🔎 Somerset Healthcare And Rehabilitation Center
Inspection Results
Inspection Overview
Somerset Healthcare And Rehabilitation Center has been cited for a total of 127 deficiencies since we began saving each survey.
In Pennsylvania, the average facility has **42.85 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: D
Assess the resident when there is a significant change in condition
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Scope/Severity: D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Scope/Severity: D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: E
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: E
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
Respond appropriately to all alleged violations.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Scope/Severity: D
Observe each nurse aide's job performance and give regular training.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Scope/Severity: E
Ensure that residents are free from significant medication errors.
Scope/Severity: D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity: E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: E
Observe each nurse aide's job performance and give regular training.
Scope/Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: E
Ensure medication error rates are not 5 percent or greater.
Scope/Severity: E
Ensure that residents are free from significant medication errors.
Scope/Severity: K
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity: D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Scope/Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity: E
Ensure that residents are free from significant medication errors.
Scope/Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Respond appropriately to all alleged violations.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity: E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Scope/Severity: E
Ensure residents have reasonable access to and privacy in their use of communication methods.
Scope/Severity: D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity: D
Assure that each resident’s assessment is updated at least once every 3 months.
Scope/Severity: E
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Scope/Severity: D
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity: E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Scope/Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**