The Manor at Seagoville

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 (200 Hall and 300 hall) out of 3 hallways reviewed for accidents and hazards. 1. The facility failed to ensure that the mechanical lift on 200 hall and 300 halls were locked and secured when not in use. This failure could place residents at risk of falls and/or injuries. Observation on 04/01/26 at 11:17 AM of 300 hall revealed an unlocked and unsecured mechanical lift parked on the doorway of room [ROOM NUMBER] residents were observed maneuvering their wheelchairs around the Hoyer lift. Observation on 04/01/26 at 10:24 AM of 200 hall revealed an unlocked and unsecured mechanical lift parked on the doorway of room [ROOM NUMBER] residents were observed maneuvering their wheelchairs around the Hoyer lift. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that enteral feeding and administration sets were properly labeled consistent with professional standards of practice for 1 (Residents #1) of 3 residents reviewed for enteral feeding. The facility failed to ensure the G tube (a method of delivering liquid nutrition directly into the stomach or small intestine when a person cannot eat enough by mouth) feeding was properly labeled and dated before administering the feeding to Resident#1. This failure could put the residents at risk of inaccurate delivery of prescribed nutrition. Record review of Resident #1's MDS assessment, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 12 indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Residents #1) of 2 residents reviewed for parenteral and intravenous care. The facility failed to ensure Resident #1's IV antibiotic was initialed and labeled with the date/time of administration. The facility failed to ensure Resident #1's IV tubing was dated, per the facility policy, when the IV antibiotic was administered. This failure could put the residents at risk of medication error and infectionRecord review of Resident #1's MDS assessment, dated 03/17/2026, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 1 of 4 residents (Resident#2) reviewed for respiratory care. The facility failed to ensure that Resident#2's oxygen tubing, and humidifier were changed per physician's orders. This failure had the potential to affect residents receiving oxygen therapy by increasing their risk of health -associated infections. Record review of Resident #2's MDS Quarterly Assessment, dated 2/04/2026 reflected the resident was an [AGE] year-old female. Initially admitted [DATE] and had a BIMs score of 12 indicating moderate cognitive impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety.1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines.2. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, 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 for 1 of 6 residents (Resident #43) reviewed for infection control. The facility failed to ensure CNA A wore the appropriate PPE while providing incontinent care to Resident #43. This failure could place residents at risk of being infected by staff in contact with other residents with infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose for 1 (Resident #1) of 4 residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose for 1 (Resident #1) of 4 residents reviewed for unnecessary medications. The facility failed to identify potential hazards and effects of medications and failed to have internal systems in place to prevent Resident #1 from receiving high doses of extended release Morphine and Oxycodone (opioid analgesics used to treat moderate to severe ongoing pain). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from misappropriation of resident rroperty for 1 (Resident #1) of 8 residents reviewed for misappropriation. The facility failed to protect Resident #1's right to be free from misappropriation of resident property when there was a drug diversion of Resident #1's approximately 23 tables of Hydrocodone pills (a controlled narcotic medication). The non-compliance was identified as past non-compliance (PNC). The non-compliance began on 05/09/25 and ended on 05/10/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for unrelieved pain due to their medication not being readily available.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an established system of records of receipt and disposition of all controlled drugs in place for accurate reconciliation for 1 Hall (600 Hall) of 4 halls for 1 (Resident #1) of 8 residents with orders for controlled substances. The facility failed to determine that drug records (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were in order and that an account of all controlled drugs were maintained and reconciled for 1 (Resident #1) of 8 residents reviewed for pharmacy services. 1. The facility failed to ensure employees with access to controlled medication properly counted the inventory of the controlled medications. 2. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to in accordance with the accepted professional standards and practices, the facility must maintain medical records for each resident for one resident (Resident #1) of 6 residents reviewed for Medical Records. The facility failed to ensure RN A documented giving Resident #1 all of his Physician ordered medications and treatments during her assigned double shift on Sunday 04/27/25; subsequently there was no documentation for most of the care provided to Resident #1 on 04/27/25 between 6:00 am and 10:00 pm. This failure could affect residents by placing them at risk of experiencing a change in their medical condition which could cause a decline in their health and psycho-social well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, in accordance with State law, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #1 ) of 6 residents reviewed for abuse/neglect. The facility failed to report to the local law enforcement agency when the Administrator was notified by staff that Resident #1's family informed them Resident #1 stated he was sexually abused by a staff member on 03/23/25 and the report to law enforcement was not made until 03/25/25. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was significant change in the resident's physical, mental, or psychosocial status for one of four residents (Resident #2) reviewed for notification of changes. LVN C failed to notify the responsible party/resident representative when Resident #2 was transferred to the hospital due to change in condition. This failure could place residents at risk of not having their responsible parties notified of changes in their condition and deny them the right to participate in the care and treatment of the resident. The noncompliance was identified as past none compliance (PNC). The noncompliance began on 12/10/2024 and ended on 12/11/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of five residents (Resident #1) reviewed for care plans. The facility failed to include the intervention/implementation of lowering the bed related to resident falls--develop/implement an intervention. This failure could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for one (treatment cart #1) of 2 carts reviewed for storage of drugs and biologicals. The facility failed to lock treatment cart# 1 while in a resident room. These failures could affect residents at risk of drug diversion or misuse of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Residents #34, #11, and #64) of 6 residents reviewed for quality of life. The facility failed to ensure: 1. Resident #34 had her fingernails cleaned and trimmed. 2. Resident #11 had her fingernails cleaned and trimmed. 3. Resident #64 had her fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility walk-in freezer were covered, labeled, and dated with the expiration date. 2. The facility failed to discard expired food items in the facility walk-in refrigerator. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for 1 (Resident #32) of 4 residents reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan to address Resident #32's dialysis access in the left forearm fistula. This failure could affect residents by placing them at risk for not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who needed respiratory care are provided such care, consistent with professional standards of practices for 1 of 6 residents (Resident #27) reviewed for respiratory care. The facility failed to have a physician's order for Resident #27's oxygen use. This failure could affect residents by placing them at risk for not receiving the appropriate care and treatment services.

Inspectors wroteBased on observations, interviews, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (300 hall nurses' medication cart) of 2 medication carts reviewed for pharmacy services. The facility failed to ensure the 300 Hall medication cart had 2 medications Valproic acid (as sodium salt) 250 mg/5 mL (5 mL) oral solution in a 16 oz bottle, and Levetiracetam 500 mg/5 mL (5 mL) oral solution in a 16 oz bottle for Resident#3 were dated when there were opened. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observations, interviews, and record reviews 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 for 1 of 6 residents (Resident #18) reviewed for infection control. CNA D failed to wear personal protective equipment during incontinence care with Resident #18, when Resident #18 was on enhanced barrier precautions. This failure could place residents at risk for cross contamination, infection, and illness.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protect and promote the rights of the resident for one of three (Resident #1) residents reviewed for resident rights. The facility failed to ensure Caregiver A removed Icy Hot (a topical, over-the-counter pain reliever with active ingredients like menthol and wintergreen oil [methy salicyclate]) after it was applied to Resident #1's bottom, and the resident complained that it burned. This failure could place residents at risk of discomfort and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. for one of five residents (Resident # 9) reviewed for pharmacy services. 1. The facility failed to ensure Resident #1 had an order for Icy Hot (a topical, over-the-counter pain reliever with active ingredients like menthol and wintergreen oil [methy salicyclate]) before Caregiver A administered it to Resident #1. 2. The facility failed to ensure Caregiver A was qualified to apply Icy Hot to Resident #1. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of four resident rooms (Resident #1) reviewed for storage of medications. The facility failed to ensure over-the-counter topical cream Icy Hot (a topical, over-the-counter pain reliever with active ingredients like menthol and wintergreen oil [methy salicyclate]) was properly stored in Resident#1's room. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for six (Residents #1, #2, #3, #4, #5, and #6) of nine residents reviewed for infection control. The Certified Nurse Aide H did not put on full Personal Protective Equipment when she served lunch trays to residents who had droplet precaution signs on their door. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for one of nine residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 was free of significant medication errors when Heparin was administered incorrectly . The noncompliance was identified as PNC. The IJ began on 11/18/2023 and ended 11/18/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the therapeutic effect of their medications as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #22, Resident #24, Resident#57, and Resident#70) of 22 residents reviewed for ADLs (Activities of Daily Living). The facility failed to ensure Resident #22, Resident #24, Resident #57, and Resident#70 had their fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 16 percent based on 4 errors out of 25 opportunities. (Residents #31 and #45) The facility failed to ensure medications were administered per physician's orders for Residents #31 and #45. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that was palatable and attractive for 13 (Resident#1, Resident#2, Resident#7,Resident#16, Resident#31, Resident#37, Resident#46, Resident#56, Resident#59, Resident#61, Resident#67, Resident#69, and Resident#229) of 23 residents who were reviewed for meals . The facility failed to serve food that was palatable. These failures could affect the residents who had their meals prepared by the facility kitchen by placing them at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the assessment with the pre-admission screening and resident review (PASRR) program for one (Resident #25) of five resident assessments reviewed for PASRR evaluations. The facility did not refer Resident #25 to the appropriate state-designated mental health authority for review when she received a new diagnosis of bipolar disorder. This failure could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the menus were followed for two (lunch on 08.07.2023) of two meals reviewed for meal accuracy: The facility failed to follow the menu for the lunch meal on 08/07/2023. This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to provide food as ordered by the physician in a form designated to meet one (Resident #61) of one of residents reviewed for individualized needs. The facility failed to ensure Resident #61's pureed meal on 08/07/2023 was at a consistency she was able to consume. These failures could affect the residents who received pureed diets by placing them at risk of weight loss and altered nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing was posted as required each day since 06/02/23 reviewed for nursing services and postings. The facility failed to update the daily staffing information posting since 06/02/23. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.