Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Somerset Ridge Center during CMS and state inspections, most recent first.
A resident with esophageal obstruction and GERD was discharged from the hospital with pantoprazole 40 mg BID, and a later consulting physician also documented the same dose. However, the MAR showed the resident received pantoprazole 20 mg BID instead, and the chart did not show that the higher dose had been clarified or declined. Nursing staff and the DON confirmed the resident should have been receiving 40 mg BID.
Medication Error Rate Exceeded 5%: During a med pass observation, an LPN made 2 errors in 35 opportunities, resulting in a 5.71% error rate. One resident received the wrong magnesium medication and dose instead of the ordered tablet, and another resident received only one lidocaine patch in the wrong location instead of two patches ordered for the bilateral rib cage. Both errors were signed off on the MAR as administered.
A facility failed to follow infection control practices for three residents. An AD entered a resident’s room under contact precautions without hand hygiene or PPE and removed a meal tray, while an RN/LPN failed to perform hand hygiene before and after medication administration for two residents. During one medication pass, the nurse applied a lidocaine patch and gave a heparin injection without proper hand hygiene and with incomplete glove use, then handled the med cart computer.
Failure to complete SCSA for significant change and hospice transition: Two residents did not receive required SCSA MDS assessments. One resident with dementia had major changes in cognition, ADLs, diet, mobility, decision-making, and significant weight loss, but no SCSA was completed. Another resident with Alzheimer's disease changed from one hospice provider to another while remaining in the facility, and staff confirmed no SCSA was done.
A resident with a history of diabetes and post-procedural pain was given hydrocodone-acetaminophen outside the prescribed parameters in a LTC facility. The medication, intended for pain levels of 7-10, was administered multiple times for lower pain levels, as acknowledged by both the resident and nursing staff. The DON confirmed the importance of adhering to physician orders due to associated risks.
A facility failed to monitor a resident's insulin administration and blood glucose levels, resulting in multiple instances of low blood sugar without proper documentation or physician notification. The resident, with a history of diabetes and renal disease, had several blood glucose readings below 70 mg/dL, but the facility did not document monitoring or follow-up actions as required by their diabetes management policy. Interviews revealed that necessary orders for monitoring and treatment were not entered, and there was no record of physician communication regarding the low readings.
Two residents in a facility were found to have deficiencies in respiratory care due to improper maintenance and storage of equipment. One resident's nebulizer mask and nasal cannula tubing were not stored in a sanitary manner, while another resident's oxygen concentrator was dusty and the tubing was not changed as required. Staff interviews confirmed that the facility's infection control policies were not followed, leading to unsanitary conditions.
A nurse improperly stored unlabeled medications in a narcotic drawer after a resident refused them, instead of disposing of them immediately. The Unit Manager and DON confirmed that the medications should not have been stored without proper packaging.
A resident receiving IV Vancomycin for an infection had incomplete medical records due to a nurse's failure to document the administration of a dose, leading to inaccuracies in the MAR. Additionally, the facility did not document physician notification of side effects from the resident's antipsychotic medication, resulting in incomplete records. The physician confirmed awareness of the symptoms but had not provided documentation of his evaluation.
During a COVID-19 outbreak, staff at the facility failed to follow proper testing procedures, leading to potential false results. Observations showed that two staff members did not adhere to the manufacturer's instructions for the CorDx rapid antigen test, including incorrect swab rotations and premature result reading. The Infection Preventionist confirmed these deviations, which could result in inaccurate test outcomes.
A facility failed to complete and transmit a discharge MDS assessment for a resident, resulting in a 137-day delay. The resident, who had multiple diagnoses including Alzheimer's and a femur fracture, was discharged without the required assessment being encoded and transmitted. This deficiency was confirmed during a review and interview with the MDS Coordinator.
The facility failed to develop and implement comprehensive care plans for three residents, resulting in deficiencies in their care. One resident lacked a smoking safety care plan despite being an active smoker. Another resident was prescribed an antidepressant for agitation without a corresponding care plan. A third resident, requiring supervision while eating due to dysphagia, was observed eating alone without supervision. Staff interviews confirmed the absence of necessary care plans and supervision.
A resident with dry eyes and insomnia did not receive proper eye drop administration due to a nurse's failure to follow the facility's protocol, which requires a three to five-minute interval between different eye drops. The nurse was unaware of this requirement, leading to ineffective medication absorption.
A resident admitted in December 2023 did not receive a monthly medication regimen review in March 2024. The resident's medical record showed reviews for February, April, and May 2024, but not for March. The DON confirmed the omission, and the consultant pharmacist noted the resident's unit switch on the review day as the cause.
A facility failed to ensure medications were administered under direct supervision, as observed with a resident who was left with Cholestyramine Light Oral Powder unattended at their bedside. The resident, who was cognitively intact and had no order to self-administer medications, confirmed that staff routinely left the medication with them, and they often did not consume it all. The DON acknowledged that medications should not be left unattended.
Failure to Implement Ordered Pantoprazole Dose
Penalty
Summary
The facility failed to ensure medication recommendations after a hospitalization and an office visit were implemented as ordered for Resident #124, who had diagnoses including esophageal obstruction and GERD. The resident returned to the facility after hospitalization, and the hospital discharge summary indicated pantoprazole 40 mg by mouth twice daily before breakfast and dinner. The medication reconciliation form listed pantoprazole 40 mg twice daily as continued on discharge, and the physician progress note on readmission documented that new medication orders were sent to and reviewed by the physician. Subsequent records showed the resident was instead receiving pantoprazole 20 mg by mouth twice daily on the MAR for September through December 2025. A consulting physician’s after-visit summary later again documented pantoprazole 40 mg twice daily before breakfast and dinner, but the progress notes did not show that the dose had been clarified. Interviews with nursing staff and the DON confirmed the resident should have been receiving pantoprazole 40 mg twice daily, and the Unit Manager stated there was no documented evidence that the recommendation for the 40 mg dose had been declined.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when one of three nurses observed during medication pass made 2 errors out of 35 opportunities, resulting in a 5.71% medication error rate. The report states that the errors affected two residents and that the nurse administered medications that did not match the physician's orders. For one resident admitted with moderate protein-calorie malnutrition and hypertensive heart disease, the nurse prepared and administered magnesium oxide 400 mg instead of the ordered magnesium oral tablet 250 mg, and the MAR was signed off as given. The nurse later stated he administered the wrong medication and dose. For another resident admitted with multiple rib fractures and thoracic vertebral compression fractures, the nurse applied one lidocaine 4% patch to the middle upper back instead of applying two patches to the bilateral rib cage as ordered, and the MAR was also signed off as administered. The nurse later stated he applied the patch to the wrong location and failed to apply the ordered two patches.
Infection Control and Hand Hygiene Failures During Resident Care and Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents. The facility’s policies required standard precautions, hand hygiene before and after resident contact and before and after aseptic tasks, safe injection practices, and use of transmission-based precautions, including contact precautions with hand hygiene and PPE when indicated. Staff education also stated that contact precautions required hand hygiene before entering and when leaving the room, and that gloves and gowns must be worn in the room. Resident #3 had diagnoses including MRSA infection, atherosclerosis with gangrene, osteomyelitis of the lower leg, and other specified bacterial agents as the cause of disease. The resident had an active order for contact precautions related to MRSA and cellulitis of the wound. A surveyor observed Activities Director #1 enter the resident’s room without performing hand hygiene or donning gloves and gown, and then exit the room with a food tray that was placed in the food delivery truck without hand hygiene. The resident had a sign posted outside the room identifying contact precautions. During interview, Activities Director #1 stated she did not perform hand hygiene or wear PPE, and Nurse #6 confirmed the resident was on contact precautions for MRSA of the wound and that staff were expected to follow the posted sign. Resident #136 had diagnoses including multiple rib fractures and thoracic vertebral compression fractures and was receiving Lidocaine 4% patches and Heparin injections. A surveyor observed Nurse #4 prepare and administer the medications without performing hand hygiene before or after administration. The nurse applied a Lidocaine patch with an ungloved left hand and administered Heparin with a glove on only the right hand while the ungloved left hand contacted the resident’s abdomen during the injection. The nurse then disposed of the syringe, did not perform hand hygiene, and typed on the medication cart computer. Resident #134 was also observed receiving medications from Nurse #4 without hand hygiene before or after medication administration, and the nurse then used the computer on top of the medication cart. Nurse #4 stated he did not perform hand hygiene before and after medication administration for both residents.
Failure to Complete SCSA for Significant Change and Hospice Transition
Penalty
Summary
The facility failed to identify a significant change in condition and complete a Significant Change in Status Assessment (SCSA) MDS assessment for a resident with dementia who experienced multiple changes in status. The resident was admitted with dementia and later had a severe cognitive deficit, was dependent on staff for eating, could not attempt walking 10 feet due to medical condition or safety concerns, was dependent for toileting transfers, and had an activated HCP. Earlier MDS documentation showed a moderate cognitive deficit, independent eating with set-up and clean-up, the ability to walk with moderate assistance, moderate assistance for toileting transfers, and an HCP that was not activated. Record review and staff interviews showed the resident had a 12.20% weight loss from 108.2 pounds to 95 pounds, a decline in transfer ability, a change from regular texture diet to puree, and a change from standing and walking to using a wheelchair when out of bed. Staff also described a decline over the last four or five months, with reduced participation in activities and a shift from active to passive participation. The MDS nurse reviewed the record and stated the resident should have had an SCSA because of the significant weight loss, change in ADL status, change in mental status, and loss of ability to make his/her own medical decisions, but one was not done. The facility also failed to complete an SCSA for a resident who was discharged from one hospice and admitted to another hospice while remaining in the nursing home. The resident had diagnoses including Alzheimer's disease and was admitted to Hospice A, then discharged from Hospice A and admitted to Hospice B at the request of the HCP. The Director of Social Work confirmed the hospice change, and the MDS nurse stated that when a resident switches from one hospice to another, an SCSA should be completed, but one had not been completed for this resident.
Improper Administration of Pain Medication
Penalty
Summary
The facility failed to administer a schedule II-controlled substance, hydrocodone-acetaminophen, in accordance with the physician's prescribed parameters for a resident. The resident, who was cognitively intact and had a history of type 2 diabetes mellitus with diabetic neuropathy, osteomyelitis, and post-procedural pain, was on a scheduled and as-needed pain medication regimen. The physician's order specified that the medication should be given for a pain scale rating of 7-10. However, the medication was administered multiple times when the resident's pain level was documented as below the prescribed threshold, ranging from 2 to 6 on various occasions in September and October 2024. During interviews, both the resident and the nursing staff acknowledged the administration of the medication outside the prescribed parameters. The resident reported frequent pain in various areas and mentioned taking Tylenol and Norco for relief. Nurse #5 admitted to administering the medication for a pain level of 5, which was not in accordance with the physician's orders. The Director of Nursing confirmed that the medication should be given as per the physician's orders due to the risks associated with improper administration, such as dependence and respiratory depression.
Failure to Monitor Insulin Administration and Blood Glucose Levels
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen for signs and symptoms of adverse consequences related to insulin administration. The resident, who was cognitively intact and had a history of type 2 diabetes mellitus with diabetic neuropathy, end-stage renal disease, and dependence on renal dialysis, was receiving insulin injections as part of their treatment plan. Despite having physician orders to monitor blood glucose levels and report any readings below 70 mg/dL or above 400 mg/dL, the facility did not document any monitoring or follow-up actions for several instances where the resident's blood glucose levels fell below 70 mg/dL. The facility's policy on diabetes management required staff to incorporate monitoring parameters into the Medication Administration Record (MAR) and care plan, and to notify the physician of any significant changes in blood sugar levels. However, the September 2024 MAR and Treatment Administration Record (TAR) lacked documentation of monitoring for adverse consequences related to insulin medications. Interviews with the resident, a nurse, and the Director of Nursing (DON) revealed that the necessary orders for hypo/hyperglycemia monitoring and treatment were not entered into the system, and there was no documentation of physician notification or treatment orders for the low blood sugar readings. The attending physician, who was familiar with the resident, confirmed that there was no documentation of the low blood sugar readings or any symptoms of hypoglycemia in the medical record. The physician typically provided verbal orders for treatment when notified by nurses, but in this case, there was no record of such communication. The lack of documentation and monitoring for the resident's blood glucose levels constituted a deficiency in the facility's care, as it failed to ensure the resident's drug regimen was free from unnecessary drugs and adverse consequences.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents, leading to deficiencies in maintaining sanitary conditions for respiratory equipment. For Resident #86, the facility did not ensure that the nasal cannula tubing and nebulizer mask/tubing were stored in a sanitary manner. Observations revealed that the nebulizer mask/tubing was not covered or contained within a bag, and the nasal cannula tubing was wrapped around the oxygen concentrator instead of being stored in a bag when not in use. Despite the facility's policy requiring weekly changes and proper storage of respiratory equipment, these practices were not followed. Resident #86, admitted with diagnoses including Post-Polio Syndrome and asthma, was observed using respiratory equipment that was not maintained according to the facility's infection control policies. The resident, who was cognitively intact, reported using the nebulizer as needed for shortness of breath. However, the equipment was not stored properly, increasing the risk of contamination. Interviews with nursing staff confirmed that the equipment should have been stored in a bag and changed weekly, but these procedures were not adhered to. Similarly, for Resident #11, the facility failed to maintain sanitary conditions for the nasal cannula tubing and oxygen concentrator. The resident, who had bronchiectasis and asthma, was observed using oxygen equipment that was dusty and not cleaned as required. The nasal cannula tubing was not changed weekly as per the physician's orders, and the oxygen concentrator was not wiped down or maintained properly. Interviews with the unit manager and the director of nursing revealed that the equipment maintenance procedures were not followed, resulting in unsanitary conditions for the resident's respiratory care.
Improper Storage of Unlabeled Medications
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional standards of practice. During a morning medication pass, a nurse poured medications for a resident, including Loratadine, Oxycodone, and Zofran, into a single medication cup. The resident, feeling nauseous, only accepted the Zofran and refused the other medications. The nurse then placed the remaining medications, which were unlabeled, into the narcotic drawer of the medication cart instead of disposing of them immediately. The nurse was unsure of the proper procedure for handling the refused medications and sought guidance from the Unit Manager. Upon consultation, the Unit Manager confirmed that the medications should not have been stored in the cart unlabeled and proceeded to destroy them. The Director of Nursing later confirmed that the medications should have been disposed of immediately after the resident's refusal, rather than being returned to the cart without proper packaging.
Deficiencies in Medical Record Documentation and Physician Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to deficiencies in documenting the administration of intravenous antibiotics and physician notification of medication side effects. The resident, who was admitted with diagnoses including malignant neoplasm of the bone, obsessive-compulsive disorder, and agoraphobia, was receiving intravenous Vancomycin for a methicillin-resistant staph aureus infection. However, the medication administration record (MAR) did not accurately reflect the administration of the IV antibiotics, as a nurse failed to document the administration of a dose on the MAR, leading to an inaccurate record of missed doses. Additionally, the facility did not ensure that the medical record reflected physician notification of an acute change in potential medication side effects. The resident was on Aripiprazole for mood stability, and side effects were identified on several occasions. However, there was no documentation that the physician or nurse practitioner was notified of these new symptoms, nor was there evidence of a follow-up assessment by the physician. The physician later confirmed that he was aware of the symptoms and had evaluated the resident but had not provided documentation of this visit to the facility. The lack of documentation and communication between the nursing staff and the physician resulted in incomplete medical records, which could lead to inaccurate information being communicated to providers making medical decisions. The facility's policies on charting and documentation, as well as acute condition changes, were not adhered to, contributing to the deficiencies observed during the survey.
Improper COVID-19 Testing Procedures During Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, as evidenced by improper COVID-19 testing procedures conducted by staff. The Director of Nursing confirmed the outbreak, with 13 residents testing positive on the Pottersville Unit. The Infection Preventionist stated that staff were testing daily before their shifts, following guidance from the CDC, Massachusetts DPH, and CMS. However, observations revealed that staff did not adhere to the manufacturer's instructions for the CorDx rapid antigen COVID-19 test, which could lead to false results. Specifically, two staff members, Rehabilitation Services Staff #1 and Nurse #4, were observed not following the correct testing procedures. Both staff members failed to rotate the swab the required number of times in each nostril and in the solution, and Nurse #4 did not wait the full 10 minutes before reading the test result. Interviews with the staff and the Infection Preventionist confirmed these deviations from the manufacturer's instructions, which are critical for ensuring accurate test results. The Infection Preventionist acknowledged that improper sample collection could result in false negatives, necessitating retesting.
Failure to Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge assessment for a resident, resulting in a significant delay. According to the facility's policy and the CMS Resident Assessment Instrument (RAI) Manual, all Minimum Data Set (MDS) assessments, including discharge assessments, must be completed and transmitted within specific timeframes. However, the discharge MDS for a resident who was admitted in January 2024 and discharged in May 2024 was not encoded and transmitted, leading to a 137-day delay. The resident involved had multiple diagnoses, including mild cognitive impairment, Alzheimer's disease, cerebral infarction, syncope, left femur fracture, muscle wasting and atrophy, and generalized anxiety. The deficiency was identified during a record review and interview with the MDS Coordinator, who acknowledged that the discharge assessment was not completed and transmitted as required by OBRA regulations.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. For one resident, the facility did not create a care plan for smoking safety, despite the resident being an active smoker and having been assessed as such upon admission and quarterly. The resident's care plans and Kardex did not reflect their smoking status, and staff interviews confirmed the absence of a smoking safety care plan. Another resident was prescribed an antidepressant for agitation, but the facility did not develop a care plan to address the use of the medication or the management of the resident's agitation. The resident's care plans and Kardex did not mention any agitation behaviors, and staff interviews revealed that care plans for the antidepressant use and agitation management were missing. The third resident required supervision while eating due to dysphagia, but the facility failed to implement the care plan for supervision during meals. Observations showed the resident eating alone without supervision, and staff interviews indicated a lack of awareness of the resident's supervision needs. The DON confirmed that the resident should have been supervised during meals, but this was not consistently implemented.
Failure to Follow Eye Drop Administration Protocol
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice in the administration of eye medications for a resident diagnosed with dry eyes and insomnia. The facility's policy on the instillation of eye drops, revised in January 2014, requires a waiting period of three to five minutes between administering different eye drops to ensure proper absorption and effectiveness. However, during an observation, a nurse administered two different eye medications consecutively without allowing the required time for absorption. The resident involved was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The nurse, identified as Nurse #3, was observed administering Restasis followed immediately by Artificial Tears without the necessary waiting period. In an interview, Nurse #3 admitted to being unaware of the required time frame between administering different eye drops. The Director of Nursing confirmed the necessity of the waiting period, explaining that failure to do so renders the medications ineffective.
Missed Monthly Medication Review for a Resident
Penalty
Summary
The facility failed to ensure a monthly medication regimen review was completed for a resident admitted in December 2023. The medical record for this resident included reviews for February, April, and May 2024, but lacked documentation of a review for March 2024. During interviews, the Director of Nurses confirmed that the March 2024 pharmacy reports did not include this resident, either with or without recommendations. The consultant pharmacist explained that the resident had switched units on the day of the monthly reviews, resulting in the omission of the review for March 2024.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered under direct supervision and not left unattended at the bedside, as observed with one resident. Nurse #3 prepared the resident's 8:00 A.M. medication, Cholestyramine Light Oral Powder, mixed it with water, and placed it on the resident's bedside table. The nurse instructed the resident to drink the medication and then exited the room, leaving the medication unattended and unsecured. This action was contrary to the facility's policy, which requires nursing staff to remain with the resident until all medications have been taken. The resident involved was admitted to the facility with a diagnosis of hyperlipidemia and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The resident did not have a care plan or physician's order to self-administer medications. During an interview, the resident confirmed that the nursing staff routinely left the medication with them alone, and they often did not consume it all due to disliking the taste. The Director of Nursing acknowledged that medications should not be left unattended and that the resident did not have an order to self-administer medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Somerset
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clifton Rehabilitation Nursing Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Fall River Healthcare | 1.3 mi | ★★★★★ | 14 | 0 |
| Fall River Jewish Home | 1.8 mi | ★★★★★ | 0 | 0 |
| Catholic Memorial Home | 1.8 mi | ★★★★★ | 2 | 0 |
| Kimwell Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.