Seminary Manor

Inspectors wroteBased on interview and record review the facility failed to notify the Health Care Power of Attorney of a change of condition for one (R1) of three residents reviewed for notification of changes.

Inspectors wroteBased on interview and record review the facility failed to prevent employee to resident mental abuse for one (R1) resident out of seven reviewed for abuse. This failure caused R1 to feel blindsided, dumbfounded, and embarrassed.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the Abuse Coordinator for one (R1) of seven residents in a sample of seven reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of abuse for one (R1) of seven residents in a sample of seven reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from sexual harassment by another resident, for one of three residents (R2), reviewed for abuse, in a sample of three. Th facility policy, Abuse Prohibition and Reporting, dated (revised) 11/28/19 directs staff that the facility prohibits abuse. The purpose of the policy is to protect residents from any kind of abuse such as verbal, sexual, mental, physical. The facility's definition of sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. R1's current Physician Order Sheet, dated March 2026 documents that R1 was admitted to the facility on [DATE]. R1's current Minimum Data Seat Assessment, dated 11/29/25 documents R1's cognitive status as 10 out of 15 (moderate impairment). R1's current Care Plan includes the following Problem Areas: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide staff supervision during toileting for a resident that was assessed as requiring toileting assistance (R2), one of three residents reviewed for falls, in a sample of 3. This failure resulted in R2 being left unsupervised, falling from a toilet resulting in a head laceration, extensive bruising and fractured ribs.

Inspectors wroteBased on record review and interview, the facility failed to: (1) return resident trust fund balances for 46 residents (R1, R5-R49) reviewed for trust fund balances after being discharged /expired 30 days; and, (2) provide notification or trust fund balances reaching $200 less than the SSI/Supplemental Security Income resource limit for three residents (R2, R3, and R4), of 111 residents, reviewed for trust fund account balances, in a total sample of 111 residents.

Inspectors wroteBased on interview and record review, the facility failed to conduct quarterly QAPI/Quality Assessment Plan Improvement meetings. This has the potential to affect all 97 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to identify, monitor and review antibiotic use for five of five residents (R25, R40, R47, R74, R297) reviewed for antibiotic stewardship in the sample of 44 residents. This failure has the potential to affect all residents who reside in the facility with a current census of 97 residents.

Inspectors wroteBased on interview and record review, the facility failed to discontinue a PRN/as needed medication for one resident (R237) of 20 residents reviewed for unnecessary drugs in a sample of 44.

Inspectors wroteBased on interview and record review, the facility failed to develop a Care Plan to include a blood thinner and Insulin for one resident (R235) of 20 residents reviewed for Care Plan development in a total sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply leg compression stockings for one resident (R69) of one residents reviewed for compression stockings in a sample of 44.

Inspectors wroteBased on interview and record review, the facility failed to identify potential triggers, triggers for a past trauma-related incident, or emotional support needed for one resident (R237) of one resident reviewed for trauma informed care in a sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions to prevent pressure ulcer development and worsening, conduct a pressure ulcer risk assessment once a week for four weeks after admission, obtain a treatment for a newly identified pressure ulcer, and accurately and thoroughly assess pressure ulcers weekly for two of three residents (R1 and R2) reviewed for facility acquired pressure ulcers in the sample of five. These failures resulted in R1 developing an unstageable pressure ulcer to the left heel six days after admission to the facility and R2 developing a stage three pressure ulcer to the right heel and an unstageable pressure ulcer to the inner ankle that required autolytic debridement (using own body's enzymes to remove dead tissue) and caused R2 severe pain.

Inspectors wroteBased on record review and interview, the facility failed to monitor the level of Oxygen in a portable Oxygen tank for a resident diagnosed with Congestive Heart Failure, ensure a continuous Oxygen supply was administered as ordered by the Physician, and failed to perform an assessment after a resident went without Oxygen and experienced respiratory distress and a low pulse oximetry reading for one of three residents (R1) reviewed for Oxygen use in the sample of five. These failures resulted in R1 being without oxygen for 20 minutes on one occurrence and 10 minutes on second occurrence, which caused R1 to experience chest pain, shortness of breath, feelings of being smothered and imminent death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a nebulizer mask and nebulizer tubing was changed every seven days and stored in a bag between uses for two residents (R2 and R18) and failed to ensure Oxygen tubing was changed every seven days for two of four residents (R2, R34, and R62) reviewed for respiratory care in a sample of 30.

Inspectors wroteBased on interview observation and record review the facility failed to ensure that wound care supplies were disinfected after each resident's wound cares. This failure has the potential to affect residents (R34, R57, R62, R67, R80, R199) that receive wound cares in the facility.

Inspectors wroteBased on interview and record review, the facility failed to document justification for the use of duplicative antidepressant therapy for one of five residents (R18) and failed to document the justification for reinstating an antipsychotic for one resident (R60) reviewed for psychotropic medications in the sample of thirty. Findings Include: The facility's Psychopharmacologic Drug Usage Procedure, dated 10/18/17, documents Definition: A psychopharmacologic Drug is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety medications, and sedatives/hypnotics. Procedure: Use of psychopharmacological medications requires assessment by the attending physician, and specific orders must be written by the attending physician with supporting diagnoses. 2. [...]

Inspectors wroteBased on interview and record review the Facility failed to reasonably accommodate one of three Residents (R1) reviewed for Resident cares in a sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately notify the physician to obtain a treatment for a UTI (Urinary Tract Infection) for one of three residents (R1) reviewed for UTI's in the sample of three. These failures resulted in R1's UTI being left untreated for 12 days and R1 experiencing increased moaning, pain, and discomfort. This resulted in R1 being sent to the emergency room and admitted to the local hospital for four days to receive treatment with intravenous antibiotics for the diagnosis of Sepsis secondary to a UTI.

Inspectors wroteBased on record review and interview the facility failed to develop a comprehensive urinary tract infection care plan for two of three residents (R2 and R3) reviewed for UTI's (Urinary Tract Infection's) in the sample of three.

Inspectors wroteBased on observation, interview and record review, the facility failed to failed to wear the proper PPE (Personal Protective Equipment) during the serving of food, failed to discard expired food, and failed to maintain cleanliness of a refrigerator used for the storage of resident food. This failure has the potential to affect all 18 residents (R4, R15, R26, R32, R33, R36, R40, R41, R48, R52, R54, R58, R66, R68 and R177 through R180) currently residing on the facility Dementia Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and document a residents pressure ulcer on a MDS (Minimum Data Set) assessment for one of two residents (R29) reviewed for pressure ulcers in the sample of 44.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan addressing the use of insulin for one of one residents (R2) reviewed for insulin in the sample of 44.