Somerset Court at University Place

The facility failed to ensure proper referral and follow-up for a resident's health care needs. Specifically, staff failed to notify a resident's physician when daily weights could not be obtained due to a broken scale. Documentation showed no evidence that the physician was informed of the broken equipment or the inability to monitor weight changes.

The facility failed to ensure proper referral and follow-up for a resident by not informing the resident's physician when daily weights could not be obtained due to a broken scale. Records showed that weights were not taken from 11/23/21 through 11/30/21, and there was no documentation that the physician was notified of the equipment failure or the inability to monitor the resident's condition.

The facility failed to ensure staff provided personal care to a resident according to their established care plan. Specifically, staff did not provide required catheter care, toileting, showers, and grooming for the resident.

The facility failed to ensure staff provided catheter care, toileting, showers, and grooming for a resident according to their care plan. Observations revealed the resident had matted hair, dirty nails, a stained shirt, and a room with a urine smell and dried feces. Staff reported the resident had become increasingly resistant to care and refused necessary personal care tasks.

The facility failed to ensure medication administration records were accurate for a resident with a physician's order for sliding scale insulin. Specifically, the electronic medication administration record (eMAR) lacked necessary accuracy regarding the documentation of insulin doses based on sliding scale parameters.

The facility failed to ensure medication administration records were accurate for a resident with a physician's order for sliding scale insulin. Specifically, the eMAR lacked a space to document the amount of additional insulin administered and failed to document insulin doses for 53 out of 58 opportunities.

The facility failed to ensure that actions were taken in response to recommendations made by the Licensed Health Professional Support (LHPS). Specifically, for one resident, there was no documentation that a recommended physical therapy evaluation was contacted or that a physician order for PT was obtained following recent falls.

The facility failed to maintain matching therapeutic diet menus for all physician-ordered therapeutic diets. During the survey, it was found that there were no therapeutic menus available for residents requiring specific diets such as Chopped Meats and Ground Meat.

The facility failed to take action following a licensed health professional review that recommended a physical therapy evaluation for a resident. Specifically, there was no documentation that physical therapy had been contacted and no physician order was obtained for the evaluation despite a recommendation due to recent falls.