Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Altercare Somerset Inc. during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including CVA, CHF, anemia, asthma, hypothyroidism, and pulmonary HTN, was cognitively intact but required assistance with bathing and other ADLs. Facility shower records showed only three showers and one refusal, with no documentation of a shower or bed bath on numerous days despite the resident being care planned for two showers weekly. The DON stated CNAs were to offer showers and provide a bed bath if refused, and the Administrator confirmed no additional bathing documentation was found.
Dirty resident equipment and oxygen concentrator: Two residents’ wheelchairs were observed to be extremely dirty, including food debris, visible dirt, and dried food on custom surfaces. An LPN verified the condition of the wheelchairs. A resident’s oxygen concentrator was also observed with a dried brown substance on the front, and an RN verified the finding. Facility policy stated equipment must be kept clean and sanitary, and the E/S coordinator said medical equipment is expected to be cleaned at least twice weekly or as needed.
Failure to honor a resident’s beverage preference: A resident with dementia and CKD required staff assistance with eating and drinking, and the facility’s food preference record identified juice as the preferred beverage at meals. However, observations showed only water available at bedside and during meals, with no juice present. The resident’s POA stated the resident does not want water and prefers juice, while an LPN and CNAs reported they were unaware of the preference and typically provided whatever fluids were available on the unit.
A resident admitted with hypertensive emergency, repeated falls, dementia, and major depressive disorder did not have the baseline care plan timely reviewed or provided within the required 48-hour window. The admission record showed an unsigned baseline care plan, and there was no evidence that the resident or resident representative received or reviewed it. Although the care conference discussed medications, orders, the care plan, and therapy progress, a regional nurse confirmed the baseline care plan had not been provided or explained during the required time frame.
Failure to Include Beverage Preference in Care Plan: A resident with dementia and CKD required staff help with eating, drinking, and hydration, but the comprehensive care plan did not include the resident's documented preference for juice over water or measurable directions for staff. The resident's POA said the resident did not want water, yet staff were observed leaving water at the bedside and reported they were not aware of the juice preference.
Missed Routine Bathing and Personal Care: The facility failed to provide routine bathing for two dependent residents. One resident with multiple chronic conditions, including dementia and hospice status for end-stage CHF, had repeated missed showers, matted hair, and long jagged nails with debris under the nails; an LPN verified the missed care and a hospice aide later provided a bed bath and hair washing. Another resident with CVA, hemiplegia, Alzheimer’s disease, and other chronic conditions also had multiple missed showers, and an LPN verified the resident had not received the scheduled shower/bed bath. Facility policy required bathing and nail care per the care plan.
A resident with CVA, vascular dementia, weakness, impaired gait, and unsteadiness on feet was observed multiple times without gripper socks despite physician orders and a falls care plan calling for them when out of bed or when non-skid footwear was not in place. The resident was also seen attempting to stand from bed while barefoot, and an RN verified the gripper socks were not in place. Facility policy required staff to ensure safety interventions were in place for each resident.
Inadequate Foley Catheter Urine Output Monitoring: A resident with an indwelling Foley catheter and a history of UTI, sepsis, and urinary retention was ordered to have urine output recorded 3 times a day, but records showed it was not documented as ordered and on multiple days was only charted once. The DON confirmed the ordered monitoring and documentation were not being completed.
Meal intake documentation was missing for three residents, and one resident also lacked documentation of an ordered supplement. One resident had sepsis, dysphagia, and DM2 with impaired cognition and required supervision for eating; another had dementia, dysphagia, and poor appetite; and a third had protein calorie malnutrition, dementia, and severe cognitive impairment. The DON confirmed meal intakes should be documented each meal, and the dietitian noted missing meal percentages affected her ability to do her job.
A resident with Parkinson’s disease, chronic respiratory failure with hypoxia, and dependence on supplemental O2 was observed with a nasal cannula in place while the O2 concentrator was turned off. An RN verified the resident was not receiving O2 because the concentrator was not on, despite a physician order for continuous O2 at 2 to 4 L via NC to keep sats above 90%.
A resident with schizophrenia and depression did not have timely follow-up with psych recommendations after hospital discharge. The discharge instructions called for psychiatry follow-up within one week and medication changes including tapering Oxcarbazepine and starting Lamotrigine, while the resident’s orders also included Doxepin, Invega Sustenna, Lamotrigine, and Olanzapine. The DON stated the psych NP saw the resident in-house, but the progress note was obtained later and its recommendations for Genesight testing and prior psych records were not completed.
A resident with multiple medical conditions did not receive documented assistance with ADLs, including eating and personal care, over a two-day period. Family observed the resident in unchanged clothes and without help during meals, and the facility could not provide evidence or policy for ADL care when requested.
Sensitive medical information, including code status forms and medication orders for three residents with multiple diagnoses, was left visible and unattended at the nurses station, with no staff present and the computer screen unlocked. A family member raised concerns about the exposure of HIPAA-protected information, and a CNA confirmed the visibility of this information. The facility did not provide a policy on protecting resident-identifiable information.
The facility failed to provide scheduled showers to three residents who were dependent on staff for personal care. Despite being scheduled for showers three times a week, documentation revealed that these residents frequently missed their scheduled showers. The Director of Nursing acknowledged the issue, attributing it to staffing challenges.
The facility failed to ensure a safe and clean environment in its shower rooms, affecting 42 residents. Observations revealed missing toilet seats, dirt and grime in grout lines, peeling vinyl flooring, and a strong mildew odor. A resident reported these issues had persisted for over a year, with the facility delaying repairs.
A resident lent $20 to a housekeeper who requested $10, and the money was not repaid. The housekeeper admitted to borrowing the money, and the facility's investigation concluded that misappropriation did not occur due to the resident's consent. However, the facility's policy prohibits staff from asking residents for money, highlighting a deficiency in compliance.
The facility failed to provide scheduled showers to three residents who were dependent on staff for personal care. One resident missed five scheduled showers, another missed five showers in a month, and a third missed one shower. There was no documentation of showers being offered or refused, and the DON confirmed the lack of evidence for these missed showers.
A facility failed to document a resident's meal and fluid intake during a respite stay, despite physician's orders to monitor nutritional status. The resident had multiple health conditions, including Alzheimer's and malnutrition. The DON confirmed the absence of documentation, which prevented evidence of adequate nutrition and hydration monitoring.
A facility failed to document ADL care for a resident with multiple health issues during a respite stay. The resident's care plans required assistance with mobility, incontinence, and hygiene, but records showed no documentation of care for the first two days. The DON confirmed the oversight, unable to explain the lack of documentation.
A resident with cognitive impairment and multiple medical conditions experienced significant weight loss due to the facility's failure to implement a recommended nutritional program. Despite a dietitian's recommendation for a house supplement, it was not administered until weeks later, and the resident's weight was not monitored adequately. Communication gaps and incorrect care plans contributed to the deficiency.
The facility failed to provide consistent assistance with activities of daily living (ADLs) for several residents, leading to missed showers and inadequate hygiene care. Staffing shortages and documentation discrepancies were noted, with residents not receiving care according to their preferences. Interviews and observations confirmed the lack of proper assistance, highlighting deficiencies in staffing and record-keeping.
A resident with multiple health conditions, including quadriplegia, did not receive a scheduled shower as per her preference. The facility's records inaccurately indicated that a shower was refused, signed by an STNA who was absent due to illness. The facility could not provide evidence of the shower being offered, highlighting a failure to follow the shower policy.
A facility failed to notify a resident's guardian about excess funds exceeding Medicaid limits. The resident, with severe cognitive impairment and multiple diagnoses, had a guardian who was not documented to have received the required notification. The Social Service Coordinator communicated with the guardian about using the funds for funeral arrangements, but lacked documentation to support these efforts.
The facility failed to implement comprehensive care plans for two residents. One resident, with multiple medical conditions, lacked a care plan for ADL assistance until it was requested. Another resident, dependent on staff for eating and rarely understood, had no care plan addressing hydration needs. These deficiencies were confirmed by facility staff.
A resident with severe cognitive impairment and multiple physical disabilities was observed to be improperly positioned in a custom wheelchair, lacking a dycem mat as ordered. Despite modifications, the resident continued to slide down, with no further attempts to improve positioning noted.
Two residents in an LTC facility experienced deficiencies in incontinence care and medication administration, leading to UTIs. One resident did not receive proper perineal hygiene, and another did not complete the prescribed antibiotic course. The DON confirmed these failures.
A facility failed to document urostomy care for a resident with chronic kidney disease, dementia, and bladder cancer. The care plan required specific interventions and care every shift, but records showed no evidence of completion. The Administrator confirmed the lack of documentation beyond output monitoring.
A resident with sepsis and MRSA infection had physician orders for weekly lab tests, including a CBC, sed rate, CRP, and Vancomycin trough level, which were not completed on two occasions. The resident was out for appointments on the scheduled lab days, but the facility's nurses did not draw the labs upon the resident's return. The Administrator confirmed the absence of lab results for the specified dates, acknowledging the failure to follow the physician's orders.
Three residents with various medical conditions did not receive scheduled showers due to insufficient staffing, particularly on weekends. The facility confirmed the lack of showers on specific days, and documentation issues were noted, including false entries by absent staff. The Administrator acknowledged prioritizing medical needs over shower preferences when staffing was inadequate.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to ensure that Resident #70 received showers or bed baths at least twice weekly. Resident #70 was admitted on 04/21/26 and discharged on 05/16/26 with diagnoses including age-related osteoporosis with current pathological fracture, right lower leg fracture with routine healing, paroxysmal atrial fibrillation, cerebral infarction, congestive heart failure, anemia, asthma, hypothyroidism, and pulmonary hypertension. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and the resident used a wheelchair and required partial/moderate assistance with toileting hygiene, showering/bathing, and bed mobility, as well as substantial/maximal assistance for transfers. Review of the facility shower sheets showed the resident received showers on 04/28/26, 05/06/26, and 05/12/26, and was offered and refused a shower on 05/07/26. There was no documentation that the resident received a shower or bed bath on 04/22/26 through 04/27/26, 04/29/26 through 05/04/26, or 05/08/26 through 05/11/26. OT notes documented that the resident could complete some ADL tasks with supervision or with full set-up, including oral care, denture care, washing hands and face, and upper body washing. The DON stated CNAs are to offer showers on scheduled shower days and provide a bed bath if the resident does not want a shower, and that residents are care planned for two showers a week but are scheduled for and offered three. The Administrator verified there was no other documentation of showers or bed baths being completed on the missing dates.
Dirty resident equipment and oxygen concentrator
Penalty
Summary
The facility failed to ensure resident equipment was maintained in a clean and sanitary manner. Observation and interview showed Resident #44’s custom wheelchair was extremely dirty, with food debris in the crevasses and visible dirt all over the wheelchair. Resident #44’s record showed an admission date of 08/20/23, a latest readmission of 05/21/24, and diagnoses including protein calorie malnutrition, UTI, depression, mood disorder, hypothyroidism, anemia, metabolic encephalopathy, solitary pulmonary nodule, chronic pain, atrial fibrillation, anorexia, osteoarthritis, dementia, macular degeneration, and cerebral atherosclerosis. The resident’s quarterly MDS assessment indicated a severe cognitive deficit. Resident #54’s wheelchair with custom padded armrests was observed to be extremely dirty, with visible dirt and dried food on the armrests. Resident #54’s record showed an admission date of 09/15/22 and diagnoses including chronic kidney disease, intellectual disabilities, dysphagia, depression, anxiety disorder, obesity, hypothyroidism, osteoporosis, scoliosis, mixed incontinence, hypertension, migraine, insomnia, and hyperlipidemia. The resident’s quarterly MDS assessment indicated a moderate cognitive deficit. Resident #9’s oxygen concentrator was also observed with a dried brown substance covering the front of the concentrator. Resident #9’s record showed an admission date of 12/13/23, a readmission date of 11/17/25, diagnoses including Parkinson’s disease and chronic respiratory failure with hypoxia, and an order for oxygen 2 to 4 liters via nasal cannula to maintain saturations above 90% every shift. RN #209 verified the substance on the concentrator, and the Environmental Service Coordinator stated medical equipment is expected to be cleaned at least twice weekly or as needed. Facility policy stated equipment will be cleaned and maintained in a sanitary condition to prevent the spread of infectious disease.
Failure to Honor Resident Beverage Preference
Penalty
Summary
The facility failed to honor Resident #22’s stated beverage preference by not consistently providing juice at meals and instead making water available. Resident #22 was admitted with diagnoses including dementia and chronic kidney disease, and the most recent MDS showed the resident was cognitively impaired and required supervision and assistance with eating and drinking, relying on staff to maintain adequate hydration. The facility’s Resident Centered Care Food Preferences document identified juice as the resident’s preferred beverage at meals, and there was no documentation that the resident preferred water over juice. During observations on multiple occasions, only water was available at the resident’s bedside or during meal periods, and no juice or other preferred beverage was observed. The resident’s daughter and POA stated the resident does not want water to drink and prefers juice, and expressed concern that the preference was not consistently honored. Staff interviews showed the LPN and CNAs were not aware of the resident’s preference for juice and reported they typically provided fluids available on the unit unless otherwise directed. The facility policy stated fluids are to be provided based on resident preferences.
Baseline Care Plan Not Timely Reviewed or Provided
Penalty
Summary
The facility failed to ensure that Resident #74’s baseline care plan was timely reviewed and provided within 48 hours of admission. Resident #74 was admitted with diagnoses including hypertensive emergency, repeated falls, dementia, and major depressive disorder. The admission nursing assessment documented an unsigned baseline care plan dated 01/28/26, but there was no evidence that the resident or the resident representative was provided with the baseline care plan or that it was reviewed with them. The initial resident care conference on 02/03/26 also showed no evidence that a copy of the baseline care plan was given to the resident or resident representative. Care conference progress notes indicated that current medications, all orders, the care plan, and therapy progress were discussed, and a regional nurse later verified that the resident had not been provided with or had the baseline care plan explained during the required time frame. Facility policy stated that a baseline care plan is completed upon admission within 48 hours based on data.
Failure to Include Beverage Preference in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident #22, who was admitted with diagnoses including dementia and chronic kidney disease. The most recent MDS showed the resident was cognitively impaired and required staff supervision and assistance with eating and drinking, including assistance to ensure adequate hydration. The resident's daughter and POA stated the resident did not want water to drink and preferred juice, and the facility document titled Resident Centered Care Food Preferences identified juice as the resident's preferred beverage at meals. However, there was no documentation showing the resident preferred water over juice. The comprehensive care plan addressed assistance with activities of daily living and monitoring intake, but it did not include a person-centered intervention identifying the resident's preference for juice instead of water, nor did it include measurable objectives or direction to staff to provide fluids consistent with the resident's stated preference. During observations on multiple dates, the resident was seen in the room with a cup of water on the bedside table, and no juice or alternative fluids were present. Staff interviews showed the LPN and CNAs were not aware of the resident's documented preference for juice and had not been informed to offer juice instead of water.
Missed Routine Bathing and Personal Care
Penalty
Summary
The facility failed to ensure residents who were dependent on staff received routine bathing and related personal care. For Resident #10, the record showed diagnoses including spinal stenosis, dementia, COPD, chronic respiratory failure, chronic pain, diabetes, depression, anxiety, atrial fibrillation, CHF, cardiomyopathy, arthritis, and anemia, and the resident was receiving hospice benefits for end stage CHF. The resident’s care plan included showers/baths, personal care, and nail care, but shower documentation showed multiple missed scheduled showers across December 2025, January 2026, and February 2026. During observation and interview, the resident stated she had not had a bath in two weeks or had her hair combed in two weeks, and staff observed large areas of matted hair and long, jagged fingernails with a brown substance under the nails. An LPN verified the resident had not received scheduled showers or bed baths, and a hospice aide later stated she provided a bed bath and washed the resident’s hair, spending most of the time removing matted areas from the hair. For Resident #36, the record showed diagnoses including CVA with left-sided hemiplegia, dysphagia, CHF, COPD, diabetes, CKD, HTN, schizophrenia, Alzheimer’s disease, bipolar disorder, anxiety, depression, insomnia, GERD, anemia, constipation, and atrial fibrillation. The resident’s MDS showed a moderate cognitive deficit and no rejection of care behaviors. Shower documentation showed multiple missed scheduled showers across December 2025, January 2026, and February 2026. During interview, the resident stated she had not been provided a shower and/or bed bath in more than a week, and observation showed her hair was unkempt and greasy. An LPN verified the resident had not received her scheduled shower and/or bed bath. Facility policy stated residents would be assisted with bathing per their plan of care and that nail care would be provided to clean, trim, and maintain nails.
Fall Prevention Interventions Not Implemented
Penalty
Summary
The facility failed to ensure fall prevention interventions were implemented as indicated for one resident reviewed for falls. The resident had diagnoses including cerebral infarction, difficulty walking, vascular dementia, muscle weakness, lack of coordination, other abnormalities of gait and mobility, and unsteadiness on feet. The medical record included physician orders to encourage the resident to wear gripper socks when non-skid footwear was not in place and to have gripper socks on while out of bed. The falls care plan identified the resident as at risk for falls and injury related to bowel and urine incontinence and impaired gait, with interventions including gripper socks applied for safety and encouragement to wear gripper socks when not wearing shoes or while in bed. Observations on multiple occasions showed the resident without gripper socks on, including when the resident was attempting to stand up from the bed and stated that the floor was slippery. A RN later verified that the resident's gripper socks were not in place. The facility policy titled Fall Prevention stated that staff will ensure safety interventions are in place for each resident to reduce the risk of falls.
Inadequate Foley Catheter Urine Output Monitoring
Penalty
Summary
Failure to provide appropriate care for a resident with an indwelling Foley catheter was identified when Resident #46 was not monitored for urine output as ordered and urine output was not documented each shift. The resident was admitted with diagnoses including sepsis due to a urinary tract infection, acidosis, metabolic encephalopathy, and retention of urine. The quarterly MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition, and the resident required an indwelling catheter for urine elimination. The care plan identified altered elimination related to obstructive uropathy and the need for a Foley catheter, with an intervention to record intake and output as ordered by the physician. A physician order required urinary output to be recorded three times a day, but review of urine output records showed it was not documented three times daily and on multiple days was documented only once, with daily output sometimes ranging from 100 to 200 milliliters. The DON confirmed in interview that the ordered urine output monitoring and documentation were not being completed.
Missing Meal Intake and Supplement Documentation
Penalty
Summary
Meal intakes were not consistently monitored and documented for three residents, and one resident also had an ordered supplement that was not documented. Resident #46 was admitted with sepsis due to a UTI, dysphagia, and type 2 diabetes, and his quarterly MDS showed moderately impaired cognition and supervision needed for eating. His care plan identified risk for dehydration and fluid imbalance, with interventions to offer fluids at meals, provide fluids at bedside, and monitor meal intakes. His physician orders included a low concentrated sweet diet with thin liquids, double portions at meals, and encouragement to drink 8 ounces of water every shift. Review of his meal intake record from late November 2025 through late February 2026 showed multiple days with only one to two meals documented, including fluids, and some days with fluid intake as low as 320 mL. Resident #74 was admitted with muscle weakness, unspecified dementia, dysphagia, constipation, and major depressive disorder. His care plan identified altered nutrition risk and included interventions to offer menu alternatives, honor food preferences, provide the ordered diet, and provide supplements per physician order. Review of his meal percentage records showed multiple missing documentation entries for breakfast, lunch, and dinner across January and February 2026. Nutrition notes documented that intake was good since admission, mostly 76-100% per MAR, then later noted family requesting Boost daily for additional nutritional support and intake mostly 50-100%, followed by a progress note stating the resident had poor appetite and was not eating meals. Resident #44 had diagnoses including protein calorie malnutrition, UTI, depression, hypothyroidism, anemia, metabolic encephalopathy, atrial fibrillation, anorexia, dementia, and cerebral atherosclerosis, and his quarterly MDS showed severe cognitive deficit and care rejection. His care plan identified altered nutrition risk with a recent history of significant weight loss and included ordered diet and supplements. Review of his meal percentage records showed numerous missing entries across December 2025, January 2026, and February 2026 for breakfast, lunch, and dinner. The DON verified that meal intakes should be documented each meal in the electronic medical record, and for Resident #44 the report also states that an ordered supplement was not documented.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician’s order for oxygen administration for Resident #9, who had diagnoses including Parkinson’s disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The most recent physician’s order dated 11/26/25 directed oxygen at 2 to 4 liters via nasal cannula to maintain saturations above 90% every shift. On 02/25/2026 at 10:11 A.M., observation showed the resident’s nasal cannula in place while the oxygen concentrator was turned off. During an interview and observation later that morning, RN #209 verified that the resident was not receiving oxygen because the concentrator was not turned on and confirmed the physician’s order for oxygen was continuous. Facility policy titled Oxygen Administration stated the facility provides oxygen services to residents using professional standards of care.
Delayed Follow-Up With Psychiatric Recommendations
Penalty
Summary
The facility failed to follow up with psychiatric recommendations in a timely manner for one resident reviewed for mood and behavior. The resident was admitted with diagnoses including schizophrenia, depression, and muscle weakness. Hospital discharge instructions dated 01/02/26 directed follow-up with psychiatry in one week and documented that Oxcarbazepine was being down titrated to 30 mg and Lamotrigine 25 mg twice daily was started with slow up titration in the outpatient setting. The resident’s physician orders included Doxepin 75 mg at bedtime, Invega Sustenna 156 mg/mL IM every three weeks, Lamotrigine 25 mg twice daily, and Olanzapine 100 mg twice daily. The DON stated the psychiatric NP visited the resident in house on 01/30/26, but progress notes typically take about a month to obtain. The DON later provided the psychiatric progress note dated 01/30/26, which recommended obtaining Genesight testing if the resident and family were agreeable and obtaining records from the previous outpatient psychiatric provider to confirm diagnosis and prior medication trials. The DON verified these recommendations were not completed.
Failure to Provide ADL Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident who required help due to multiple medical conditions, including a displaced midcervical fracture of the left femur, respiratory failure, chronic obstructive pulmonary disease, and hypertension. Record review showed no documentation that the resident received assistance with ADLs such as bed mobility, transfers, eating, toileting, bathing, or incontinence care over a two-day period prior to discharge. Family members reported that during visits, the resident's clothes had not been changed, she had not received help with eating, and was left lying flat while eating, resulting in food on her clothes and face. The administrator confirmed the absence of documentation for ADL assistance on the specified dates, and the facility was unable to provide a policy for ADL care when requested by the surveyor. This deficiency was identified during a complaint investigation and affected one resident out of six reviewed for ADL assistance, with a facility census of 71.
Failure to Safeguard Resident Confidential Information at Nurses Station
Penalty
Summary
The facility failed to protect residents' confidential information as required by accepted professional standards. During record review, observation, and interviews, it was found that code status forms for three residents with various diagnoses, including type II diabetes, muscle weakness, respiratory failure, osteomyelitis, altered mental status, syncope, and congestive heart failure, were left visible on the nurses station desk. Additionally, a computer screen displaying a resident's medical orders was left unlocked and unattended, making sensitive information accessible to visitors and others in the area. A family member reported concerns about resident information being visible, and a Certified Nursing Assistant confirmed that the information was accessible at the nurses station. The facility was unable to provide a policy regarding the protection of HIPAA-protected information.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for personal care received the assistance needed to receive showers as scheduled. This deficiency affected three residents who were reviewed for activities of daily living (ADL). Resident #3, who was admitted with multiple diagnoses including a dislocation of his right hip prosthesis and diabetes mellitus, required substantial assistance with showers and transfers. However, documentation revealed that he missed six out of twelve scheduled showers between late November and late December, with no evidence of receiving a shower or bath on those days. Resident #9, who had diagnoses including orthopedic aftercare and adult-onset diabetes mellitus, was also dependent on staff for showers. Despite being scheduled for showers three times a week, documentation showed that he did not receive showers on ten scheduled days, although he did receive showers on four non-scheduled days. This inconsistency in care was noted during his stay until his discharge in late December. Resident #30, with diagnoses such as hypertension and chronic pain syndrome, required partial assistance for showers. She was scheduled for showers three times a week but did not receive them on five scheduled days, according to documentation. An interview with the resident confirmed the accuracy of the documentation regarding missed showers. The facility's Director of Nursing acknowledged the lack of documentation for the showers and attributed the issue to staffing challenges, as the current shower aide was also assisting on the floor.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment for its residents, as evidenced by the conditions observed in the main shower rooms on Unit 1 and Unit 2. On Unit 1, the commode was missing a toilet seat, and there was a black substance on the vinyl floor near the shower stall, which transferred to a paper towel when wiped. The grout lines in the tiled shower stall were filled with dirt and grime, and the vinyl flooring was peeling back, exposing the underlayment. A metal transition strip separated the tiled floor from the vinyl flooring, and standing water was observed in the area where the vinyl was peeling. On Unit 2, similar issues were noted, including dirt and grime in the grout lines, torn vinyl flooring with loose sealant, and a strong mildew odor. A brown substance resembling feces was found on the shower stall floor, and the DON confirmed that the shower stall should be cleaned between each resident use. Resident interviews revealed concerns about mold and the condition of the shower rooms. One resident expressed that the issues had persisted for a year or more, with the facility claiming they were waiting on something to fix it. The resident also noted the missing toilet seat in Unit 1's shower room had been an issue for over a month. These observations and interviews indicate a failure to provide a safe and clean environment, affecting 42 of the 67 residents, as 25 residents were identified not to use the facility's two shower rooms.
Resident's Money Misappropriated by Staff
Penalty
Summary
The facility failed to protect a resident's personal money from being misappropriated by a staff member. The incident involved a resident who lent $20 to a housekeeper after she requested to borrow $10. The resident, who had a friendly relationship with the housekeeper, did not report the incident immediately as he did not have concerns at the time. However, the money was not repaid, leading to the resident eventually mentioning it to another staff member. The housekeeper admitted to borrowing the money and acknowledged that she had not repaid it. She stated that she had a good relationship with the resident and had never borrowed money from any other residents. The facility's investigation included interviews with the resident and the housekeeper, as well as a review of the facility's policies. Despite the housekeeper's admission, the facility unsubstantiated the allegation, concluding that misappropriation did not occur because the resident had consented to the loan. The facility's policy defines misappropriation as the wrongful use of a resident's belongings or money without consent. The Director of Nursing acknowledged that staff members are not permitted to ask residents for monetary assistance, as it could be perceived as coercion or undue influence. The facility's investigation was reviewed by a state investigator, but no further action was taken. The incident was documented as a deficiency in compliance with the facility's policies.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with bathing and showers to residents who were dependent on staff for personal care. This deficiency affected three residents who were reviewed for showers. Resident #8, who had multiple fractures and pressure ulcers, was scheduled for showers three times a week but did not receive them on five occasions. There was no documentation of the showers being refused, and the Director of Nursing (DON) confirmed the lack of evidence for these missed showers. Resident #14, diagnosed with polyosteoarthritis and muscle weakness, was also scheduled for showers three times a week. However, she did not receive showers on five scheduled days within a 30-day period. The resident reported that she often received only two showers a week due to staffing issues, although the DON denied that staffing was a factor. Again, there was no documentation of the showers being offered or refused. Resident #20, who had difficulty walking and other medical conditions, missed one scheduled shower day. The DON confirmed there was no documentation to support that the shower was offered or refused. The lack of documentation and failure to provide scheduled showers for these residents represent a deficiency in the facility's care practices.
Failure to Document Nutritional Monitoring
Penalty
Summary
The facility failed to adequately monitor a resident's nutritional status by not recording meal percentages and fluid intake amounts during her stay. The resident, who was admitted for a respite stay, had several diagnoses including Alzheimer's disease, dementia, unspecified protein calorie malnutrition, hypertensive heart disease with heart failure, and a pressure ulcer. Despite having physician's orders in place for monitoring her meal and fluid intakes, no documentation was recorded for the duration of her stay. The Director of Nursing confirmed that there was no documentation of the resident's meal and fluid intakes, acknowledging that staff should have entered this information into the computer. Without this documentation, the facility could not provide evidence of the resident receiving adequate nutrition and hydration, nor could they demonstrate proper monitoring of her nutritional status. The lack of documentation was unexplained, and the deficiency was noted as an incidental finding during a complaint investigation.
Incomplete Documentation of ADL Care for Resident
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, specifically regarding the documentation of activities of daily living (ADL) care provided to the resident. This deficiency affected a resident who was admitted for a respite stay and had multiple diagnoses, including Alzheimer's disease, dementia, malnutrition, hypertensive heart disease with heart failure, pressure ulcers, muscle contractures, and a history of breast cancer. The resident's care plans included interventions for skin breakdown, existing wounds, and hospice care, which required assistance with bed mobility, incontinence care, personal hygiene, and oral care. Upon review of the resident's electronic medical record, it was found that there was no documentation of ADL care provided on the first two days of the resident's stay. The Point of Care History report showed that ADL assistance was only documented on the third day of the stay. An interview with the Director of Nursing confirmed the lack of documentation for the first two days, although the resident was reportedly assisted with ADL care. The Director of Nursing could not explain why the staff failed to document the care provided.
Failure to Implement Nutritional Program Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive and individualized nutritional program for a resident, leading to significant weight loss. The resident, who was cognitively impaired and had multiple medical conditions including protein-calorie malnutrition and unspecified dementia, experienced a severe weight loss over a period of time. Despite a dietitian's recommendation on May 19th for a house supplement to be administered twice daily, this was not implemented until June 6th, after being recommended again on June 5th. During this period, the resident's weight was not monitored adequately, with no documented weights from May 8th to May 18th, and incorrect weight entries were noted. The resident's weight continued to decline, with a severe 8.5% weight loss noted by June 24th. The facility's failure to act on the dietitian's initial recommendation and the lack of timely nutritional assessments contributed to the resident's deteriorating condition. The resident's care plan was not updated appropriately to reflect her nutritional needs, and significant weight changes were not addressed in a timely manner. Interviews with the dietitian and the Director of Nursing revealed gaps in communication and implementation of nutritional interventions. The dietitian worked remotely and was not always aware of the resident's status, while the Director of Nursing confirmed that the supplement was not started when the resident returned from the hospital. The resident's nutrition plan of care was also found to be incorrect, as it did not reflect her status after she stopped receiving hospice care.
Deficiencies in ADL Assistance and Documentation
Penalty
Summary
The facility failed to ensure that residents received the necessary assistance for activities of daily living (ADLs) according to their preferences, affecting four residents. Resident #40, who required substantial assistance with bathing, did not receive showers as scheduled due to staffing issues. Documentation discrepancies were noted, with staff initials falsely indicating that care was provided. The resident confirmed missing showers and not being offered alternatives, such as bed baths, on certain days. Resident #20, with intact cognition and requiring maximal assistance for bathing, also missed scheduled showers due to staff shortages, particularly on weekends. The resident expressed distress over the missed showers, which were not rescheduled. Observations confirmed poor hygiene, with dark material under the resident's fingernails, despite documentation falsely indicating that showers and nail care were provided. Resident #55, who preferred to be clean-shaven, did not receive regular assistance with shaving. Documentation was lacking, and interviews with staff confirmed that shaving was not consistently offered or documented. Resident #264, with severely impaired cognition, missed several scheduled showers, and documentation was inconsistent, with the DON completing forms without clear evidence of care being provided. The facility's failure to provide consistent and documented care for ADLs highlights significant deficiencies in staffing and record-keeping.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for personal care, received the assistance needed to complete activities of daily living according to her preferences. The resident, who had multiple diagnoses including toxic encephalopathy, muscle weakness, and quadriplegia, expressed a preference for three showers weekly. However, she reported not receiving a shower on a specific date, which was confirmed by the absence of a shower sheet entry for that day. Further investigation revealed discrepancies in the documentation. The shower sheet for the date in question was signed by a State Tested Nursing Assistant (STNA) who was not present at the facility due to illness. This was corroborated by timeclock records and an interview with the staff coordinator, confirming the STNA's absence. The facility was unable to provide evidence that the resident received a shower on the specified date, as per her preference, indicating a failure to adhere to the facility's shower policy.
Failure to Notify Guardian of Excess Resident Funds
Penalty
Summary
The facility failed to provide a spend down notification for a resident who received Medicaid benefits, affecting one of the five residents reviewed for funds. The resident, who had a guardian, was admitted with multiple diagnoses including senile degeneration of the brain, contracture of multiple muscle sites, dysphagia, schizoaffective disorder, depression, attention and concentration deficit, vascular dementia, and persistent mood disorder. The resident's comprehensive Minimum Data Set (MDS) assessment indicated severe cognitive impairment, and the resident was unable to complete the Brief Interview for Mental Status (BIMS) assessment. The resident's quarterly statements showed an increasing balance that exceeded Medicaid limits, but there was no evidence that the guardian received the required notification about the excess funds. The Social Service Coordinator (SSC) acknowledged that the resident's funds had exceeded Medicaid limits for some time and had been in communication with the guardian about using the funds for funeral arrangements. However, there was no documentation to support these communications, and the guardian had not provided the necessary information to proceed with the arrangements. The SSC reported that the guardian did not want the funds spent on anything other than funeral arrangements, but there was no evidence to substantiate this claim. The lack of documentation and failure to ensure the guardian received the spend down notification contributed to the deficiency identified in the facility's handling of resident funds.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for all residents, affecting two residents out of the 20 care plans reviewed. Resident #55, who was admitted with multiple complex medical conditions including fractures, diabetes, and Parkinson's disease, was assessed to need varying levels of assistance with activities of daily living (ADLs). However, there was no care plan developed for his ADL assistance until it was requested on 07/17/24, despite his need for assistance being evident. This was confirmed by the Assistant Director of Nursing during an interview. Similarly, Resident #28, who was admitted with conditions such as dysphagia, vascular dementia, and major depressive disorder, was found to have a care plan that did not address her hydration needs. The resident was dependent on staff for eating and was rarely or never understood, indicating a significant need for a comprehensive care plan. The absence of a hydration plan was verified by the Administrator during an interview.
Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to ensure proper positioning of a resident in a wheelchair, affecting one of the three residents reviewed for positioning. The resident, who has spastic quadriplegia, cerebral palsy, traumatic brain injury, and scoliosis, was observed to be improperly positioned in a custom wheelchair on multiple occasions. Despite having a physician's order for a dycem mat to prevent sliding, the mat was not present during observations. The resident's medical record indicated severe cognitive impairment and dependence on others for all activities of daily living. Observations revealed that the resident was sliding down in the wheelchair, with their head not positioned on the headrest and leaning to the left. Interviews with staff and the resident's brother confirmed dissatisfaction with the wheelchair's effectiveness in maintaining proper positioning. The occupational therapist acknowledged the resident's scoliosis and the challenges in maintaining upright seating, despite modifications made to the wheelchair. There was no evidence of further attempts to improve the resident's positioning after the initial modifications.
Inadequate Incontinence Care and Medication Errors Lead to UTIs
Penalty
Summary
The facility failed to provide appropriate incontinence care for two residents, leading to urinary tract infections (UTIs). Resident #8, who had a history of UTIs and was frequently incontinent, did not receive proper perineal hygiene. During an observation, a nursing assistant used dry toilet paper instead of wet wipes or a washcloth with soap and water to clean the resident's perineal area, leaving the area inadequately cleansed. This was contrary to the facility's policy, which required thorough washing and rinsing to prevent infections. Additionally, Resident #8 received more doses of an antibiotic than prescribed for a UTI, indicating a medication administration error. Resident #20, who was also frequently incontinent, did not receive the full course of prescribed antibiotics for a UTI. The resident's daughter expressed concerns about confusion, prompting a urinalysis that confirmed a UTI. However, the resident missed a morning dose of the antibiotic, resulting in only 12 out of the 14 prescribed doses being administered. The Director of Nursing confirmed the discrepancies in medication administration for both residents, highlighting a failure in ensuring proper treatment and services to prevent UTIs.
Failure to Document Urostomy Care
Penalty
Summary
The facility failed to provide evidence that urostomy care was completed as care planned and ordered for a resident. The resident, who had diagnoses including chronic kidney disease, dementia, mood disorder, and malignant neoplasm of the bladder, was admitted with an ostomy. The care plan required urostomy care every shift and as needed, along with specific interventions such as keeping the drainage bag below the bladder, using a leg strap, and changing the catheter bag per policy. However, the Medication Administration Record from April to July showed no evidence that the ostomy care was completed as ordered. An interview with the Administrator confirmed that the only documentation available was related to output monitoring, with no documented evidence of the required urostomy care being performed.
Failure to Complete Routine Laboratory Testing as Ordered
Penalty
Summary
The facility failed to ensure that routine laboratory testing was completed weekly as ordered by the physician for a resident. The resident, who was admitted with diagnoses including sepsis, MRSA infection in a diabetic ulcer, and adult-onset diabetes mellitus, had a physician's order for Vancomycin IV and weekly lab tests including a CBC with differential, sed rate, CRP, and Vancomycin trough level. However, there was no evidence that these labs were drawn on the specified dates of 07/09/24 and 07/16/24. The Director of Nursing confirmed that the resident was out for appointments on the days the labs were scheduled, but acknowledged that the facility's nurses could have drawn the blood upon the resident's return. The Administrator provided a lab result from 07/16/24 that was incomplete, missing the sed rate and Vancomycin trough level. The Administrator also confirmed the absence of lab results for 07/09/24, acknowledging the failure to obtain the labs as ordered by the physician.
Insufficient Staffing Leads to Missed Showers for Residents
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, particularly affecting three residents. Resident #20, who has diabetes, chronic obstructive pulmonary disease, and schizoaffective disorder, did not receive scheduled showers on multiple occasions due to staffing shortages, particularly on weekends. The resident expressed distress over not receiving showers as scheduled, and the facility confirmed the lack of showers on specific dates. Resident #40, with diagnoses including low back pain, muscle weakness, and unspecified dementia, also did not receive scheduled showers on several occasions. The resident reported receiving only two showers a week instead of three, and documentation confirmed the absence of showers on certain days. The Director of Nursing acknowledged the lack of documentation and the resident's preference for showers, which were not consistently provided. Resident #7, diagnosed with conditions such as toxic encephalopathy and quadriplegia, reported not receiving a shower on a scheduled day due to insufficient staffing. Documentation falsely indicated that a staff member who was not present had provided care. The facility's staffing schedule showed fewer staff on weekends, and the Administrator confirmed that medical needs were prioritized over shower preferences when staffing was inadequate.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Somerset
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Lane Gardens Rehab & Nursing Ctr | 8.1 mi | ★★★★★ | 49 | 3 |
| Majestic Care Of New Lexington | 8.1 mi | ★★★★★ | 23 | 0 |
| Altercare Thornville Inc. | 9.7 mi | ★★★★★ | 13 | 1 |
| Lanfair Center For Rehab & Nsg Care Inc | 14.9 mi | ★★★★★ | 0 | 0 |
| Buckeye Care And Rehabilitation | 15.4 mi | ★★★★★ | 23 | 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.