Somerset Nursing and Rehabilitation Facility

In the surveyor’s words

From the most serious findings on record at Somerset Nursing and Rehabilitation Facility, in the surveyor’s own words.

• Actual harm, isolatedF656Apr 17, 2026

  Based 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). The findings include: Review of the facility's policy titled, Care Plan Policy, reviewed on [DATE], revealed the facility would develop and implement a person-centered care plan for each resident to include measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Continued review of the facility's policy revealed each resident's Comprehensive Care Plan was designed to incorporate identified problem areas and risk factors associated with the identified problems. […]

• Actual harm, isolatedF689Apr 17, 2026

  Based 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. The findings include: Review of the facility's policy titled, Falls Policy, reviewed [DATE], revealed the policy was to ensure the facility provided an environment as free from accident hazards as possible, over which the facility had control to prevent avoidable falls/accidents. Review of R1's admission Record revealed the facility admitted the resident on [DATE], with diagnoses of osteoporosis, presence of right artificial hip joint, and dementia. […]

• Actual harm, isolatedF657Feb 3, 2021

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to review/revise the comprehensive care plan for two (2) of three (3) sampled residents (Resident #6 and Resident #8). Review of Resident #8's record revealed on 12/14/2020, a cancerous lesion was removed from the resident's scalp. Staff instructions included not removing the dressing and the resident was to return to the physician three (3) days later. However, the resident was not able to keep that appointment and the facility rescheduled the appointment for 12/23/2020 (9 days after the procedure). The facility failed to obtain any further orders related to the wound and failed review/revise the care plan to reflect the delayed treatment. […]

• Actual harm, isolatedF684Feb 3, 2021

  Based on observation, interview, record review, review of facility policy, and review of information from the Cleveland Clinic and woundsource.com, it was determined the facility failed to provide necessary care and services, in accordance with professional standards of practice and facility policy for one (2) of three (3) sampled residents (Resident #8 and Resident #6). Review of Resident #8's record indicated Physician #1 removed a cancerous lesion from the resident's scalp, as an outpatient procedure on 12/14/2020. According to the record, staff were instructed not to remove the surgical dressing, and the resident was instructed to return to the physician's office on 12/17/2020 for a follow up appointment. […]

• No harm, potential for more than minimal, widespreadF838Aug 11, 2021

  Based 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) The findings included: Review of the Facility Assessment Tool revealed the date of the assessment was 12/07/2020. The assessment did not have the name of the current Administrator or current Director of Nursing (DON) listed as persons who were involved in completing the assessment. Further review of the assessment revealed the section titled Our Resident Profile did not include residents with bariatric needs. […]