Somerset Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Somerset Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF584Jan 28, 2022

  Based on a review of facility policy and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that a safe and comfortable environment was maintained for all residents on the C wing when the temperature outside was dangerously low, creating a situation in which 38 of 38 residents reviewed (Residents 1-38) were placed in Immediate Jeopardy related to low temperatures. Findings Include: Review of the facility policy HVAC Failure, last reviewed January 2021, indicated that in the event of a heating failure residents would be provided with extra blankets and if required, relocated to warmer spaces within the facility. Interview with Resident 1 on January 27, 2022, at 9:51 a.m. revealed that she was cold and could not get warm. […]

• Actual harm, isolatedF689Nov 20, 2024

  Based on review of fire safety plans, clinical records, and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans and emergency evacuation plans for one of seven residents reviewed (Resident 1) who required the use of a mechanical lift for transfers, resulting in a left hip fracture. Findings include: The facility's current Fire Response Plan revealed for emergency removal of a resident from bed when working alone revealed that staff were to slip both arms under the resident's body and pull the resident towards the edge of the bed then drop to their knee nearest the head. […]

• Actual harm, isolatedF689Jul 10, 2024

  Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for one of three residents (Resident 2) reviewed who ingested hand sanitizer, resulting in a blood alcohol level of 0.29. Findings include: Review of the clinical record for Resident 2 revealed that she was a new admission to the facility on [DATE], from the hospital. A progress note for Resident 2, dated June 28, 2024, revealed that report was received from a hospital nurse. The resident was admitted to the hospital on June 19, 2024, for alcohol intoxication, hypotension (low blood pressure), and a fall in which she hit her head. […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2026

  Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety.Findings include: The facility's policy for storage of refrigerated foods, dated February 4, 2026, revealed that refrigerated foods would be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.Observations in the main kitchen on April 13, 2026, at 9:05 a.m. […]

• No harm, potential for more than minimal, widespreadF804Mar 13, 2025

  Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding food quality and palatability, dated February 24, 2025, indicated that food would be palatable, attractive, and served at a safe and appetizing temperature. Food was to be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimize the risk for scalding and burning. Food Committee meeting minutes, dated February 5 and March 7, 2025, revealed that residents complained that food was not served at the proper temperature and the food was cold. […]