Somerset Nursing and Rehabilitation Facility

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to implement the comprehensive person-centered care plan for 1 of 6 sampled residents (Resident (R)1).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to provide each resident with adequate supervision to prevent accidents for 1 of 6 sampled residents (Resident (R)1). R1 sustained a fall with a fracture.

Inspectors wroteBased on interview and record review it was determined the facility failed to review and update the facility assessment when there was a change in facility administration and failed to address the facility's resident population with regards to a resident with bariatric needs. (Refer to F558)

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the plan of care for six (6) out of twenty two (22) sampled residents (Residents #1, #41, #59, #69, #96, and #101) related to personal hygiene. Review of the individualized care plans for Residents #1, #41, #59, #69, #96, and #101, revealed the residents were to have a showers twice weekly and bed baths, five (5) days per week, on the days showers were not completed. Review of the bathing documentation, revealed the Resident #1, #41, #59, #69, #96, and #101 were not receiving showers twice weekly.

Inspectors wroteBased on observation, interview, record review, it was determined the facility failed to ensure six (6) of twenty two (22) sampled residents (Resident #1, #41, #59, #69, #96, and #101) received the necessary care and services to maintain grooming and hygiene. Review of facility bathing documentation, revealed residents were to have received showers twice weekly. However, review of bathing documentation for Residents #1, #41, #59, #69, #96, and #101, revealed the residents were not receiving showers twice weekly.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Interviews with residents during the survey revealed that food was often served cold and observations of the tray line on 08/03/2021 during the lunch meal revealed food items on the steam table were not held at the appropriate temperatures. Further observations in the kitchen on 08/03/2021 revealed food items in the refrigerator that were not labeled/dated with the date they were opened. Also, observations of food items in the dry storage area were opened, but not labeled/dated with the date they were opened.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #94) received services in the facility with reasonable accommodations of the resident's needs and preferences related to bariatric equipment (Geri Chair and Shower Bed).

Inspectors wroteBased on interview and record review, it was determined the facility failed to protect the rights of one (1) of twenty two (22) sampled residents (Resident #1). Family Member #1 who was also Resident #1's Power of Attorney (POA) verbally requested a copy of the resident's medical records, on 07/29/2021, and the family member signed the request for the medical record, on 07/29/2021. However, the family member did not receive the medical record until 08/03/2021 (3 business days after the initial request).

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) was protected from abuse. On 12/03/19, Resident #17 did not want staff to remove his/her dentures. State Registered Nurse Aide (SRNA) #29 told the resident, If I have to do it you know your [you're] not going to like it. Then, when the resident turned his/her head and stated, Don't do that, SRNA #29 put her fingers in the resident's mouth and attempted to jerk the resident's dentures from his/her mouth. Another staff member intervened and SRNA #29 left the room. Resident #17 cried and stated that his/her mouth hurt as a result of the incident.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) received the necessary care and assistance to maintain good grooming and personal hygiene. The facility failed to honor Resident #17's preference when providing oral care on 12/03/19, when the resident refused to remove his/her dentures. A State Registered Nurse Aide (SRNA) put her fingers in the resident's mouth and attempted to jerk the resident's teeth from his/her mouth. Resident #17 cried after the incident and reported that his/her mouth hurt.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, it was determined the facility failed to report an allegation of abuse timely to the Administrator and to state agencies for one (1) of thirty-three (33) sampled residents (Resident #68). A resident abuse allegation was reported to facility staff on 10/22/19 at 5:00 PM; however, the facility failed to ensure the allegation was reported to the Administrator until 10/23/19 at 8:50 AM and to the state agencies until 11:00 AM on 10/23/19.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse/neglect for five (5) of sixteen (16) sampled residents (Resident #7, Resident #17, Resident #45, Resident #204, and Resident #211) and an unknown number of residents who were allegedly neglected. On 12/03/19, staff reported that Resident #17 did not want staff to remove his/her dentures and State Registered Nurse Aide (SNRA) #29 told Resident #17, If I have to do it you know your [you're] not going to like it. When Resident #17 turned [his/her] head, SRNA #29 shoved her finger into the resident's mouth and jerked [his/her] top denture halfway out of the resident's mouth. The facility initiated an investigation; [...]

Inspectors wroteBased on interview, record review, and review of the Administrator's job description, the facility failed to ensure the facility was administered in a manner that enabled the use of its resources effectively and efficiently. The facility was cited at F609 and F610 for failure to report and investigate allegations of resident abuse on 09/06/19. On 11/16/19, the facility was cited for failure to report an allegation of abuse (F609). In addition, during the visit on 12/20/19, the facility was again cited for failure to report and investigate allegations of abuse (F609 and F610) and for failure to review/revise the comprehensive care plan (F657). The Administrator failed to ensure plans of corrections were implemented related to cited deficiencies and failed to ensure ongoing monitoring was completed to ensure corrective actions were effective (refer to F609 and F610).

Inspectors wroteBased on interview, record review, and review of the facility policy it was determined the facility failed to have an effective performance improvement program which measured the success and tracked the performance of implemented plans to ensure improvements are sustained in the facility. On 09/06/19, F609 and F610 were cited due to the facility's failure to report and investigate allegations of resident abuse, and on 11/16/19, the facility was cited again for failure to report an allegation of abuse (F609). The State Agency received a Plan of Correction (POC) on 10/11/19 for a survey exit date of 09/06/19. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined that the facility failed to promote and protect the dignity of one (1) of sixteen (16) sampled residents (Resident #45). Interviews with staff and/or review of the resident's medical record revealed the resident was cognitively impaired, was combative at times, and did not like for his/her feet to be touched. On 12/11/19, State Registered Nurse Aides (SRNAs) #37 and #38 tickled the resident's feet and teased/aggravated the resident. Subsequently, the resident hit his/her arm on the bed rail causing a skin tear and bruising. Interviews revealed on 12/04/19, SRNA #20 was intoxicated and provoked/taunted the resident to hit the SRNA.

Inspectors wroteBased on observation, record review, and review of the facility's policies and procedures, it was determined the facility failed to review and revise the care plan for one (1) of thirty-three (33) sampled residents (Resident #2). The facility failed to review and revise Resident #2's care plan when the resident developed a new pressure sore on 11/11/19.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide the appropriate treatment and services for pressure sores for one (1) of thirty-three (33) sampled residents (Resident #2). Observation of a wound assessment for Resident #2 on 11/13/19 at 2:48 PM revealed the resident had two (2) open areas on the left posterior upper thigh. However, the ordered treatment was only for one (1) area. In addition, staff failed to provide appropriate handwashing/sanitizing during wound treatment and failed to provide incontinence care when needed during a wound treatment.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for one (1) of thirty-three (33) sampled residents (Resident #66). Observation during the morning meal service on 11/15/19 at 8:47 AM revealed SRNA #2 failed to accurately document the meal intake for Resident #66.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review it was determined the facility failed to maintain an effective infection control program for one (1) of two (2) sampled residents (Resident #86) on transmission-based precautions out of thirty-three (33) sampled residents. A nurse entered Resident #86's room on 11/16/19 without wearing personal protective equipment as directed by the facility policy.