Somerset Post Acute Care

Inspectors wroteBased on interview and record review, the facility failed to ensure personal and medical documents remained secured and confidential for 2 of 2 (1,3) sampled residents when the facility sent Resident 1 and Resident 3's personal and medical information to the family representatives of other residents (2,4). This failure had the potential to result in misuse of confidential resident information by unauthorized individuals.1. Resident 1 was admitted to the facility on [DATE] with a diagnosis of generalized anxiety disorder per the facility face sheet. Resident 2 was discharged from the facility on 1/17/26 per the facility face sheet. A review of Resident 1's order summary report, active 1/17/26, indicated the document included Resident 1's name, date of birth , admission date, physician, diagnosis, and current prescribed medications and treatment orders. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the physical environment was maintained in a safe and well-kept condition by not addressing a ceiling leak during rainy weather. These deficient practices placed 4 out of 8 sampled residents (Resident 1, 2, 5, and 6) and eleven residents who used the physical therapy room at risk for exposure to safety hazards and potential health risks related to unresolved ceiling leaks.

Inspectors wroteBased on interview and record review, the facility failed to ensure the confidentiality of residents' personal and medical information was protected when binders containing sensitive resident data was left unsecured at the nursing station, resulting in the unauthorized removal of the binders by unauthorized personnel. As a result, all residents at the facility were at risk for unauthorized access to their personal and medical information, in violation of their right to privacy and confidentiality.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and policy when: 1. Expired food items were stored in the kitchen storage and used in the kitchen areas. 2. The Kitchen Supervisor (KS) did not remove gloves and perform hand washing after disposing the kitchen garbage. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control procedures were followed when: 1. A Licensed Nurse (LN) 2 and two Certified Nursing Assistants (CNA) did not wear a gown when providing care for one resident (Resident 26) on enhanced barrier precautions (EBP - gown and gloves must be worn during high-contact resident care activities [example: residents with medical devices]). 2. Urinary catheter (tube inserted into the bladder to aid in urine flow) bag for two residents (37 and 40) was touching the floor. 3. A resident's (34) nasal cannula (tubing connected to the oxygen and to the resident for supplement) was not properly stored. These failures had the potential for cross contamination, spread of infection, and residents' decline of health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights (device used to communicate a need for help) were within residents' reach for two of two sampled residents (10 and 26). The concerns for the call light within reach had been an ongoing issue during the Resident Council (RC) Meetings from August 2024 through November 2024. In addition, the facility failed to provide the appropriate call bell for one resident (17) with contractures (stiffening/shortening at any joint, that reduces the joint's range of motion). These failures had the potential to not meet the needs of the residents when needing help. Cross reference to F-656.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents' rights to confidentiality of protected health information (PHI - includes name, diagnoses, treatment of patients) for multiple residents when a vital signs sheet (VSS - form/record that included residents medical information) was found in the medical cart's trash bin. This failure had the potential to unnecessarily expose residents' PHI to individuals such as visitors and/or other residents.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to having a call light within reach for two of two sampled residents (10 and 26). In addition, the facility failed to implement a physician's order related to the administration of wound treatment and measurement of wound for one resident (37). These failures had the potential to not meet the goals of treatment and needs for Resident 10, Resident 26, and Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when a Licensed Nurse (LN) 2 did not auscultate (listening to the stomach with a stethoscope when administration of air to check the placement of the gastrostomy tube [g-tube, a tube inserted through the stomach that brings nutrition or medications directly to the stomach]) before giving a resident (26) his tube feeding (TF) formula. This failure had the potential for Resident 26 to have respiratory aspiration of gastric contents, that may cause a life-threatening aspiration pneumonia (bacterial infection in your lungs, it can happen when you aspirate, or inhale, something other than air into your respiratory tract).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's order for one of seven sampled residents, when Resident 2's compression stocking (CS- worn to decrease swelling) was not worn. This failure had the potential to affect Resident 2's well-being.

Inspectors wroteBased on interview and record review, the facility did not ensure wound treatment for one of one resident (Resident 37) was completed as ordered by the physician. This failure had the potential to affect Resident 37's care and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to consistently monitor and document urine output (UO) per the facility's policy, for three of three sampled residents (8, 37, and 40) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). In addition, there was no urinary catheter order for Resident 40. This failure had the potential for Resident 8, Resident 37 and Resident 40 to have urinary retention and develop urinary tract infection (UTI).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of two residents investigated for dialysis (246). This failure had a potential for Resident 246's dialysis access to clot.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled medications (CM -medications with high potential for abuse and addiction) were accurately accounted for when four out of 10 CMs were not documented on the Electronic Medication Administration Records (EMAR) and controlled drugs accountability sheet (CS-count sheet that monitors the storage and usage of controlled medications) to indicate the CMs were given to the resident. This failure had the potential for misuse or diversion of CMs. An observation of CM handoff (report that typically occurs at the end of the shift; includes necessary information to ensure safe transition of care) between Licensed Nurse (LN) 14 and LN 15 was conducted on 3/11/25 at 3:12 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to indicate the appropriate and measurable target behavior of antidepressant (medication used to treat depression, sad mood and lack of interest) for one of two sampled residents (Resident 8) reviewed for unnecessary psychotropic (mind-altering medications) medication use. This failure had the potential for unnecessary psychotropic medication use, side effects, and a decline for resident's psychological and mental well-being.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 6.45% when two medication errors occurred out of 31 opportunities during medication administration, for two out of four residents (Resident 65 and Resident 27). These failures resulted in medications not given in accordance with the physician's orders which resulted in residents not receiving the therapeutic effects of the medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and appropriate storage of medications when: 1. One out of one intravenous medication cart (IV cart - medications used through the vein) was left unlocked and unattended by a licensed nurse (LN). 2. A medication room key was left in the doorknob and left unattended by a LN. 3. Multiple medications were left unattended by a LN in the nursing station. These failures had the potential for unauthorized access of residents, visitors, and/or unlicensed staff to medications.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate assistance to a resident (Resident 2) who required total dependence with activities of daily living (ADL-bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) reviewed for accidents. This failure resulted in Resident 2 falling from bed.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) for medical care, when the facility did not document a reason for refusal to readmit Resident 1 after GACH 2 had deemed Resident 1 medically and psychologically safe for discharge back to the facility according to facility policy. This deficient practice placed the resident at risk for confusion and psychosocial harm related to the inability to return to the facility and an unnecessary, extended stay at the GACH 2.

Inspectors wroteBased on interview and record review, the facility did not have a written transfer agreement in place with a General Acute Care Hospital (GACH) when the facility ordered a resident (1) to transfer to GACH 2 for medical and psychological treatment. This failure could potentially place residents at risk for inadequate continuity of care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide interventions to prevent the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) for two of six residents reviewed for pressure injuries (Resident 17, Resident 26.) As a result, Resident 17 developed a new pressure injury on the right trochanter (hip) and Resident 26 developed a new pressure injury on the right trochanter area.

Inspectors wroteBased on interview and record review, the facility failed to provide RNA services for six of six residents reviewed (Residents 2, 3,12, 26, 27, 28). This failure had the potential to cause: 1. A reduction in range of motion (ability to move and use joints) for six residents. 2. An increase in contractures due to splints not being used for three residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to document administration of a controlled medication (a medication with a high potential for abuse) on the Controlled Drug Record for three of unsampled residents (12, 20, 37). As a result, there was a potential risk for diversion (theft) of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Medications were stored and labeled according to the manufacturer's specifications and policy. 2. Medications were disposed appropriately. As a result, the facility could not ensure medications were safely stored to ensure their integrity.

Inspectors wroteBased on interview and document review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) when: - The facility's pressure injury (a localized damage to the skin and underlying soft tissue usually over a bony area) data was not analyzed to identify trends. - A root cause analysis (a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) was not attempted to identify cause of acquired pressure injuries in the facility. (Refer to F 686, F 725)

Inspectors wroteBased on interview and record review the facility failed to promote care in a manner that maintains two of 15 sampled residents (Resident 20 and Resident 17) with dignity and respect when: 1. Resident 20 was inappropriately dressed in a hospital gown and covered with a shower blanket on a stretcher in the nursing hallway for an outside appointment and a urinary catheter bag not covered with a dignity bag (a cover that conceals the urinary catheter bag to promote dignity). 2. Resident 17 was in the shower room with doors wide open exposing Resident 2's feet while being showered by CNA 2. This failure had potential to violate the Resident 20's and Resident 17's rights for respect and dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 12) was assessed and provided with the appropriate call light type to call staff when needed. This failure increased the risk for Resident 12 to experience psychological and physical harm (banging on bed rails)with needs not addressed appropriately.

Inspectors wroteBased on observation, interview, record review, and document reviews, the facility failed to ensure a low air loss mattresses (LAL - an air flow mattress used to prevent skin breakdown by distributing weight over the mattress to reduce pressure to the skin) were set according to the physician's order for one of six residents (Resident 30) reviewed for pressure ulcer. These failures increased the risk for skin breakdown for all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide enough staff to meet the needs of three of six residents (Resident 26, 27, 28) reviewed for basic nursing care and RNA services. As a result, three residents did not receive RNA services as prescribed by a physician and were not positioned according to the posted facility turning schedule.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.45%. Two medication errors were observed out of 31 opportunities, during the medication administration process for two of three randomly observed residents (Resident 3, 17, 39). As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training (prior to assuming the role of the Infection Preventionist) in Infection Prevention and Control who are responsible for the facility Infection Control Program. This failure had the potential to cause a decline in Infection Control practices in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post actual staffing hours for four of four days. This failure resulted in the total number of staff and actual hours worked by staff not accessible to residents and visitors.

Inspectors wroteBased on observation, interview and record review the facility failed to reconcile, dispose, and account for a discontinued controlled medication (medications that are regulated by the government due to the likelihood for being misused and high risk for abuse) to prevent drug diversion (the illegal distribution or abuse of prescription drugs) for one resident (Resident 1). As a result of this deficient practice, six tablets of the controlled medication went missing, and there was an inaccurate count of the controlled medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a safe/sanitary manner and in accordance with acceptable standards of practice when: 1. Spoiled produce was stored among non-spoiled produce. 2. Salad dressings that required refrigeration were stored unrefrigerated. 3. Personal food items were stored in the main kitchen refrigerators and dry storage room. 4. Bread and biscuit mix were not properly labeled/dated. Failure to ensure safe food storage operations may result in exposing resident food to cross contamination and bacterial growth which may result in foodborne illness. Foodborne illness may further compromise the medical and nutritional status of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 14 residents (Resident 42) was treated with respect and dignity when the resident had his head shaved without consent. This failure had the potential for Resident 42 to experience shame and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 14 residents (Resident 392 and 37) were evaluated for the need of hand mitts (a type of physical restraint that covers a person's entire hand and limits the ability to grasp and use fingers) and had physician's orders for hand mitts prior to the use of the physical restraint. In addition, there was no documentation Resident 392 and 37 were being monitored for proper body alignment, neurocirculatory compromise, and other safety issues while the physical restraint was in use. These deficient practices had the potential to negatively impact Resident 392 and Resident 37's well-being while restrained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 residents (Resident 392) reviewed for care plans, had a written care plan that was individualized and resident specific for the use of a hand mitt (a type of physical restraint that covers a person's entire hand and limits the ability to grasp and use fingers). This failure had the potential for Resident 392's care and safety needs to not be met while being physically restrained (Cross reference F604 #1).

Inspectors wroteBased on observation, interview, and record review, the facility did not assure that 1 of 14 residents received accurate daily assessments of their medical condition when Resident 1 went to the hospital for pulmonary edema (fluid in the lungs). As a result, Resident 1 potentially suffered from difficulty breathing.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a physician's ordered amount of enteral (tube) feeding (liquid food provided via tube) was followed for one of seven residents (Resident 37) reviewed for tube feeding. As a result, Resident 37 had a potential to have protein-calorie malnutrition (a form of malnutrition where there is lack of dietary protein and/or calories) and unplanned weight loss while receiving nutrition via tube feeding.

Inspectors wroteBased on observation, interview, and record review for 1 of 14 residents the facility failed to ensure that Resident 14 was sufficiently assessed for the use and side effects of her psychotropic drug treatment. This created the potential for Resident 14 to experience side effects that affected her mood and level of independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. The facility's medication error rate was 8.33%. Three medication errors were observed, with a total of 36 opportunities, during the administration process for one of 3 randomly observed residents ( Resident 37). As a result, the facility failed to ensure medications were administered correctly to Resident 37.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses (LN) documented insulin (injectable hormone that regulates blood sugar) administration for one of 14 residents (Resident 12), reviewed for documentation. As a result of this deficient practice, it could not be determined if Resident 12 consistently received insulin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control processes were followed when : 1) Hand hygiene (washing hands with soap and water or using an alcohol-based hand rub) was not performed according to CDC hand hygiene guidelines. 2) Licensed Nurse (LN) 17 entered a contact isolation room (required personal protective equipment such as gloves and gowns when entering to prevent the spread of infection) and placed a notebook from her pocket on Resident 37's side table and then placed it back into her pocket. As a result, residents were at risk for healthcare acquired infections.