Somerset Ridge Center

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide services that met professional standards of practice for one Resident (#124,) out of 24 sampled residents and one of two closed records. Specifically, the facility failed to ensure medication recommendations, after a hospitalization and an office visit, were implemented as recommended.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of three nurses observed during the medication pass made two errors out of 35 opportunities, resulting in a medication error rate of 5.71%. Those errors impacted two Residents (#134 and #136). Findings Include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated and revised April 11, 2018, indicated but was not limited to the following: Nurses Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for three Residents (#3, #134, #136), out of a total of seven residents. Specifically, the facility failed:1. For Resident #3, to implement personal protective equipment (PPE) for Transmission-Based Precautions when entering the Resident's room;2. For Resident #134, to follow hand hygiene procedures prior to handling medication(s) and after administering medication(s); and3. For Resident #136, to implement PPE, safe injection practices, and hand hygiene procedures prior to handling medication(s) and after administering medication(s).

Inspectors wroteBased on record reviews and interviews, the facility failed to identify a significant change in condition and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment for two Residents (#11 and #25), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #11, to identify a significant change in his/her condition and complete a SCSA; and2. For Resident #35, to complete a SCSA when he/she was discharged from Hospice A and admitted to Hospice B.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for one Resident (#61), out of a total sample of 23 residents. Specifically, the facility failed to ensure a schedule II-controlled substance (hydrocodone-acetaminophen, high potential for abuse) medication to treat pain was administered to the Resident within parameters as ordered by the physician.

Inspectors wroteBased on record review and interview, the facility failed to monitor for signs and symptoms of adverse consequences (i.e., side effects) of medications for one Resident (#61), out of 23 sampled residents. Specifically, the facility failed to monitor for signs and symptoms of hypoglycemia and hyperglycemia (low and high blood sugars) with the administration of insulin (anti-diabetic injectable medication).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary respiratory care and services for two Residents (#86 and #11), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #86, to ensure nasal cannula (device that delivers extra oxygen (O2) through a tube into the nose) tubing and nebulizer mask/tubing (device that delivers aerosolized medication through tubing into the mouth and nose) was maintained to ensure sanitary conditions and decrease the risk of potential contamination by germs; and 2. For Resident #11, to maintain sanitary conditions of nasal cannula tubing and O2 equipment to help decrease the risk of potential contamination and exposure of infection to the Resident.

Inspectors wroteBased on observation, document review, and interview, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to store drugs and biologicals in accordance with accepted professional standards of practice until time of disposal, on one of three units.

Inspectors wroteBased on document review and interview, the facility failed to maintain complete medical records to accurately reflect the care of one Resident (#111), out of a total sample of 23 residents. Specifically, the facility failed to: 1. Document an administered dose of intravenous antibiotics (IV ANTBX) on the medication administration record (MAR) to reflect the date and time it was received; and 2. Ensure the medical record reflected physician notification of an acute change in potential medication side effects and the physicians follow up assessment to the presence of the condition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to ensure staff rapid antigen COVID-19 testing (CorDx) was conducted in a manner that is consistent with current standards of practice and manufacturer's instructions for use for two of three staff members observed.

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge assessment to ensure timely coding and transmitting of a Minimum Data Set (MDS) assessment for one Resident (#80), out of one resident assessment reviewed, resulting in a 137-day delay in the encoding and transmission of a MDS post-discharge from the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to develop and implement comprehensive person-centered care plans for three Residents (#84, #107, and #77), out of a sample of 24 residents. Specifically, the facility failed to: 1. For Resident #84, to develop and implement a care plan for resident safety with smoking; 2. For Resident #107, to develop and implement a person-centered care plan to address the use of antidepressant medication and behaviors; and 3. For Resident #77, to implement the plan of care for supervision while eating.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to follow professional standards of nursing practice for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to allow adequate time for absorption of eye medication, when administering two eye medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a monthly medication regimen review was completed once per month for one Resident (#52), out of a total of five residents selected for unnecessary medication review.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were administered under direct supervision and not left at the bedside for one Resident (#6), out of a total sample of 24 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had severe cognitive impairment, but could make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 01/19/24, Certified Nurse Aide (CNA) #1 spoke to Resident #1 in a loud, tough, degrading and inappropriate manner during care.