Inspection Reports for
Somerset Nursing and Rehabilitation Facility

106 GOVER STREET, SOMERSET, KY, 42502

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 5.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

13% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

12 9 6 3 0
2019
2021
2025

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Jun 25, 2025

Visit Reason
The inspection was conducted as an annual survey of Somerset Nursing and Rehabilitation Facility to assess compliance with health and safety regulations.

Findings
No health deficiencies were found during the inspection.

Inspection Report

Routine
Deficiencies: 6 Date: Aug 11, 2021

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including accommodations for bariatric equipment, resident rights to access medical records, implementation of care plans, hygiene and bathing services, food service safety, and facility-wide assessment.

Findings
The facility failed to provide reasonable accommodations for a bariatric resident, failed to provide timely access to medical records, failed to implement care plans related to personal hygiene and bathing for multiple residents, failed to maintain proper food temperatures and labeling in food service, and failed to update the facility-wide assessment to reflect changes in administration and resident needs.

Deficiencies (6)
Failed to ensure reasonable accommodations for a bariatric resident related to bariatric equipment (Geri Chair and Shower Bed).
Failed to protect the rights of a resident by not providing medical records within the required timeframe.
Failed to implement the plan of care for six residents related to personal hygiene and bathing, specifically not providing showers twice weekly as required.
Failed to provide necessary care and services to maintain grooming and hygiene for six residents, with showers not given twice weekly as per care plans.
Failed to store and serve food in accordance with professional standards, including improper food temperatures on steam tables and unlabeled/undated food items in storage.
Failed to conduct and document a facility-wide assessment reflecting changes in administration and resident population needs, specifically bariatric residents.
Report Facts
Residents sampled: 22 Residents affected by bariatric equipment deficiency: 1 Residents affected by medical record access deficiency: 1 Residents affected by care plan implementation deficiency: 6 Residents affected by grooming and hygiene deficiency: 6 Food temperatures below standard: 2 Residents affected by facility assessment deficiency: Many

Employees mentioned
NameTitleContext
State Registered Nurse Aide #7 SRNA Interviewed regarding bariatric chair for Resident #94
Station One Unit Manager Interviewed regarding Resident #94's chair and bathing
Rehabilitation Director Interviewed regarding bariatric chair and shower chair for Resident #94
Director of Nursing DON Interviewed regarding efforts to obtain bariatric chair and bathing care plans
Administrator Interviewed regarding bariatric equipment, medical record access, bathing care, and facility assessment
State Registered Nurse Assistant #11 SRNA Interviewed regarding bathing care for Resident #1
State Registered Nurse Assistant #12 SRNA Interviewed regarding bathing care for Resident #69
State Registered Nurse Assistant #13 SRNA Interviewed regarding bathing care for Residents #1 and #69
State Registered Nurse Assistant #14 SRNA Interviewed regarding shower team and bathing care
Corporate Nurse Interviewed regarding shower policy
Assistant Dietary Manager Interviewed regarding food temperatures and steam table issues
Dietary Manager DM Interviewed regarding food temperature expectations and food labeling

Inspection Report

Annual Inspection
Deficiencies: 10 Date: Nov 16, 2019

Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements, including investigation of abuse allegations and review of care plans and infection control.

Findings
The facility was found to have multiple deficiencies including failure to protect residents from abuse, failure to timely report and investigate abuse allegations, failure to maintain accurate and complete medical records, failure to provide appropriate pressure ulcer care, failure to revise care plans timely, failure to provide necessary assistance with activities of daily living, failure to maintain an effective infection control program, and failure to implement an effective quality assurance program.

Deficiencies (10)
Failure to honor resident's dignity and protect from abuse, including staff teasing and provoking residents, and intoxicated staff behavior.
Failure to protect resident from abuse when staff forcibly removed dentures causing distress and injury.
Failure to timely report suspected abuse to Administrator and state agencies.
Failure to thoroughly investigate allegations of abuse and neglect for multiple residents.
Failure to review and revise care plan timely after resident developed new pressure ulcers.
Failure to provide necessary care and assistance with activities of daily living, including oral care respecting resident's preferences.
Failure to provide appropriate pressure ulcer care including hand hygiene and incontinence care during wound treatment.
Failure to administer the facility effectively to ensure implementation and monitoring of plans of correction related to abuse reporting and investigation.
Failure to maintain medical records accurately, including documentation of meal intake.
Failure to maintain an effective infection prevention and control program, including failure to use personal protective equipment for residents on droplet precautions.
Report Facts
Number of sampled residents: 33 Number of residents affected by dignity abuse: 1 Number of residents affected by abuse: 1 Number of residents affected by abuse reporting delay: 1 Number of residents affected by incomplete abuse investigations: 5 Number of new pressure ulcers: 2 BIMS score: 3 BIMS score: 1 BIMS score: 6 BIMS score: 9 BIMS score: 12

Employees mentioned
NameTitleContext
SRNA #29 State Registered Nurse Aide Involved in forcibly removing Resident #17's dentures and intimidating behavior
SRNA #20 State Registered Nurse Aide Reported intoxicated while working, provoked residents, and caused injury
SRNA #42 State Registered Nurse Aide Reported abuse incidents and intoxication concerns, witnessed teasing of Resident #45
SRNA #41 State Registered Nurse Aide Reported intoxication of SRNA #20 and abuse incidents
RN #8 Registered Nurse Conducted oral assessment for Resident #17 and notified DON and RP
RN #1 Registered Nurse Provided wound care to Resident #2 with hand hygiene lapses
Administrator Facility Administrator Failed to ensure timely reporting and investigation of abuse allegations
Director of Nursing Director of Nursing Failed to ensure care plan revisions and proper abuse investigation and reporting
Quality Assurance Nurse Quality Assurance Nurse Failed to review incident reports for abuse reporting and investigation
RN #2 Registered Nurse Entered isolation room without mask

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