Somerset Woods Rehabilitation & Nursing Center

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policy and protect residents from sexual abuse after a cognitively intact resident made an allegation of rape. The resident, who had a BIMS score indicating cognitive intactness, reported the incident to a registered nurse and subsequently called the police. Despite the seriousness of the allegation, the Director of Nursing (DON) did not investigate or report the incident to the New Jersey Department of Health (NJDOH). The facility's inaction placed all residents at risk for abuse, resulting in an Immediate Jeopardy situation. Additionally, the facility failed to investigate and report an allegation of neglect and intimidation in a timely manner. A resident reported not receiving a requested respiratory treatment and being spoken to in an intimidating manner by staff. Despite the resident's intact cognition and the report being made during a Resident Council Meeting, the Director of Nursing was not made aware of the incident until the surveyor's inquiry. The Activities Director, who was informed of the issue, failed to follow up appropriately, leading to a delay in addressing the resident's concerns. The facility's deficiencies in handling these allegations highlight a breakdown in communication and adherence to established protocols for reporting and investigating abuse and neglect. The lack of timely investigation and reporting of these incidents demonstrates a failure to protect residents from potential harm and ensure their safety and well-being.

Removal Plan

• Investigation started with conclusion completed
• NJDOH and the Ombudsman's office were notified of the allegation
• Employee files of staff scheduled during the incident were reviewed to ensure appropriate background checks
• The Quality Assurance committee reviewed the facility's abuse policy with no revisions
• The LNHA inserviced the DON on the facility's abuse policy, reporting allegations to the LNHA and appropriate authorities
• The DON or designee inserviced all staff in the building on the facility's abuse policy and all staff would be inserviced before their next shift
• The DON interviewed cognitively intact residents for any concerns on abuse
• The DON interviewed designated staff to determine if any residents had made allegations of abuse

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of sexual abuse within the required two-hour timeframe to the New Jersey Department of Health (NJDOH). A cognitively intact resident, identified as Resident #155, reported being raped to a Registered Nurse (RN #1) while in bed with their Resident Representative (RR #1) present. The resident independently called the local police to report the incident, and the police arrived at the facility to speak with the resident. Despite the seriousness of the allegation, the Director of Nursing (DON) did not report the incident to the NJDOH, as required by the facility's abuse policy. The facility also failed to report an allegation of neglect and intimidation involving another resident, identified as Resident #73. This resident, who was cognitively intact, reported experiencing respiratory distress and requested a nebulizer treatment from a Certified Nurse Aide (CNA #1). The treatment was delayed, and the resident felt intimidated by the staff's response. The Activities Director (AD) was informed of the incident during a Resident Council Meeting but failed to report it to the Licensed Nursing Home Administrator (LNHA) or follow up with the DON in a timely manner. Both incidents highlight the facility's failure to adhere to its abuse policy, which mandates immediate reporting and investigation of all allegations of abuse, neglect, or mistreatment. The lack of timely reporting and investigation placed residents at risk of serious harm and resulted in an Immediate Jeopardy situation, as the facility did not ensure the safety and well-being of its residents by promptly addressing and reporting these serious allegations.

Removal Plan

• The allegation was reported to the NJDOH and the Ombudsman.
• An investigation and conclusion was completed immediately for Resident #155.
• The LNHA ensures that all allegations will be reported to the appropriate authorities (NJDOH, Ombudsman, and local police department).
• The DON was re-educated by the LNHA regarding the requirement to report any allegation of abuse or neglect immediately to the LNHA, NJDOH, Ombudsman, and local police department.
• The DON or designee has inserviced all staff currently available in the building regarding reporting allegations of abuse and completion of incident report and investigations.
• Any staff member who has not received the inservice in person or over the phone will not be allowed to work their next scheduled shift until receiving re-education regarding reporting of abuse allegations.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policy and investigate an allegation of sexual abuse reported by a cognitively intact resident. The resident, who had a history of depression and heart failure, reported being raped to a registered nurse while in bed with their representative present. Despite the resident's call to the police and subsequent hospital evaluation, the Director of Nursing confirmed that no investigation was conducted into the allegation, and the incident was not reported to the New Jersey Department of Health. This failure to investigate placed all residents at risk for abuse and resulted in an Immediate Jeopardy situation. Additionally, the facility did not investigate an allegation of neglect and intimidation made by another cognitively intact resident. This resident reported not receiving a requested respiratory treatment in a timely manner and being spoken to in an intimidating manner by a staff member. The resident's concerns were documented in Resident Council Minutes, but the Director of Nursing was unaware of the incident until informed by the surveyor. The Activities Director had emailed the concern to the DON but did not follow up or report it verbally, leading to a lack of investigation. The facility's failure to investigate these allegations of abuse and neglect demonstrates a significant lapse in following their established policies and procedures. The lack of timely and thorough investigations into these serious allegations highlights deficiencies in communication and response protocols within the facility, potentially compromising resident safety and well-being.

Removal Plan

• Initiate an investigation and complete a conclusion
• Report the allegation to the NJDOH
• Reeducate the DON on Investigations/Prevention/Correct Alleged Violations
• Educate all staff on the facility's abuse policies and procedures

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of the facility's abuse policies and procedures, resulting in a serious deficiency. An allegation of rape was reported by a cognitively intact resident, who had diagnoses including depression and heart failure, to a Registered Nurse (RN). The RN documented the allegation and informed the Director of Nursing (DON) and the Registered Nurse Supervisor. However, the facility did not investigate or report the allegation to the New Jersey Department of Health (NJDOH), which posed a serious and immediate threat to resident safety. The deficiency was further compounded by the facility's failure to investigate and report an allegation of neglect and intimidation made by another resident. This resident claimed they did not receive a requested respiratory treatment and were spoken to in an intimidating manner by staff. Despite the Activities Director (AD) sending an email to the DON regarding the allegation, it was not addressed promptly, as the email was sent to a previous director's email address and was not seen in time. The DON acknowledged the oversight but did not take immediate action to investigate or report the incident. Interviews with various staff members, including the Infection Prevention Nurse, Assistant Administrator, and Medical Director, revealed a lack of clarity and communication regarding the reporting and investigation of abuse allegations. The LNHA, who was identified as the abuse officer, admitted responsibility for ensuring that allegations were reported and investigated according to the facility's policy. However, there was no evidence of an investigation into the rape allegation, and the facility's administration failed to follow their established procedures, leading to an Immediate Jeopardy situation.

Removal Plan

• Educated the Administrator regarding Administration.
• Educated the Administrator on the abuse policy including reporting abuse.
• Educated the Administrator on conducting a thorough investigation to ensure resident's safety.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food and drink served to residents were at safe and appetizing temperatures. During a resident council meeting, seven out of eight residents expressed dissatisfaction with the temperature of hot foods. On a subsequent observation, surveyors tested food temperatures during a lunchtime meal service on one of the nursing units. The temperatures recorded for various food items, including milk, canned peaches, mashed potatoes, chicken patty, corn, and coffee, were outside the acceptable range as per the facility's policy. The milk and canned peaches were above the maximum temperature for cold foods, while the hot foods were below the minimum temperature required for hot foods. The Food Service Director (FSD) was unaware of the specific temperature requirements for hot foods upon arrival at the units, although he expected them to be at 150 degrees Fahrenheit. The facility's policy required hot foods to be at or above 135 degrees Fahrenheit and cold foods at or below 45 degrees Fahrenheit. The FSD conducted random test tray audits but did not provide these audits to the Director of Nursing (DON). The facility's policy also required three test trays per week, but the FSD only conducted two to three audits per month. The facility's failure to adhere to its own policies and procedures regarding food temperatures and test tray audits contributed to the deficiency.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide and document nourishing evening snacks for residents when there was more than a 14-hour gap between dinner and breakfast. This deficiency was identified during a resident council meeting where seven out of eight residents reported not receiving evening snacks, and two residents stated they were never offered snacks. Interviews with the Divisional Director of Food Service Operations and the Registered Dietitian confirmed the requirement to provide snacks when there is a long gap between meals, but there was no accountability system in place to ensure snacks were provided. Further interviews with nursing staff revealed a lack of clarity and consistency in the documentation and accountability for snack delivery. The Licensed Practical Nurses and Registered Nurse interviewed were unsure if there was a system to document snack provision unless there was a physician's order. The Director of Nursing confirmed that the electronic medical record did not include evening snack accountability, and she was unaware that documentation was required for all residents, not just those with specific dietary needs. The facility's job descriptions for food service and dietitian roles included responsibilities for ensuring nutritional standards, but these were not being met in practice.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely care to residents dependent on staff for activities of daily living (ADLs), specifically incontinence care. This was observed in the case of a resident who required assistance with changing a soiled brief. The resident activated the call bell for help, and although a nurse initially responded, the resident's needs were not addressed promptly. The resident had to wait approximately 35 minutes before receiving the necessary care, despite the presence of a strong foul odor indicating the need for immediate attention. The resident's medical records indicated frequent incontinence and a need for assistance from two staff members and a mechanical lift for transfers. During the incident, the Licensed Practical Nurse/Unit Manager (LPN/UM) deactivated the call bell without providing assistance or ensuring that another staff member would attend to the resident. The Certified Nurse Aide (CNA) who eventually responded was not the resident's assigned aide and had to seek additional help due to the resident's care requirements. The Director of Nursing (DON) later confirmed that any licensed staff member should have been able to assist with changing the resident's brief and that the call bell should not have been turned off until the resident's needs were met. Additionally, during a resident council meeting, seven out of eight residents expressed concerns about not receiving timely care. The facility's policies on ADLs and incontinence care emphasize the importance of maintaining hygiene and addressing incontinence promptly to prevent infections. However, the facility's failure to adhere to these policies resulted in prolonged wait times for residents requiring assistance, as evidenced by the observations and interviews conducted by the surveyors.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate staffing to meet the needs of residents, as evidenced by multiple instances of insufficient Certified Nursing Assistant (CNA) coverage on various day shifts. The staffing deficiencies were documented over several periods, including from October 29, 2023, to November 11, 2023, January 7, 2024, to February 10, 2024, and January 5, 2025, to January 18, 2025. During these times, the facility did not meet the required CNA-to-resident ratios, leading to delays in resident care, particularly in responding to call bells and providing timely incontinence care. One specific incident involved Resident #22, who experienced a significant delay in receiving incontinence care. The resident, who had a history of hypertension and a cerebral infarction, was found in a soiled state and had activated the call bell for assistance. Despite the call bell being answered by a nurse, the resident's needs were not addressed promptly, resulting in a wait time of approximately 35 minutes. The resident required two staff members and a lift for assistance, but the assigned CNA was on break, and the available staff did not prioritize the resident's care needs. Additionally, during a resident council meeting, seven out of eight residents reported delays in call bell responses, with some waiting up to an hour or more for assistance. The Director of Nursing (DON) acknowledged the issue and stated that call bells should not be turned off until residents' needs were met. However, there was no documentation of call bell audits, and the facility's policies did not specify expected response times. The lack of adequate staffing and ineffective call bell response procedures contributed to the facility's failure to meet the residents' care needs in a timely manner.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who elected hospice benefits, as required by the Resident Assessment Instrument (RAI) process. This deficiency was identified for a resident with diagnoses including unspecified dementia, bipolar disorder, and hypertension. The resident was observed lying in bed without complaints, and a fall mat was noted beside the bed. The resident's admission to hospice was ordered on April 7, 2024, but the SCSA was not completed within the required 14-day period, instead being completed on April 26, 2024, which was 20 days after the hospice admission. The MDS Coordinator, responsible for completing the significant change MDS, stated that she followed her training. However, the facility's policy, which aligns with the RAI manual, mandates that a SCSA must be completed no later than the 14th calendar day after a significant change in the resident's status is determined. The facility's failure to adhere to this policy resulted in the deficiency, as the assessment was not completed within the stipulated timeframe.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the correct diet consistency according to physician's orders for a resident with dementia and oral phase dysphagia. The resident was observed with food items that did not match the prescribed pureed diet, as the food was crumbly and dry instead of smooth and cohesive. The resident's meal ticket indicated a pureed diet, but the food provided did not meet the required consistency, which was acknowledged by the Registered Nurse/Unit Manager. The Food Service Director admitted to preparing the pureed food the night before, which was then heated by another staff member. Upon inspection, the pureed food was found to be dry and not of the appropriate consistency. The Division Director of Food and Nutrition Operations and the Registered Dietitian both confirmed that the pureed diet should be smooth and pudding-like, without chunks or particles. The Speech Language Pathologist also noted that improper consistency could be harmful to residents with swallowing deficits. The facility's guidelines and policies clearly outlined the requirements for a pureed diet, emphasizing a smooth, homogenous, and cohesive texture. Despite these guidelines, the facility failed to ensure that the resident received the correct diet consistency, as evidenced by the observations and interviews conducted by the surveyors. The deficiency was identified through a combination of record reviews, staff interviews, and direct observations of the resident's meal preparation and presentation.

Penalty

Inspection fine: $104,680

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide lunch menu items in accordance with resident preferences, meal tickets, and physician orders for two residents. Resident #62, who had a physician order for a pureed diet due to dementia and oral phase dysphagia, did not receive the preferred fruit yogurt and fortified mashed potatoes as indicated on the meal ticket. Instead, regular mashed potatoes were served, and the resident's representative had to bring yogurt from home daily. Additionally, the resident's meal ticket indicated extra gravy/sauce, which was also missing. The Registered Nurse/Unit Manager acknowledged these discrepancies during the surveyor's observation. Resident #31, who had a physician order for a No Added Salt (NAS) diet, did not receive the main menu item, pork, as checked on the selected menu. Instead, only diced potatoes were present on the tray. Furthermore, the meal ticket indicated an 8 oz portion of whole milk, but only a 4 oz container was provided. The Food Service Director (FSD) and other staff members acknowledged these mistakes but could not explain how they occurred. The FSD admitted that he was not present in the kitchen to monitor the tray line for accuracy when the food truck for the unit was prepared. The facility's policies and procedures were not followed, as evidenced by the lack of tray accuracy and the absence of a recipe for fortified mashed potatoes. The Registered Dietitian (RD) and Speech Language Pathologist (SLP) both acknowledged the importance of providing the correct diet consistency and honoring resident food preferences. The RD stated that fortified foods were nutritional interventions to promote weight gain or prevent loss, and the SLP noted that incorrect diet consistency could be harmful. Despite previous concerns raised during food committee meetings, the facility did not implement a plan of correction, and the tray accuracy audit was not ongoing at the time of the survey.