Pennsylvania Department of Health
SOMERSET HEALTHCARE & REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SOMERSET HEALTHCARE & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on April 20, 2026, it was determined that Somerset Healthcare and Rehabilitation Center, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:
Name: - Component: -- - Tag: 0026
Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to provide a plan for the role of the facility under a waiver declared by the Secretary of the Department of Health.

Findings include:

1. Interview and documentation review on April 20, 2026, at 8:50 a.m., revealed procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials, was not included in the EP plan.

Interview with the Facility Administrator and Maintenance Director on April 20, 2026, at 11:30 a.m. confirmed the EP plan lacked a written plan of the facility's role during a waiver declared by the Secretary of the Department of Health.

Plan of Correction - To be completed: 05/03/2026

The facility added the information related to 1135 waiver under the Stafford Act or National Emergency Act to out disaster plan in the event that the President declares a disaster or emergency. Also the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act.
The department heads will be in serviced on this added information by the Maintenance director / designee.
The review of this information as well as the entire disaster manual will be reviewed yearly by the maintenance director and Nursing Home Administrator to ensure that the policy and procedures remain pertinent to regulations.
The review of emergency policy and procedures will be discussed in Quality Assurance and Performance Improvement committee meetings monthly for two months then annually.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 970202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 20, 2026, at Somerset Healthcare and Rehabilitation Center, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected wood frame building, without a basement, which is fully sprinklered.

Plan of Correction:

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