review, resident and staff interview, review of staffing schedules, and policy review, the facility failed to have sufficient staff to meet the needs of each resident. This affected three of 24 sampled residents (Residents #7, #20, and #40). The facility census was 62.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure routine laboratory testing was completed weekly as ordered by the physician. This affected one (#61) of five residents reviewed for unnecessary medications. The facility census was 62.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure appropriate infection control practices were followed in regards to the use of personal protective equipment (PPE) and donning/ doffing procedures were followed to help limit the spread of Covid-19 throughout the facility. This had the potential to affect all residents residing in the facility. The facility's census was 64.