Somerset Ridge Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF725Apr 21, 2022

  Based on observation, interview, and schedule review, the facility 1. Failed to ensure there was sufficient staff available to provide nursing services and care required to meet the residents needs; and 2. Failed to ensure there was sufficient clinical staff to assure resident safety for one Resident (#93). Findings include: 1. During an interview on 4/12/22 at 3:30 P.M., the Ombudsman said the family members of residents had been complaining about the facility not having enough staffing and not replacing staff when there was a call-out, especially in the evenings. On 4/14/22 at 11:00 A.M., the surveyor held a group meeting with 10 residents in attendance. During the meeting, residents said there were not enough staff working on the units and sometimes on the 3:00 P.M. to 11:00 P.M. […]

• Immediate jeopardy, patternF580Apr 21, 2022

  Based on interview and record review, the facility failed to immediately notify and consult with the physician that significant medications were not administered to 34 of 39 residents and treatments were not administered for 7 of 39 residents on the [NAME] Unit on 7/10/22 to potentially alter or commence a new course of treatment resulting in the likelihood of serious outcomes and specifically, for one Resident (#1 A) requiring an extended duration of intravenous (IV) antibiotic therapy and an extended stay at the facility. It was determined the Immediate Jeopardy began on 7/10/22 and was identified on 7/15/22. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 7/15/22, including the Immediate Jeopardy Templates. […]

• Immediate jeopardy, patternF658Apr 21, 2022

  Based on observation, record review, policy review, and interview the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for 10 Residents (#12, #20, #52, #82, #107, #258, #94, #259, #108, and #109), out of a total sample of 30 residents. Specifically, the facility failed 1. For Resident #12, to obtain a physician's order for the administration of eye drops. 2. For Resident #20, to ensure that a treatment recommendation from a consultant was addressed by facility staff or the Physician, and a follow up appointment was made. 3. For Resident #52, to: a. Ensure the physician's order for the Resident being-1:1 (one to one) feed (order dated [DATE]) was implemented. b. […]

• Immediate jeopardy, patternF760Apr 21, 2022

  Based on record review and interview, the facility failed to: 1.) Ensure that 34 of 39 residents on the [NAME] unit were administered significant medications as ordered on 7/10/22 resulting in the likelihood of significant adverse outcomes to the residents, including 2.) Resident #1G for which the facility failed to administer pain medication as prescribed resulting in the Resident experiencing pain at an 8 on a 0-10 pain scale (with zero being none and 10 being the worst pain ever felt in their life) without relief or intervention until 10:00 P.M.; 3.) Provide ordered intravenous antibiotics to Resident #1A, resulting in an extension of both the duration of the antibiotic and the Resident's stay in the facility; and 4.) In addition, the facility failed to ensure Resident #95 was… […]

• Immediate jeopardy, patternF835Apr 21, 2022

  Based on observation, interview, record review and policy review, the facility failed to utilize resources effectively and failed to ensure resident care attained or maintained the highest practicable physical, mental, and psychosocial well-being for each resident. Findings include: The facility failed to: a. Adequately address concerns brought to their attention from the Resident Council: On 4/14/22 at 11:00 A.M., the surveyor held a group meeting with 10 residents in attendance. […]