Somerset Post Acute Care

In the surveyor’s words

From the most serious findings on record at Somerset Post Acute Care, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 21, 2024

  Based 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. Findings: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure; subdural hemorrhage (bleeding in the brain); anoxic brain damage (lack of oxygen to the brain); tracheostomy (a surgical opening in the neck to help air and oxygen reach the lungs, and sepsis (a serious… […]

• Actual harm, isolatedF689May 26, 2023

  Based on interview and record review, the facility failed to prevent an avoidable accident for one of three residents (Resident 1), when: - 1:1 supervision (one staff assigned to provide continuous supervision to a resident) was not provided when Resident 1 was agitated and pulling on her trach (tracheostomy tube/breathing tube) collar (device that secured a trach in position). - Resident 1 ' s cognitive impairment and behavior was identified, but was not evaluated, analyzed, or care planned with resident-specific interventions to meet the resident ' s behavioral, and supervision needs. […]

• Actual harm, isolatedF689Nov 11, 2022

  Based on observation, interview, and record review, the facility failed to prevent a resident, Resident 1, from falling out of bed while having a [CONDITION(S)] (a sudden, uncontrolled surge of electrical activity in the brain, resulting in uncontrolled muscle and body movements) when, A) Resident 1 was left unattended with the bed in a high position, at an unsafe level. B) Certified nurse's assistants (CNAs) were not trained on procedures to protect the resident during a [CONDITION(S)]. As a result, Resident 1 suffered a fractured ankle and head trauma and required transfer to the hospital. […]

• No harm, potential for more than minimal, patternF583Apr 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF584Jan 7, 2026

  Based 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.Findings:On 1/6/26 at 1:19 P.M., an interview was conducted with the Maintenance Director (MNTD). The MNTD stated roofing contractors visited the facility on Friday (1/2/26) due to the heavy rain which had occurred on 12/26/25. […]