Seminole Manor Nursing Home

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self Administration of Medication, the facility failed to ensure one of 30 sampled residents(R) (R8) did not have unauthorized and unsecured medications and medicated treatment products at the bedside. This deficient practice had the potential to cause adverse effects for R8 and allow unsecured medications and medicated treatment products to be accessible to other residents.

Inspectors wroteBased on observations, staff interviews and review of the policy titled, Safe Homelike Environment, the facility failed to ensure that dust and grime buildup was addressed in three of 13 rooms (N115, N118, and N122) in the facility with portable units. The facility also failed to repair one room (N122) with a hole in the wall and failed to fix or replace one fixture on the wall border interior in the same room.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to develop a comprehensive care plan for three of 30 sampled residents (R) (R19, R10, and R11). The facility failed to address wound care for R19 and failed to address oxygen therapy use for R10 and R11 related to oxygen administration. This failure had the potential to affect residents by resulting in inconsistent care, unmet needs, and an increased risk of adverse outcomes.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Policies and Procedures, the facility failed to assure two of 15 residents (R) (R10 and R11) receiving oxygen therapy was administered oxygen in accordance with the physician's order. Specifically, the facility failed to ensure that residents received oxygen at the rate prescribed by the physician and failed to ensure oxygen signage was posted during the administration of oxygen therapy to prevent accident hazards. This deficient practice had the potential to result in residents not receiving adequate oxygenation as ordered and increased the risk of fire hazards due to the absence of appropriate safety signage.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to ensure one of three medication carts was locked and secured. This deficient practice increased the risk of misuse, diversion, and potential harm to residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Pureed Diets, the facility failed to ensure pureed, therapeutic diets were properly prepared for two out of nine sampled residents (R) (R20 and R60) receiving a therapeutic pureed diet. This deficient practice had the potential to cause medical complications and place the residents at risk for unmet nutritional needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Food: Preparation, the facility failed to ensure sanitary practices were followed during food preparation. This deficient practice had the potential to place the 62 residents who received food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, staff interview, and review of the facility's policy titled Storage of Records, the facility failed to ensure confidential medical, financial, and legal records were stored in a manner to prevent unauthorized access to the records. This deficient practice had the potential to compromise the confidentiality of resident records.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policie titled Dignity and Routine Resident Checks, the facility failed to provide care in a manner to promote dignity and respect for five of seven residents (R) (R3, R9, R57, R60, and R54) who were noted to have food spills on their clothing or dirty, jagged fingernails. This failure had the potential to diminish R3, R9, R57, R60, and R54's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Pharmacy Services For Medications and Multi-Dose Vials, the facility failed to ensure routine medications were available for two of four residents (R) (R8 and R62) observed during medication administration. The deficient practice had the potential to place R8 and R62 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Medication Storage And Labeling, the facility failed to ensure one of three medication carts was locked and secured when unattended and out of the sight of authorized personnel, failed to ensure expired medications and medical supplies were discarded from the storage room and treatment cart, and failed to ensure a multi-dose vial of insulin was dated when opened. These deficient practices created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and placed residents at risk of receiving medications with altered effectiveness. The facility's census was 64 residents.

Inspectors wroteBased on observations, resident interviews, and staff interviews, the facility failed to serve food to residents that was palatable, attractive, and appetizing. This deficient practice had the potential to adversely affect 62 residents who received meals from the kitchen.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled Call System, Resident, the facility failed to ensure one of 41 sampled residents (R) (R9) call devices was within reach.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure four of 42 sampled residents (R) diagnoses were kept private and confidential. This failure had the potential to affect all residents with a diagnosis of diabetes living in the facility. Observation on 4/22/2025 at 9:30 am revealed that an undated handwritten list titled Diabetics was seen posted on the wall in the activity room. There was a window between the lobby and the activity room that allowed clear visibility of the list to anyone visiting the facility. The activity room was used daily by residents and staff. During an interview with the Activities Director on 4/24/2025 at 2:35 pm, she stated that the list was used to ensure residents with diabetes received snacks appropriate for them and acknowledged that she was unaware that posting that sign was a privacy and confidentiality issue.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policies titled Nebulizer Equipment and Oxygen Equipment, the facility failed to maintain respiratory equipment in a sanitary manner for four residents (R) (R9, R14, R28, and R37) of 41 sampled residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Psychotropic Medications, the facility failed to ensure that as-needed (PRN) orders for psychotropic medications were limited to 14 days for one of six residents (R) (R29) reviewed for the use of unnecessary medications.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Pharmacy Services For Medications, the facility failed to ensure the medication error rate was less than 5 percent. A total of 30 opportunities were observed with two errors for two residents (R8 and R62), resulting in an error rate of 6.67 percent. This failure had the potential to place R8 and R62 at risk of medication not being given in accordance with the physician's orders and had the potential to adversely affect the residents' clinical conditions.

Inspectors wroteBased on interview and review of policy titled Infection Preventionist, the facility failed to employ a qualified Infection Preventionist who had completed the required specialized training in infection prevention and control. This deficient practice had the potential for creating an ineffective infection prevention program that may contribute to the spread of COVID-19 for all residents in the facility. The census was 55 residents.

Inspectors wroteBased on observations, record reviews, staff observations, and review of policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to follow the care plans related providing oxygen as ordered for one resident (R) (R#29) and failed to follow care plan related to cleaning or storage of nebulizer mask after each use for one resident (R#30) for 30 sampled residents. Findings Include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered revised date March 2022 revealed the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. [...]

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility policy titled, Administering Medications, the facility failed to ensure a Physician's Order for oxygen therapy was followed for one of 12 residents (R) (#29) with orders for oxygen therapy.

Inspectors wroteBased on observation, staff interviews, record review and review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to prevent the spread of infections by not cleaning and properly storing a nebulizer mask for one resident (R) (#30), of seven sampled residents receiving nebulizer treatments. Findings Include: Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment (revised date September 2022) revealed the following: Policy Statement - Resident-Care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. [...]