Somerset Healthcare: Repeated Pressure Ulcer Failures - PA
Somerset Healthcare & Rehabilitation Center was cited for failing to provide adequate treatment and prevention of pressure ulcers during an inspection that ended November 20, 2024. The facility responded the way facilities are required to respond: it developed a plan of correction. That plan included completing audits and reporting the results of those audits back to the facility's Quality Assurance and Performance Improvement committee for review.
Four months later, inspectors returned. They found the same violation.
The March 13, 2025 inspection cited Somerset Healthcare again for the identical failure, pressure ulcer treatment and prevention, and added a second finding on top of it: the facility's QAPI committee had failed to successfully implement the correction plan it had created after the first citation.
That second finding is what separates a single bad inspection from a pattern. A QAPI committee exists specifically to catch problems before they become recurring ones. It is the internal mechanism a nursing home uses to monitor itself, to review audit results, to identify when something is drifting back toward failure. At Somerset Healthcare, inspectors found that mechanism hadn't worked. The audits were supposed to happen. The results were supposed to go to the committee. The committee was supposed to act on them. Somewhere in that chain, the process broke down, and residents remained at risk for the same wound care failures that had already drawn a federal citation.
Pressure ulcers, also called bedsores or pressure injuries, develop when sustained pressure cuts off blood flow to skin and underlying tissue. They are among the most closely watched indicators of nursing home care quality because they are largely preventable with consistent repositioning, proper nutrition, and attentive wound monitoring. When they develop or worsen, it often means someone wasn't being turned, wasn't being checked, wasn't being treated on schedule.
The inspection report does not describe individual residents by name or detail the specific wounds inspectors found. What it documents is institutional failure at two levels: the direct care failure that produced the first citation, and the oversight failure that allowed the same problem to persist until the second.
Somerset Healthcare is not alone in this pattern. Nursing homes across the country receive citations, write correction plans, and receive the same citation again. The correction plan requirement exists to prevent exactly that cycle. When a QAPI committee fails to close the loop, when audits either don't happen or their results don't produce change, the plan of correction becomes a document rather than a remedy.
What the March 2025 inspection established is that Somerset Healthcare's plan was the latter.
The facility now carries two consecutive inspection cycles with pressure ulcer citations, and a finding that its own quality assurance process didn't catch or correct the problem in between. For residents who develop pressure injuries, or who are at risk of developing them, the gap between November 2024 and March 2025 was not a period of improvement. It was four months in which the facility's written commitments didn't translate into the care happening in the rooms.
The inspection report ends where it begins: with a committee that reviewed audit results and a deficiency that appeared anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Somerset Healthcare & Rehabilitation Center from 2025-03-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
SOMERSET HEALTHCARE & REHABILITATION CENTER in SOMERSET, PA was cited for violations during a health inspection on March 13, 2025.
The facility responded the way facilities are required to respond: it developed a plan of correction.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.