Seneca Trail Healthcare Center

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to honor residents' rights to maintain respect and dignity. For Resident #29, the facility failed to ensure the resident's indwelling catheter urine collection bag was covered for privacy. This was true for one (1) of three (3) residents reviewed for the care area of urinary catheter. For Resident #57, the facility failed to ensure the resident received his meal drink when the other residents received their drinks. This was true for one (1) of eight (8) residents observed in the first floor dining room. For Resident #49, the facility failed to ensure the resident was not exposed to a staff member complaining about her job caring for residents. This was true for one (1) of two (2) residents reviewed for the care area of dignity. Resident Identifiers: #29, #57, and #49. Facility census: 78.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure activities of daily living were completed for dependent residents. This was true for two (2) of four (4) residents reviewed under the care area of activities of daily living throughout the Long-Term Care Survey Process. Resident Identifiers: #88 and #57. Facility Census: 79. Findings Included: a) Resident #88 On 03/19/2026 at 11:15 AM, a record review was completed for Resident #88. The documentation for 01/2025 and 02/2025 found showers and bed baths were not provided for Resident #88. The following dates show the length of time the resident did not receive showers or bed baths: --01/11/25-01/18/25 seven (7) days --02/12/25-02/22/25 10 days On 03/19/26 at 12:25 PM, the Director of Nursing (DON) confirmed showers and bed baths were not provided to the resident during the above-mentioned timeframes. [...]

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure palatable food. The baked potatoes for the noon meal on 03/18/26 were not thoroughly cooked. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #18, #15, #60, #13, #4, #38, #74, #20, #40, #9, #73, #22, #37, #68, #66, and #10. Facility Census: 78.

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards of practice. This had the potential to affect more than a limited number of residents in the facility. Facility census 79.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records in the areas of pneumococcal vaccination consents for four (4) of five (5) residents reviewed for immunizations. Additionally, the facility failed to ensure complete and accurate medical records in the areas of medication administration records (MARs), medication and supplement orders, and skin assessments for three (3) of 25 residents reviewed during the Long-Term Care Survey Process. Resident Identifiers: #47, #9, #83, #2, #6, #5, and #27. Facility Census: 78.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Transmission based precautions were not followed. A nebulizer mask was not stored in an appropriate sanitary manner. Food was not served in a sanitary manner. Additionally, wheelchairs had holes, cracks, and exposed padding which made the wheelchairs unable to be thoroughly cleaned. These were random opportunities for discovery. Resident Identifiers: #29, #14, #23, #62, #68, #51, #66, and #14. Facility census: [...]

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to honor a resident's choice about the schedule that was important to them, such as when the resident preferred to have a shower. This was true a random opportunity for discovery. Resident identifier: #49. Census: 79.

Inspectors wroteBased on policy review, resident interview, and staff interview, the facility failed to ensure staff documented verbal grievances from residents and share the information with the grievance officer in order to ensure prompt efforts to resolve a grievance. This was true for one (1) of three (3) residents sampled for missing personal property throughout the Long-Term Care Survey Process. Resident identifier: 77. Census: 79.

Inspectors wroteBased on policy review, resident interview, observation, and staff interview, the facility failed to identify a resident's statement as an allegation of verbal abuse and report it to the appropriate state agencies according to state law. This was true of one (1) of two (2) residents sampled for abuse throughout the Long-Term Care Survey Process. Resident identifier: #49. Census: 79.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all diagnoses were included on the Pre-admission Screening and Resident Review (PASARR) for Resident #10. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #10. Facility Census: 79. Findings Included: a) Resident #10 On 03/16/2026 at 3:59 PM, a review of the PASARR, dated 04/08/25, for Resident #10 was reviewed. The review found all diagnoses were not included on the PASARR. The following diagnoses were not included: --Moderate Intellectual Disabilities, added to the medical record on 04/08/25--Vascular Dementia, moderate with anxiety and psychotic disturbance, added to the medical record on 02/02/26 On 03/19/2026 at 10:21 AM, an interview was held with the Director of Social Services #70. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to implement the care plan regarding an indwelling urinary catheter. This was true for one (1) of three (3) residents reviewed for the care area of urinary catheters. Resident Identifier: #29. Facility Census: 78.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure the retained documentation to reflect Resident #57 was given the choice on a daily basis to wear splints on both hands to prevent further decrease in range of motion. This was true for one (1) of three (3) residents sampled for limited range of motion (ROM) throughout the Long-Term Care Survey Process. Resident identifier: #57. Census: 79.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure Resident #57 was offered sufficient fluid intake to maintain proper hydration. This was true for one (1) of two (2) residents sampled for hydration throughout the Long-Term Care Survey Process. Resident identifier: #57. Census: 79.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure Resident #1 received oxygen therapy as ordered by physician. This was true for one (1) of one (1) residents sampled for respiratory care throughout the Long-Term Care Survey Process. Resident identifier: #1. Census: 79.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to update the daily staff postings at the beginning of the shifts regarding changes in staffing numbers. This was true for nine (9) of nine (9) daily staff postings reviewed under the care area of staffing throughout the Long-Term Care Survey Process. Facility Census: 79. Findings Included: a) Daily Staff Postings On 03/17/2026 at 11:00 AM, a review of nine (9) daily staff postings was completed. The review found all nine (9) daily staff postings had not been updated at the beginning of the shift to indicate changes in staffing. The dates were as follows: [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents were provided adaptive eating equipment as ordered by the physician. This deficient practice had the potential to affect one (1) of eight (8) residents reviewed for the care area of nutrition. Resident Identifier: #13. Facility Census: 78.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure food was stored and served under sanitary conditons and that food temperatures were logged for three (3) meals. There were items not labeled, opened and expired. Census 78.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure trash and debris were stored in a safe and sanitary manner to prevent harborage of pests. The facility failed to keep the dumpster closed when not in use. This failed practice had the potential to affect more than a limited number of residents. Facility census: 78.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) record was completed correctly for a resident's discharge. This was true for one (1) of 24 residents whose MDS records were reviewed during the long-term care survey process. Resident Identifier: #78. Facility Census: 78. a) Resident # 78 During a medical record review on 09/05/24 at approximately 9:00 AM the MDS dated [DATE] was reviewed and identified the following; * Section (A) A 0310- (f) that the discharge assessment anticipated the resident to return. * Section (A) A 2105 the resident is discharged to home/community. * Section (A) A 2123 was not completed to identify if the provision of the current reconciled medication list for the resident at discharge was provided at time of discharge. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement Resident #77's care plan. For Resident #77, the facility failed to implement the care plan to educate on end-of-life decisions. This was true for one (1) of two (2) residents reviewed for the Long-Term Care Survey Process. Resident identifier: #77. Facility census: 78.

Inspectors wroteBased on medical record review and staff interview the facility failed to revise the comprehensive care plan for anxiety. This was true for 1 of 5 residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review during the long term care survey process. Resident Identifier: #60. Facility Census: 78. a) Resident #60 During a medical record review on 09/05/24 it is identified that Resident #60 has a diagnosis of anxiety order date 03/09/23. It is further identified that the resident has a past medical history of anxiety, depression, insomnia, mood disorder and inappropriate sexual behaviors. It is identified that the resident has been seen for psychiatric services since 01/26/24 due to behaviors including but not limited to sexual behaviors. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure care and services provided to one (1) of three (3) resident's were in accordance with professtional standards of practice to meet the resident's highest possible level of functioning and well being of the resident. Resident #67 received enteral feeding. The resident experienced a weight loss. The facility had not ensured the resident's enteral feeding volume was being documented and the nurse practitioner did not follow up for concerns regarding the resident's weight loss. Resident identifier: #67. Facility census: 78.

Inspectors wroteBased on a review of the facility records and staff interviews, the facility failed to ensure the staff posting forms were accurate with direct care nursing staff totals and direct care nursing staff hour totals. The facility also failed to retain the staff posting form for 18 months. This was identified during the long term survey process and had the ability to affect a limited number of residents. Facility Census: 78.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the residents medical record was completed accurately when completing the skilled documentation. This was true for one (1) of 24 residents' medical records reviewed during the long-term care survey process. Resident Identifier: #56. Facility Census: 78. a) Resident #56 During a medical record review on 09/10/24 at 12:31 PM it is identified that the Skilled Documentations (User Defined Assessment) UDA's from 08/15/24 through 09/02/14 was completed with the functional status under section (A), number four (4), that Resident #56 was receiving occupational and physical therapy services per each day from 08/15/24 through 09/02/14. Further review of the resident's orders, the occupational and physical therapy services had been discontinued as of 08/14/24. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to maintain an effective pest control program for flies. This was a random opportunity for discovery during the long term care survey process. This had the opportunity to affect a limited number of residents. Resident #55. Facility Census. 78.

Inspectors wroteBased on resident interview, and staff interview the facility failed to promptly investigate an alleged violation of verbal abuse and mistreatment and failed to prevent further potential neglect and mistreatment while the investigation is in progress. This had the potential to affect all residents at the facility. Resident identifier: #9. Facility census 76. The facility was first notified of the Immediate Jeopardy (IJ) on 09/27/23 at 4:33 PM. The State Agency (SA) received the Plan of Correction (POC) at 5:56 PM on 09/27/23. The SA accepted this POC at 5:59 PM on 09/27/23. The following is the facility's POC typed as written: Abatement Plan F610. On 09/28/23 the Nursing Home Administrator and the Director of Nursing implemented the following plan: Plan of correction accepted on 09/27/23 at 5:59 PM 1. [...]

Inspectors wroteBased on resident interview, and staff interview the facility failed to implement written policies and procedures that: promptly report, investigate and protect the resident from an alleged abuser in a timely manner. This had the potential to affect all Residents at the facility. Resident identifier: #9. Facility census 77.

Inspectors wroteBased on resident interview, and staff interview the facility failed to promptly report an allegation of alleged verbal abuse and mistreatment to the proper State authorities. This had the potential to affect all residents at the facility. Resident identifier: #9. Facility census 76.

Inspectors wroteBased on Resident interview, Resident council meeting members, observation and review the facility Grievance/ Concerns forms found the facility failed to ensure all meals served were palatable, attractive, and served at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents who reside at the facility. Resident identifiers: #42, #6, #52, #15, #77, #68, #48, #76, #39, #9, #13, #2, #8, #14, #56, #55, and #7. Facility census 77.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The physician's orders were not followed regarding the amount of nutritional supplement to be given. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #19. Facility census: 71.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that a copy of the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of three (3) reviewed for the care area of hospitalization during the Long-Term Care Survey Process. Resident Identifiers: Resident #62. Facility Census: 71. Findings Included: a) Resident #62 A review of a facility policy titled Transfer of a Resident with an effective date of 10/01/22 found the following. .8. The facility will send a copy of the notice to the State Long-Term Care Ombudsman as directed by state law. A medical record review on 10/31/22 at 3:24 PM revealed Resident # 62 had the following hospital stays: -On 07/10/22 Resident #62 was sent to the local emergency room for behaviors, admitted to another hospital then returned to facility on 07/25/22. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to accurately code the minimum data set (MDS) in the area of a ventilator for Resident #47. This was true one (1) of 23 resident MDS assessments reviewed during the Long Term Care Services Process. Resident identifier: #47. Facility census: 71.

Inspectors wroteBased on observation, resident interview, record review and staff interview the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. This was true for two (2) of 23 sampled residents during the Long-Term Care Survey Process. Resident Identifiers: Resident #61 and Resident #28. Facility census: 71. Findings Included: a) Resident #61 During an interview on 10/31/22 at 11:52 AM Resident # 61 stated I can't hear you. I don't have my hearing aides in. During an interview on 10/31/22 at 11:53 AM Activity Assistant #28 stated No Resident #61 does not have her hearing aides in, I will let someone know. During an interview on 10/31/22 at 11:54 AM Licensed Practical Nurse (LPN) #30 stated she only wears them at times. She refuses to wear them a lot. [...]

Inspectors wroteBased on observation, resident interview, medical record review and staff interview the facility failed to provide care to a resident that required assistance for hearing aid placement, for a resident who is dependent for Activities Of Daily Living (ADL) care. This was true for one (1) of two (2) review in the care area of ADL's. Resident Identifiers: Resident #61. Facility Census: 71 Findings Included: a) Resident #61 During an interview on 10/31/22 at 11:52 AM Resident # 61 stated I can't hear you. I don't have my hearing aides in. During an interview on 10/31/22 at 11:53 AM Activity Assistant #28 stated No Resident #61 does not have her hearing aides in, I will let someone know. During an interview on 10/31/22 at 11:54 AM Licensed Practical Nurse (LPN) #30 stated she only wears them at times. She refuses to wear them a lot. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents received necessary treatment and services to promote the healing of a pressure ulcer, prevent complications, and prevent new ulcers from developing. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifier: #28. Facility census: 71.

Inspectors wroteBased on observation, staff interview and record review the facility failed to ensure the resident's environment was as free from accident hazards as possible. The facility failed to complete a post fall investigation for one (1) of (3) three residents reviewed for falls. During a random opportunity for discovery, a Medication cart was found to be left unlocked while unattended by staff. These failed practices had the potential to affect a limited number of residents. Resident identifier: #28. Facility census: 71. Findings incuded: a) Medication Cart Observation on 11/03/22 at 12:12 PM found the Long Hall Medication cart on the first floor sitting outside of the dining room in the hallway, the medication cart was unlocked and unattended by staff. Registered Nurse (RN) #4 returned to the medication cart at 12:13 PM. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure enteral (tube) feeding was administered in accordance with professional standards of practice. The bags containing enteral tube feeding and enteral water flush were not labeled to indicate when the bags and tubing had been hung. This failed practice had the potential to affect one (1) of two (2) residents reviewed for care area of tube feeding. Resident identifier: #27. Facility census: 71.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to use proper infection control measures during the storage of Bilevel Positive Airway Pressure (BiPap) mask for Resident #29. This failed practice was random opportunity for discovery and was true for Resident #29. Resident identifier: #29. Facility census: 71.