Somerset Woods Rehabilitation & Nursing Center

Inspectors wroteComplaint #: NJ 168006 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) implement their abuse policy and ensure residents were protected from sexual abuse after a cognitively intact resident (Resident #155) made an allegation of rape on 9/30/23, and was sent to the hospital for evaluation. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #155). A review of a Nursing Note dated 9/30/23, revealed that Resident #155 was in bed with their Resident Representative (RR #1) at bedside, when the resident reported to the Registered Nurse (RN #1) that they were raped. The note further indicated that the resident, without RR #1 or RN #1's knowledge, had called the local police to report the rape. [...]

Inspectors wroteComplaint #: NJ 168006 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) a.) an allegation of sexual abuse for a cognitively intact resident (Resident #155) who reported being raped. This deficient practice was identified for 1 of 2 residents reviewed for abuse. A review of a Nursing Note dated 9/30/23, revealed that Resident #155 was in bed with their Resident Representative (RR #1) at bedside, when the resident reported to the Registered Nurse (RN #1) that they were raped. The note further indicated that the resident, without RR #1 or RN #1's knowledge, had called the local police to report the rape. RN #1 documented that they spoke to the physician who ordered the resident to be transferred to the hospital for evaluation. [...]

Inspectors wroteComplaint #: NJ 168006 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) implement their abuse policy and investigate an allegation of sexual abuse for a cognitively intact resident (Resident #155) who reported being raped. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #155). A review of a Nursing Note dated 9/30/23, revealed that Resident #155 was in bed with their Resident Representative (RR #1) at bedside, when the resident reported to the Registered Nurse (RN #1) that they were raped. The note further indicated that the resident, without RR #1 or RN #1's knowledge, had called the local police to report the rape. RN #1 documented that they spoke to the physician who ordered the resident to be transferred to the hospital for evaluation. [...]

Inspectors wroteComplaint #: NJ 168006 Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by ensuring a.) an allegation of rape was thoroughly investigated and reported to the New Jersey Department of Health (NJDOH) for Resident #155. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #155). 1. Resident #155, who was cognitively intact with diagnoses which included but not limited to; depression (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities) and heart failure (a condition in which the hear does not pump blood as well as it should). [...]

Inspectors wroteCOMPLAINT #: NJ 169737, NJ 171801 Based on observations, interviews, record review and review of pertinent facility documents it was determined that the facility failed to ensure timely care to resident's dependent on staff for care. This was a.) observed for 1 of 3 residents reviewed for activities of daily living (ADLs) Resident #22 who required incontinence care and b.) revealed during a resident council meeting for 7 of 8 residents (Resident's #9, #13, #15, #44, #61, ##73 and 80) in attendance. This deficient practice was evidenced by the following: 1. On 1/23/25 at 11:12 AM, Surveyor #1 observed Resident #22 in bed. Upon entering the room, there was a strong foul odor. The resident stated they rang the call bell for staff to change their brief as the resident stated they soiled themselves. [...]

Inspectors wroteCOMPLAINT #: NJ 169737, NJ 171801 Based on observations, interviews, record review and review of pertinent facility documents it was determined that the facility failed to provide adequate staff to answer call bells and ensure residents were provided with timely care. This included a.) incontinence care for 1 of 3 residents reviewed for activities of daily living (ADLs) (Resident #22), and b.) 7 of 8 residents who attended a resident council meeting with a state surveyor (Resident's #9, #13, #15, #44, #61, #73 and #80). This deficient practice was evidenced by the following: Refer to F 677 Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot and cold foods served to the residents. This deficient practice was identified for 7 of 8 residents (need Resident #s?) interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 1/30/25 for 1 of 3 nursing units tested for food temperatures by two surveyors and was evidenced by the following: On 1/24/25 at approximately 11:00 AM, the surveyor met with eight residents for a resident council meeting. Seven out of eight residents stated that hot food temperatures were unacceptable. On 1/30/25 at 12:39 PM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. [...]

Inspectors wroteBased on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 8 of 8 (Resident's #9, #13, #15, #44, #49, #61, #73 and #80) residents during the resident council meeting and was evidenced by the following: On 1/24/25 at approximately 11:00 AM, the surveyor conducted a group meeting with eight residents who were alert and oriented and selected by the facility to participate. Seven out of eight residents stated they did not receive snacks in the evening. Two residents stated they were never offered evening snacks (Resident #13 and #61). [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 1 residents reviewed for hospice (Resident # 4). This deficient practice was evidenced by the following: On 1/23/25 at 10:36 AM, the surveyor observed Resident #4 lying in bed. The resident denied any complaints or issues. A fall mat was noted on right side of bed. A review of Resident #4's admission record revealed that the resident had diagnoses which included but not limited; [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) provide lunch menu items in accordance to resident preferences, meal tickets and physician orders (PO) for 2 of 3 residents (Resident #31 and #62), and b.) provide fortified mashed potatoes (super mashed) at lunch for 1 of 3 residents (Resident #62) reviewed for food. This deficient practice was evidenced by the following: On 1/24/25 at 12:15 PM, the surveyor observed Resident #62 in their room, groomed and seated in a wheelchair with an overbed table over their lap area. There was yogurt in a plastic cup, a liquid supplement and a six-ounce (oz) [name redacted] juice on the table. The resident's representative was present, and the surveyor interviewed them in the presence of a second surveyor. [...]

Inspectors wroteBased on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to provide the correct diet consistency according to physician's orders (PO). This deficient practice was identified for 1 of 3 residents (Resident #62) reviewed for food and evidenced by the following: On 1/24/25 at 12:15 PM, the surveyor observed the resident groomed and seated in a wheelchair with an overbed table over their lap area. There was yogurt in a plastic cup, a liquid supplement and a six-ounce (oz) [name redacted] juice on the table. The resident's representative was present, and the surveyor interviewed them in the presence of a second surveyor. The resident's representative stated the resident had a PO for a puree diet. The surveyor reviewed the electronic medical record for Resident #62. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident's dignity was maintained during an enteral tube feeding (a flexible feeding tube placed into the stomach for nutrition) for 1 of 1 residents (Resident # 21) reviewed for tube feeding. This deficient practice was evidenced by the following: On 09/23/23 at 2:21 PM, the surveyor observed Resident # 21's room door open. The resident was awake out of bed and seated in a Geri chair (large padded reclining chair on wheels) in the center of the room and which faced the opened door. A Registered Nurse (RN) was administering a bolus enteral feeding via the gastronomy tube (an opening into the stomach from the abdominal wall, made surgically and used to insert a tube to provide a route for tube feeding). [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to develop and implement a comprehensive care plan for 2 of 3 residents (Resident # 46 and Resident # 48 ) reviewed for behaviors. This deficient practice was evidenced by the following: 1. On 09/20/23 at 12:45 PM, the surveyor observed Resident # 46 awake and seated in a wheelchair in the main dining room for lunch. The resident was screaming and yelling. Staff members were in the dining room attempting to calm and redirect the resident's behavior. On that same day at 12: 49 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated, this is the usual behavior for the resident. She further stated, in the morning [the resident] is ok, no behaviors it starts in the afternoon. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations for 1 of 5 residents (Resident #96) reviewed for unnecessary medications. The deficient practice was evidenced by the following: On 9/21/23 at 12:10 PM, the surveyor observed Resident #96 in bed with their eyes closed. The surveyor reviewed Resident #96's medical records. [...]