Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seminole Manor Nursing Home during CMS and state inspections, most recent first.
Unauthorized Medications and Treatment Products at Bedside: A resident with intact cognition, a sacral pressure ulcer, and a G-tube had multiple medicated treatment products and eye drops left on the bedside table even though there was no order or assessment for self-administration. The resident stated nurses provided all treatments and that he could not do his own wound care or eye drops, while the RN UM and DON confirmed the items were present and that the resident had not been assessed to self-administer.
Dirty vents and unrepaired wall damage in resident rooms. Observations found dark, dusty AC filters in Rooms N115, N118, and N122, and staff confirmed the vents contained dark black substance, grime, and bugs. Room N122 also had a patched hole in the wall and a cracked wall border interior that needed replacement. The ADM confirmed the rooms needed filter cleaning and that the wall damage in N122 required repair or replacement.
Failure to develop comprehensive care plans for oxygen therapy and wounds. Two residents with physician orders for O2 therapy had no care plan focus areas for oxygen use, and a resident with multiple pressure ulcers had no wound care plan. The DON confirmed the missing care plans, and the RN MDS Coordinator acknowledged the wound care plan for the resident was not developed.
Incorrect Oxygen Flow Rates and Missing Oxygen Signage: Two residents were observed receiving oxygen by NC at flow rates below the physician-ordered settings, and no oxygen-use signage was posted on the room door or inside the room. The DON confirmed the incorrect settings for both residents and adjusted the flow rates during the room tour. One resident had COPD and vascular dementia, and the other had SOB and COVID-19 acute respiratory disease.
An unlocked medication cart was observed unattended in a hallway between resident rooms while an LPN was providing care to residents. The LPN later locked the cart and confirmed she had left it unlocked, and the DON stated that medication carts should always be locked when unattended.
Pureed Diets Not Prepared Correctly: Two residents with physician-ordered CCD-Dys Puree diets were served eggs that were thick, lumpy, and not pureed to the correct consistency. Both residents had severe cognitive impairment and dysphagia-related diet orders, and the RD confirmed the eggs were not pureed properly. The DM also confirmed dietary staff served non-pureed eggs to pureed-diet residents.
Staff failed to properly sanitize a food thermometer probe between measuring different food items, using only a paper napkin instead of a clean probe wipe as required by facility policy. This practice was observed during meal preparation and confirmed by interviews with dietary staff and management, potentially exposing 62 residents to cross-contamination.
Staff did not properly secure confidential medical, financial, and legal records, leaving bins and filing cabinets containing sensitive information unlocked and accessible in multiple areas, including the copy room and behind the Nurse's Station. The storage room containing resident files also used a common entry code and had cabinets with unlocked hasps, increasing the risk of unauthorized access.
Staff did not consistently provide care that promoted dignity and respect, as several residents were observed with food spills on clothing and dirty, jagged fingernails. Despite policies requiring regular checks and assistance with hygiene, residents with cognitive and physical impairments, as well as those on hospice, were not kept clean or neat, and staff did not always intervene to address these issues.
Staff did not ensure that two residents had timely access to their prescribed medications, including Vitamin D3 and Lantus insulin, during medication administration. An LPN found that one resident's Vitamin D3 was not available and another resident's insulin vial was missing an open date and lacked a back-up supply. Facility policy requires medications to be available, properly labeled, and reordered before supplies run out, but these procedures were not followed.
Surveyors found that an LPN left a medication cart unlocked and unattended, and another LPN left a prepared medication unsecured on top of a cart while away. Expired medications and medical supplies, as well as opened and unclean items, were found in storage and treatment areas. A multi-dose insulin vial was also in use without an open or discard date, all in violation of facility policy and accepted standards.
Residents reported that meals were often cold and bland. A test tray sampled by surveyors and the Administrator revealed that food items, including a chicken salad sandwich and green pea salad, were poorly presented, lacked seasoning, and were served at inappropriate temperatures. The green pea salad's liquid caused the sandwich bread to become soggy, and both the soup and salad were bland and not served at the correct temperature.
A resident receiving hospice care for congestive heart failure, who was cognitively intact and required moderate assistance with ADLs, was observed lying in bed with the call bell cord wrapped around the bed rail and not within reach. An LPN confirmed the call device was inaccessible, which was not in accordance with facility policy requiring call systems to be easily accessible to all residents.
A list identifying residents with diabetes was posted in a location visible to visitors and staff, compromising the confidentiality of their medical information. The Activities Director stated the list was used to manage appropriate snacks for these residents but was unaware of the privacy concern.
Staff did not follow facility policies for cleaning, changing, and dating respiratory equipment for four residents receiving nebulizer treatments or oxygen therapy. Nebulizer cups and masks were found assembled and moist, tubing was undated, and there was no documentation of required equipment changes or cleaning. In some cases, oxygen tubing was in contact with the floor or staff were unclear on change frequency.
Surveyors found that the medication error rate exceeded 5% after two residents did not receive scheduled medications due to unavailable supplies and improper labeling. In both cases, LPNs confirmed the omitted doses, and the administrator acknowledged that medications should be reordered before supplies run out.
Unauthorized Medications and Treatment Products at Bedside
Penalty
Summary
The facility failed to ensure that one sampled resident, R8, did not have unauthorized and unsecured medications and medicated treatment products at the bedside. The facility’s policy stated that a resident may self-administer medications only after the interdisciplinary team determines which medications may be safely self-administered, and that bedside storage arrangements must be reflected in the care plan. Review of R8’s records showed diagnoses including cerebral infarction, a stage 3 sacral pressure ulcer, and an encounter for gastrostomy attention. The resident’s MDS showed a BIMS score of 15, indicating intact cognition, but the record contained no order for self-administration of medications and no evidence that a self-administration evaluation had been completed. During observations, a bottle of sodium hypochlorite solution, hemorrhoidal ointment, H-Chlor 12 solution, spray cleanser, two bottles of eye drops, and a jar of menthol topical ointment were seen on top of R8’s bedside table. R8 stated that nurses provided all treatments and administered medications, and later stated he was unable to do his own wound care or administer eye drops and that the items had been on the table since admission from the hospital. The RN Unit Manager confirmed the items were on the bedside table and stated the medicated treatment products came from the hospital while the eye drops and menthol ointment came from home. The DON confirmed that R8 had not been assessed to self-administer medications or medicated treatments.
Dirty vents and unrepaired wall damage in resident rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment in three rooms with portable units, including Rooms N115, N118, and N122. Observations on multiple dates showed the air conditioning unit filters in these rooms were dark and dusty, and staff later confirmed that the air vents contained dark black substance, grime, and bugs. The facility policy titled Safe and Homelike Environment stated that residents should receive care and services safely and that the environment should be clean and homelike. In Room N122, observations also identified a hole in the wall that had been patched with drywall plaster and a cracked wall border interior that required replacement. During interview, the Utility Mechanic 1 and the Maintenance Director confirmed the condition of the vents in Rooms N115, N118, and N122, and confirmed that Room N122 had holes in the wall needing repair and a wall fixture requiring replacement. The Administrator also confirmed that the identified rooms required air filter cleaning and that the hole and wall fixture in Room N122 needed repair or replacement.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Wounds
Penalty
Summary
The facility failed to develop comprehensive care plans for three sampled residents. Review of the facility policy titled Comprehensive Care Plans stated that each resident should have a person-centered care plan with measurable objectives and timeframes based on the resident’s comprehensive assessment. The survey found that R10 and R11 did not have care plan focus areas for oxygen therapy, and R19 did not have a care plan addressing wounds. R10 had diagnoses including COPD, a BIMS score of 9 indicating moderate cognitive impairment, and a physician order for oxygen at 4 LPM via nasal cannula PRN. During multiple observations, R10 was seen in bed receiving oxygen from an oxygen concentrator by nasal cannula at 3.5 LPM instead of 4 LPM. Review of the care plan showed no focus area for oxygen therapy. R11 had diagnoses including shortness of breath and COVID-19 acute respiratory disease, a BIMS score of 4 indicating severe cognitive impairment, and a physician order for oxygen at 2 LPM via nasal cannula PRN. During multiple observations, R11 was seen in bed receiving oxygen at 1.5 LPM instead of 2 LPM. Review of the care plan also showed no focus area for oxygen therapy. R19 had diagnoses including pressure ulcer of the left hip, stage 3, and pressure ulcer of the sacral region, stage 2. The resident’s MDS showed severe cognitive impairment, dependence on staff for ADLs, and skin assessments identified a pressure ulcer to the left hip, right thoracic back, and coccyx. Physician orders directed wound care for the back, coccyx, and left hip, but the care plan did not address the resident’s wounds. The RN MDS Coordinator confirmed there was no wound care plan for R19, and the DON confirmed that R19 should have had a care plan to address the wounds.
Incorrect Oxygen Flow Rates and Missing Oxygen Signage
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with physician orders for two residents, R10 and R11. R10 had diagnoses including chronic obstructive pulmonary disease and vascular dementia, and a physician order dated 11/10/2025 for oxygen at 4 liters per minute via nasal cannula as needed. On 05/01/2026 and 05/02/2026, R10 was observed lying in bed receiving oxygen from an oxygen concentrator at 3.5 LPM instead of 4 LPM, and no oxygen signage was posted on the exterior door or inside the room. The DON later confirmed the flow rate was set below the ordered amount and adjusted it to 4 LPM during the room tour. R11 had diagnoses including shortness of breath and COVID-19 acute respiratory disease, with a physician order dated 01/01/2026 for oxygen at 2 LPM via nasal cannula as needed. On 05/01/2026 and 05/02/2026, R11 was observed receiving oxygen at 1.5 LPM instead of 2 LPM, and no oxygen-use signage was posted on the exterior door or inside the room. R11’s MDS showed a BIMS score of 4 indicating severe cognitive impairment, and the care plan had no focus area for oxygen therapy. The DON confirmed the incorrect flow rate and adjusted it to 2 LPM during the room tour, and also confirmed that oxygen signage was not posted in the shared room.
Unlocked Medication Cart Observed Unattended
Penalty
Summary
The facility failed to ensure that one of three medication carts was locked and secured. The facility policy titled Medication Storage stated that all drugs and biologicals must be stored in locked compartments, including medication carts, and that medications should be stored according to proper sanitation, temperature, lighting, ventilation, moisture control, segregation, and security requirements. During an observation and interview on 05/01/2026 at 10:06 AM, a medication cart was observed unlocked in the hallway between resident rooms 103-107 on the South Hall. At approximately 10:08 AM, an LPN exited a resident room and went to the unlocked medication cart and locked it while the surveyor was present. The LPN confirmed she had left the cart unlocked while providing care to residents and stated that the medication cart should always be locked while unattended. The DON later stated that medication carts should always be locked when left unattended.
Pureed Diets Not Prepared to Correct Consistency
Penalty
Summary
The facility failed to ensure pureed therapeutic diets were properly prepared for two residents who had physician orders for a consistent carbohydrate dysphagia puree diet. The facility policy stated that puree foods were to be prepared following recipe and blended until the correct consistency, and the dietary recipe for scrambled eggs instructed staff to blend the food until smooth and add liquid or thickener as needed to achieve the desired pureed consistency. R20 had diagnoses including Alzheimer's disease, GERD, ulcerative esophagitis, and prostate cancer, and his MDS showed severely impaired cognition and a mechanically altered diet for dysphagia. His physician order specified CCD-Dys Puree. On observation, he was eating meals that were not pureed, and the pureed scrambled eggs on his tray were described as thick and lumpy on one occasion and thick, scrambled, and grainy on another. R20's tray card identified a regular diet with dysphagia puree and pureed scrambled eggs. R60 had diagnoses including vascular dementia, senile degeneration of the brain, and excessive salivary secretions, and her MDS also showed severely impaired cognition and a mechanically altered puree diet. Her physician order specified CCD-Dys Puree. On observation, she was eating a meal that was not pureed, and the pureed scrambled eggs on her tray were described as thick and lumpy. The Registered Dietitian reviewed photos of the eggs served to both residents and stated the eggs were not pureed to the correct consistency. The Dietary Manager confirmed that dietary staff served non-pureed eggs to pureed-diet residents and stated she was unaware the eggs were not pureed until it was brought to her attention.
Improper Sanitization of Food Thermometer Probe During Meal Preparation
Penalty
Summary
The facility failed to ensure sanitary practices were followed during food preparation, as observed during a survey. The Dietary Manager (DM) was seen measuring the temperatures of 11 food items on the steam table and used a paper napkin to wipe the residue from the probe thermometer between each food item, without sanitizing the probe. The DM then used the same unsanitized probe to measure the temperature of a bowl of fruit and a bowl of applesauce. When questioned, the DM placed the probe in a cup of sanitizing solution, stating it was the same solution used in the sanitization buckets, and also provided a box of food probe wipes that appeared tattered and had an illegible date. Interviews with the DM, District Manager, and Registered Dietitian confirmed that the expected practice was to use a clean probe wipe to sanitize the thermometer between each food type to prevent cross-contamination. The failure to follow these procedures was not in accordance with the facility's policy, which required food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical agents. This practice had the potential to affect the 62 residents who received food from the kitchen.
Failure to Secure Confidential Resident Records
Penalty
Summary
Staff failed to safeguard resident-identifiable information and maintain medical, financial, and legal records in accordance with accepted professional standards. Observations revealed that a bin for storage of medical records to be destroyed was left unlocked in the copy room, and the door to this room was also unlocked. Additionally, a shred bin behind the Nurse's Station was found unlocked with the door slightly ajar, and the Nurse's Station itself had an open floor plan with no barriers to restrict access to the area where the bin was located. Multiple staff members were present in and around the area at the time of observation. Further observations showed that the storage room on [NAME] Hall, which contained multiple filing cabinets labeled with sensitive information such as financial, social service, business office, and resident files, used the same entry code as the restroom. Several cabinets labeled as Resident Files had unlocked hasps attached, making them accessible. These findings indicate that confidential records were not stored securely, allowing for potential unauthorized access.
Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
Staff failed to provide care in a manner that promoted dignity and respect for five residents, as evidenced by multiple observations of food spills on clothing and dirty, jagged fingernails. Facility policies on dignity and routine resident checks required staff to ensure residents' well-being and maintain a clean, neat appearance, but these were not consistently followed. For example, one resident with diabetes and impaired vision was observed with food on his hospital gown after breakfast, despite being dependent on staff for personal hygiene and requiring assistance with eating. Another resident with multiple sclerosis, who was dependent on staff for all ADLs, was seen with food on his shirt and overbed table after breakfast, with no meal tray present, indicating the meal had already been completed. A third resident with vascular dementia and intellectual disabilities was repeatedly observed throughout the day and on multiple days wearing T-shirts with visible orange stains, and staff interviews confirmed that he would only change his shirt if prompted. Additional residents, including those on hospice care, were observed with dirty, jagged, or untrimmed fingernails and dried food on their hands, face, and clothing, with no evidence that staff had addressed these hygiene needs. Interviews with staff and the administrator confirmed expectations for regular rounding and personal hygiene assistance, but the observations indicated these expectations were not met. The failure to provide timely and adequate assistance with personal hygiene and clothing cleanliness had the potential to diminish the quality of life for the affected residents, contrary to facility policy and regulatory requirements for dignity and respect.
Failure to Ensure Timely Availability and Proper Labeling of Routine Medications
Penalty
Summary
Staff failed to ensure that routine medications were available for two residents during medication administration. One resident did not receive a scheduled dose of Vitamin D3 1000 units because the medication was not present in the resident's supply, and the LPN confirmed it was not available in the medication storage room. The LPN stated she would order the medication from the pharmacy. In another instance, a resident with an order for Lantus insulin did not have a properly labeled multi-dose vial, as neither the box nor the vial was marked with an open date, and there was no back-up supply available. The LPN confirmed the absence of a back-up supply and reordered the insulin from the pharmacy. Facility policy requires that pharmacy services be available 24/7, that residents have a sufficient supply of prescribed medications, and that medications are labeled and stored according to standards. The policy also prohibits borrowing medications due to failure to order or reorder in time. The administrator stated that her expectation was for a back-up container of insulin to be available for each resident prescribed insulin and for medications to be available as ordered. These observations and interviews demonstrate that the facility did not follow its own policies regarding medication availability and labeling.
Medication Storage, Security, and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of drugs and biologicals. One medication cart was observed unlocked and unattended in a hallway, accessible to unauthorized individuals, while the responsible LPN was not in direct line of sight. Additionally, a prepared cup of MiraLax was left unsecured on top of a medication cart while the nurse left the area, leaving the medication unattended and accessible. Expired medications and medical supplies were found in both the central supply storeroom and the treatment cart. Items such as gastrostomy feeding tubes, dressing change trays, infusion sets, IV start kits, suction catheters, packing strip dressings, and various wound care supplies were all past their expiration dates. Some items were also found opened, compromising their sterility and cleanliness, including dressings and cotton-tipped applicators spilling from open packaging. A multi-dose vial of Lantus insulin was found in use without an open or discard date, contrary to facility policy and accepted pharmaceutical practices. The DON and Administrator confirmed that these practices did not meet facility expectations, as expired and opened items should have been removed from use, and multi-dose vials should have been properly dated.
Meals Served Lacked Palatability, Proper Temperature, and Presentation
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and served at an appropriate temperature, as evidenced by resident complaints and direct observations. During a Resident Council meeting, residents reported that meals were often cold and lacked flavor. A test tray was later prepared and delivered to the Activity Room, where it was sampled by two surveyors and the Administrator. The tray included a chicken salad sandwich, green pea salad, broccoli and cheese soup, and barbeque potato chips. Observations revealed that the green pea salad's liquid had spread across the plate, causing the sandwich bread to become soggy. The chicken salad was described as bland and lacking seasoning, while the soup was lumpy, bland, and of an inappropriate consistency. Both the soup and the pea salad were served at temperatures that were neither hot nor cold, and the pea salad lacked seasoning and was not served cold as expected. All participants agreed that the presentation and taste of the food items were unsatisfactory, with the Administrator acknowledging that most resident complaints were about the supper meal. The improper plating, lack of seasoning, and failure to maintain appropriate food temperatures contributed to the deficiency, affecting the quality and palatability of meals served to residents. No specific resident medical histories or conditions were mentioned in relation to the deficiency.
Call Device Not Accessible to Resident
Penalty
Summary
A deficiency occurred when a resident's call device was not placed within reach, contrary to the facility's policy requiring that each resident have access to a functional call system at all times. During an observation, the resident was found lying in bed with the call bell cord wrapped around the right upper half bed rail, with the pendant dangling below the rail and not accessible to the resident. The resident's left hand was free, but the call device was not within reach, and this was confirmed by an LPN during the observation. The resident involved had been readmitted to the facility and was on hospice care for congestive heart failure. Assessment records indicated the resident was cognitively intact and required partial to moderate assistance with eating and activities of daily living. The care plan documented the need for limited assistance with ADLs due to debility. The facility's policy specifically states that cords are to be placed easily in reach of the resident, and if a resident cannot use the call system, an alternative must be provided and documented. However, in this instance, the call device was not accessible, resulting in noncompliance with the policy.
Resident Medical Information Posted Publicly
Penalty
Summary
A handwritten list titled 'Diabetics' containing the names of four residents with diabetes was posted on the wall in the activity room, which was visible through a window from the lobby. This allowed anyone visiting the facility to see the list, compromising the privacy and confidentiality of the residents' medical diagnoses. The activity room was used daily by both residents and staff. During an interview, the Activities Director stated that the list was intended to help ensure residents with diabetes received appropriate snacks, but she was unaware that posting the list constituted a privacy and confidentiality issue.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for four residents who required nebulizer treatments or oxygen therapy. Facility policies required staff to clean nebulizer equipment after each use, disassemble and air-dry components, and change and date tubing and masks every 14 days. However, observations and record reviews revealed that nebulizer cups, masks, and tubing were not dated, and there was no documentation of routine changing or cleaning of these items as required. In several cases, nebulizer equipment was found assembled and moist after use, indicating it had not been properly disassembled and air-dried. For one resident with scheduled nebulizer treatments for shortness of breath, the equipment was found on the floor, attached to the compressor, and undated, with no documentation of tubing or mask changes despite multiple treatments administered. Another resident receiving frequent nebulizer treatments for COPD had equipment resting on paper towels, with visible moisture inside the cup and no dates on the tubing, cup, or mask. The MARs for both residents lacked documentation of required cleaning or equipment changes. Two additional residents using oxygen therapy also had deficiencies in equipment maintenance. One resident receiving oxygen via nasal cannula had undated tubing, and staff were unclear on the required frequency for changing it. Another resident's oxygen tubing was found in direct contact with the floor, undated, and not in use at the time of observation. In all cases, the facility failed to follow its own policies and physician orders regarding the cleaning, changing, and dating of respiratory equipment.
Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by policy, resulting in an observed error rate of 6.67 percent during the survey. Out of 30 medication administration opportunities, two errors were identified involving two residents. In the first instance, an LPN was unable to administer a scheduled dose of Vitamin D3 1000 units to a resident because the medication was not available in either the resident's medication supply or the back-up supply. The LPN confirmed the omission of the dose. In the second instance, another LPN was preparing to administer Lantus insulin to a resident as ordered, but the multidose vial of insulin did not have an open date labeled, and there was no way to determine when it had been opened. Due to the lack of an open date and the absence of a back-up or emergency supply, the medication was not administered. The LPN confirmed this as an omitted dose. The administrator stated that her expectation was for medications to be available for each resident and that medications should be reordered before the supply is exhausted.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Donalsonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller Nursing Home | 12.2 mi | ★★★★★ | 2 | 0 |
| Bainbridge Landing Of Journey Llc | 20.1 mi | ★★★★★ | 5 | 0 |
| Memorial Manor Nursing Home | 21.8 mi | ★★★★★ | 0 | 0 |
| Early Memorial Nursing Facility | 22.7 mi | ★★★★★ | 5 | 0 |
| Marianna Nursing And Care Center | 27.4 mi | ★★★★★ | 0 | 0 |
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