Seville Care Center

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents at risk of exposure which could lead to illness. The facility census was 45. 1. Review of the Centers for Medicare and Medicaid Services (CMS), QSO-17-30, dated 06/02/17 and revised 07/06/18, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an appropriate emergency discharge notice when staff discharged one resident (Resident #1) to the hospital and refused to allow the resident to return to the facility. The facility census was 45.1. Review of the facility's Making and Emergency Transfer or Discharge policy, revised April 2007, showed staff are directed to only make an emergency discharge when it is in the best interest of the residents. To make an emergency discharge the facility will implement the following procedures:-Notify the residents attending physician;-Notify the receiving facility that the transfer is being made;-Prepare the resident for transfer;-Prepare a transfer form to send with the resident;-Notify the representative and other family members;-Assist in transportation.2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent misappropriation of money from one resident, (Resident #1), out of five sampled residents, when the Director of Nursing (DON) stole $1700.00 from the resident, without the resident's consent. The facility census was 48. The administrator was notified on 12/10/25 of past Non-Compliance which occurred on 12/05/25. On 12/05/25, the administrator investigated and notified the police department of the theft. The administrator terminated the DON on 12/05/25; in-serviced all staff on the facility's abuse, neglect, and misappropriation policies on 12/05/25; and reimbursed the resident $1700.00. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify two resident's (Resident #2 and #3's) physician out of three sampled residents after staff documented they assessed the residents with abnormal blood pressure (BP) readings. The facility's census was 46.1. Review showed the facility did not provide a policy in regard to vital signs (measurements of the body's basic functions to include blood pressure). Review of the facility's Significant Condition Change and Notification policy, undated, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to keep one resident (Resident #1) free from verbal and emotional abuse when Licensed Practical Nurse (LPN) A yelled at the resident to shut up multiple times, directly in his/her face. The facility census was 50. The administrator was notified on 4/25/25 of past Non-Compliance, which occurred on 4/09/25 when staff reported the allegation. Staff immediately suspended LPN A pending the results of the investigation, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 4/09/25. 1. Review of the facility's Abuse, Prevention and Prohibition policy, dated 11/2018, showed the facility prohibits the mistreatment, neglect, or abuse of residents. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to develop an abuse and neglect policy which met the required time frame to report immediately, but not later than two hours after an allegation of abuse or neglect. The facility census was 49. 1. Review of the facility's Policy & Procedure Abuse and Neglect Prevention policy, revised on 02/15/2012, showed: -The resident has the right to be free from verbal, sexual, and physical, and mental abuse, corporal punishment, and involuntary seclusion; -Once the facility administration becomes aware of any of these alleged violations, the home must report immediately to the designated state agency, CMS indicates that the term immediately means as soon as possible, but no more than 24-hours after the alleged incident is discovered. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure services provided met professional standards of practice when staff did not contact the physician for a pain medication refill order in a timely manner for one resident (Resident#30) of one sampled resident. Facility staff failed to follow physician orders when staff did not document the administration of medications and tube feedings for one resident (Resident #45). Staff failed to complete and document neurological checks for three (Resident #1, #18, and #30) of six sampled residents who had unwitnessed falls, as directed by the facility policy. The facility's census was 49. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 49. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: -Thursday 07/04/24; -Friday 07/05/24; -Saturday 07/06/24; -Sunday 07/07/24; -Wednesday 07/10/24; -Saturday 07/13/24; -Sunday 07/14/24; -Monday 07/15/24; -Tuesday 07/16/24; -Saturday 07/20/24; -Sunday 07/21/24; -Saturday 07/27/24; -Sunday 07/28/24. 3. Review of the facility's RN staff schedule, dated August 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates on: [...]

Inspectors wroteBased on observation, interviews and record review, facility staff failed to properly complete weekly skin assessments, and failed to notifiy the physician and obtain a treatment order for one resident (Resident #6) of one sampled resident who developed a new facility-acquired pressure ulcer to the resident's right buttock. The facility's census was 49. 1. Review of the facility's policy titled, Pressure Ulcer/Pressure Injury Prevention, dated April 2018, showed, if a pressure ulcer/pressure injury is present, provide treatment to heal it and prevent development of additional pressure ulcers/pressure injuries. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. The facility census was 49. 1. Review of facility's policies showed staff did not provide a policy in regards to qualifications for the Activity Director position. 2. Review of the facility's Activities Designee job description, undated, showed the Activity Director must receive Activity Designee certification within six months of hire. 3. Review of the facility maintained personnel records showed the Activity Director with a hire date of 05/17/24. During an interview on 01/15/25 at 11:45 A.M., the Activity Director said he/she does not have his/her Activity Director certification. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to protect residents' privacy when staff failed to provide privacy during perineal care for two residents (Resident #1 and # 9) out of two sampled residents. The facility's census was 49. 1. Review of the facility's policy titled, Resident Rights, dated October 2009, showed employees shall treat all residents with kindness, respect, and dignity, and each resident has the right to privacy and confidentiality. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 11/03/24 showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent on staff for dressing, toileting hygiene, and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the comprehensive care plan for one resident (Resident #2) out of two sampled resident care plans, when the resident wandered into another resident room. The facility census was 51. 1. Review of the facility's Comprehensive Care Plan policy, dated 02/01/24, showed staff are directed as follows: -The Minimum Data Set (MDS), a federally mandated assessment tool, Coordinator or designee shall act in a case management role by knowledge of ongoing care needs; -The policy did not contain direction or guidance when the care plan should be updated when changes in resident care is observed. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/29/24, showed staff assessed the resident as: -Cognitively impaired; -Used a wheelchair; [...]

Inspectors wroteBased on record review and interviews, the facility staff failed to ensure one resident (Resident #1) out of three residents were allowed to make choices about aspects of their lives when staff did not allow the resident who is his/her own responsible party and assessed to smoke a cigarette independently as a consequence for his/her behavior. The facility census was 44. 1. Review of the facility's Resident Rights policy, undated, showed residents have the right to a dignified existence and self-determination. Review of the facility's smoking policy, dated 01/08/23, showed: -Resident's will be assessed at the time of admission and reassessed at a minimum quarterly or with a significant change to determine the level of assistance and supervision required to ensure resident safety; [...]

Inspectors wroteBased on interviews and record review, facility staff failed to notify the physician in a timely manner for one resident (Resident #1) who stated he/she felt like harming himself/herself. The facility census was 44. 1. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, dated February 2023, showed staff were directed to do the following: -Any resident with a behavior that has been identified would present a potential danger to either himself/herself or other residents will be placed on increased visual monitoring, unless other immediate interventions are needed; -The charge nurse will notify the attending physician and family of the behavior. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/22/23, showed staff assessed the resident as follows: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. The facility census was 44. 1. Observation on 11/13/23 at 12:15 P.M., showed [NAME] N served residents the noon meal per the Week one, Day two preplanned menu. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain kitchen exhaust fans, lighting devices and ceiling surfaces in a clean sanitary manner to prevent the potential for cross-contamination. The facility census was 44. 1. Observation of the kitchen on 11/13/23 at 11:05 A.M., showed: -The ceiling above the three part sink had a large unfinished, repaired area. Observation showed the gypsum wallboard was unpainted and the joints were not taped or sealed, leaving gaps in the ceiling. Observation also showed the patched area was not flush and large areas hung below the ceiling level, exposing gypsum material; -Two ceiling exhaust fans had large accumulations of dust and grease; Six fluorescent tube light fixtures had missing covers, exposing twelve light bulbs; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for five residents (Residents #21, #24, #25, #34 and #43), when facility staff did not honor residents dietary preferences. The facility census was 44. 1. Review of the facility's policy titled, Resident's Rights, dated Month 2009, showed staff employees shall treat all residents with kindness, respect, and dignity. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Review of the facility's policy titled, Resident Food Preferences, dated December 2008, showed the Dietician will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. [...]

Inspectors wroteBased on observation and interview, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, doors, door frames, lighting devices, and an effective pest control program. The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for environmental concerns. 2. Observations on 11/13/23 and 11/14/23 during the Life Safety Code tour showed: -a broken hall light cover outside resident room [ROOM NUMBER]; -a large accumulation of dead insects in the hall light between resident rooms [ROOM NUMBERS]; -a large brown stain on the ceiling outside resident room [ROOM NUMBER]; -a broken light cover outside resident room [ROOM NUMBER]; -a missing hall light cover between resident rooms [ROOM NUMBERS]; -a cracked hall light cover outside resident room [ROOM NUMBER]; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for four residents (Resident #7, #30, #41, and #46). The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for baseline care plans. 2. Review of Resident #7's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 3. Review of Resident #30's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 4. Review of Resident #41's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 5. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure eight residents (Residents #5, #7, #11, #23, #32, #34, #36 and #37), who were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene. The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for ADLs. 2. Review of Resident #5's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/31/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not reject care; -Dependent on staff for toileting, bathing, dressing, bed mobility and transfers; -Always incontinent of bowel and bladder; [...]

Inspectors wroteBased on interview, and record review, facility staff failed to provide a 14-day stop date for as needed (PRN) psychotropic medications (any drug that affects behavior, mood, thoughts or perceptions), for three residents (Residents #6, #30, and #41). The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for psychotropic medications. 2. Review of Resident #6's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/18/23, showed staff assessed the resident as: -Severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a safe mechanical lift transfer for one resident (Resident #8) and failed to keep residents safe while smoking by not implementing smoking interventions and utilizing smoking assistive devices for two residents (Resident #34 and #36). The facility census was 44. 1. Review of the facility's policy titled, Lifting Machine, Using a Portable, dated 10/10, showed staff were directed to do the following: -To transfer a resident from a bed to a chair, you should position the resident comfortably in the chair, grasp the top of the sling with one hand and pull back on the sling while lowering the resident into the chair. -Review showed it did not contain direction for staff to guide the resident while using the machine or the positioning of the legs of the machine. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). Additionally, facility staff failed to remove soiled gloves and/or properly wash hands during incontinence care for two residents (Resident #8 and #25) to prevent the spread of bacteria and other infection causing contaminants. The facility census was 44. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight memo (QSO-17-30- Hospitals/CAHs/NHs), revised 7/06/18 showed: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to conduct inspections of bed rails as part of a regular maintenance program for two residents (Resident #8 and #20) to identify areas of possible entrapment. The facility census was 44. 1. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013 identifies seven different potential, zones of entrapment. [...]

Inspectors wroteBased on observation, record review and interviews, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) and cold foods at or below 41° F for for 9 residents (Resident #5, #16,#17,#25, #28, #29, #31, #35, and #494) at the time of meal service and failed to implement a system of monitoring food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents who received room trays. Further, staff failed to serve palatable food to residents. The facility census was 42. 1. Review of the facility's Meal Service Temperatures policy dated, revised January 2017, showed staff were directed as follows: -Meal temperatures shall be monitored by the dietary manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff failed to appropriately wash and sanitize manually washed kitchenware to prevent cross-contamination. Facility staff failed ensure kitchen waste containers were covered when not in actual use to deter the attraction of pests and rodents. Facility staff failed to prepare pureed food items in accordance with standardized recipes to ensure pureed foods served to four residents (Residents #11, #12 #15 and #34) were reheated to an internal temperature of 165 degrees Fahrenheit (dF) or greater prior to service to prevent the growth of food-borne pathogens and food-borne illness. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to refund resident funds within 30 days of discharge for six residents (Resident # 286, #287, #288, #289, #290 and #291). The facility census was 42. Review of the facility policies showed they did not have a policy for resident refunds after discharge. 1. Review of the facility's aging report, dated 9/15/22, showed the following residents had money in the facility's operating account: -Resident #286 was discharged on 5/21/20: with a balance of $763.35; -Resident #287 was discharged on 2/14/22: with a balance of $1681.80; -Resident #288 was discharged on 2/1/21: with a balance of $152.67; -Resident #289 was discharged on 3/5/21: with a balance of $152.55; -Resident #290 was discharge on [DATE]: with a balance of $976.38; -Resident #291 was discharged on 6/3/22: with a balance of $1,410.66. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 42. 1. Review of the resident's trust fund account for September 2021 through August 2022, showed an average monthly balance of $34,001.33, which requires a surety bond of $45,000.00. Further review showed the current ledger amount was $32,430.90. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $40,000.00. During an interview on 9/16/22 at 10:30 A.M., the Business Office Manager (BOM) said the administrator was responsible to ensure the bond amount was sufficient. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to include the triggered care areas for four residents (Resident #14, #17, #24 and #30). The facility census was 42. 1. Review of the facility's Care Planning- Interdisciplinary Team Policy, dated 2/2021, showed staff is directed to the following: -Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual; -To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the comprehensive care plans were updated for three residents (Resident #3, #21, and #489). The facility census was 42. 1. Review of the facility's Care Planning- Interdisciplinary Team Policy, dated 2/2021, showed staff is directed to the following: -Every resident will be assessed using the Minimum Data Set (MDS), a federally mandated assessment tool, according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual; Use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practicable level of mental functioning, physical functioning, and well-being as possible; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to meet professional standards of care delivery when they failed to date and time Fentanyl patches for two residents (Residents #7 and #30), obtain a physician's order for the delivery of Continuous Positive Airway Pressure / Bilevel Positive Airway Pressure (CPAP / BiPAP, a device that helps with breathing) for two residents (Resident #14 and #35), ensure correct delivery of respiratory medications for two residents (Residents #3 and #490), address multiple treatment refusals or inability to perform treatments for one resident (Resident #490) and follow physician's orders for two residents (Residents #3, and #10). The facility census was 42. 1. Review of the facility policies showed staff did not provide a policy for dating and timing of Fentanyl patches. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. The facility census was 42. 1. Review of the facility's Infection Prevention and Control Program, dated 2019 showed: -Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually, based upon the facility assessment and as necessary. This would include revision of the IPCP as national standards change; -The Infection Preventionist (IP) will oversee the facility Antibiotic Stewardship Program; [...]

Inspectors wroteBased on observation, interview and record review the facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two residents (Residents #21 and #35). The facility census was 42. 1. Review of American Geriatrics Society (AGS), updated 2019, AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: - Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others; -Strength of recommendation - Strong. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to store and label medication in a safe and effective manor in one of two medication storage rooms and in one of two medication storage carts. The facility census was 42. 1. Review of the facility's Medication Storage Policy, dated [DATE], showed expired medication will be removed by the facility and destroyed or sent back to the pharmacy. Disposal of any medications prior to the expiration date will be required if contamination or decomposition is apparent. Observation on [DATE] at 10:15 A.M., showed the 100 hall medication storage room contained; - 6 100 tablet bottles of folic acid 400 mg with an expiration date of 8/22; - 2 100 tablet bottles of calcium 250 mg + D3 with an expiration date of 6/22; - 2 insta-Glucose 2 mg tubes with an expiration date of 6/22. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Residents #7, and #34). Additionally, staff failed to provide wound care in a manner to reduce the risk of infection for two residents, (Residents #31, and #494). The facility census was 42. 1. Review of the facility's Infection Prevention and Control Manual, dated 2019, showed the hand hygiene procedure referred to the CDC website for further information on appropriate hand hygiene. Review of the CDC website showed: -Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: --Before moving from work on a soiled body site to a clean body site on the same patient; --Immediately after glove removal. 2. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to post in a form and manner accessible to residents, the Department of Health and Senior Services (DHSS) hotline information (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA). The facility census was 42. 1. Review of the facility's admission package, Resident Grievance Procedure, showed; if at any time a resident or any person who believes that there has been a violation of a resident's rights concerning abuse, neglect or the misappropriation of a resident's property, the resident or third party is instructed to call the pertinent office listed on the Local Government Resources insert. A statement containing the rights of Resident will be provided to the Resident upon execution of this Agreement. Observations from 09/13/22 at 3:00 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete or post the required nurse staffing information in an area readily accessible to residents and visitors. The facility census was 42. 1. Review of the facility's Posting Direct Care Daily Staffing Numbers policy, dated February 2021, showed staff are directed to: -Post the staffing on a daily basis at the beginning of each shift; -List the licensed staff including Registered nurses (RN), Licensed practical nurses (LPN), Licensed vocational nurses (LVN), and Certified nurse aides (CNA); -Each staff member will be listed by first name only, the actual hours worked, and the total number of hours worked will be posted. Review of the Daily Staffing sheets, dated 09/13/22, 09/14/22, and 09/15/22, showed the sheets did not contain the following: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to update a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies as required. The facility census was 42. 1. Review of the facility assessment showed the assessment has not been updated since 04/1/20. During an interview on 09/15/22 at 11:28 A.M., the administrator said he/she does not have an updated facility assessment and that he/she is responsible for updating it. He/she said that the facility assessment is supposed to determine the level of competency required for the staff with the facility assessment.