Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Seneca Nursing during CMS and state inspections, most recent first.
Staff failed to consistently document administration of controlled pain medications on both the MAR and the controlled substance records for three residents receiving opioid analgesics for chronic and PRN pain. Facility policy required special recordkeeping for DEA-controlled drugs and stated that current accountability records be maintained in the MAR or designated book. Record review showed numerous instances where hydrocodone-acetaminophen and oxycodone doses were signed out on the narcotic sheets without matching entries on the MAR, and in some cases, doses were documented on the MAR without corresponding narcotic sheet entries. Nursing staff and CMTs reported that they were expected to document on both records and that the two should match, while the administrator described the problem as a documentation issue.
Failure to Honor Resident Shower Preferences: The facility did not honor shower preferences for three residents with significant care needs, including dementia, COPD, a catheter, and severe cognitive impairment. Shower records showed limited bathing, while progress notes did not document showers or refusals. One resident reported feeling dirty and wanting showers twice weekly, another appeared with oily hair and body odor, and a responsible party reported an unshaved resident with long toenails, poor oral care, and soiled clothing. The DON and Administrator said residents should be kept clean and preferences should be honored, but were unaware the residents were not receiving showers twice per week.
Failure to protect residents from resident-to-resident abuse occurred when a resident with severe cognitive impairment and repeated boundary-crossing behaviors touched, kissed, bit, and attempted to lie on or undress around other residents. Multiple residents reported unwanted breast and chest touching, one reported the resident naked on top of him/her and pulling at a central line, and another reported an attempted bite near a pacemaker area. Staff interviews showed they recognized such conduct as abuse, but several incidents were not documented in progress notes and reporting was inconsistent.
Failure to Report Resident-to-Resident Abuse Allegations: Staff did not immediately report multiple abuse allegations involving unwanted touching, kissing, and other inappropriate resident-to-resident contact to management and DHSS within the required 2-hour timeframe. The incidents involved a resident with intellectual disabilities, deafness, and hemiplegia, another resident with dementia and CKD, and additional residents who reported being touched, bitten, or awakened to unwanted sexual contact; records showed the events were documented inconsistently or not at all, and DHSS self-reports were not made.
Failure to Investigate Resident-to-Resident Abuse Allegations: The facility did not document timely or thorough investigations, or steps to protect residents, after multiple allegations of unwanted touching and sexualized behavior between residents. A resident with intellectual disabilities and communication limitations was repeatedly involved in inappropriate conduct with other residents, while another resident with dementia was observed fondling the resident’s breasts. Other residents reported being touched, bitten at, and sexually approached, but the record lacked documented investigation and protective actions.
A resident with multiple chronic conditions, including DM, CHF, HTN, and CKD, had admission labs ordered, and subsequent CBC results showed critically low Hgb and Hct values. Although facility policy required immediate practitioner notification and documentation of abnormal lab values, there was no record that the physician or family were notified, and later MD notes and dietician entries indicated no labs were available or reviewed. The Medical Director confirmed she had not been informed of the critical results and that the signature on the lab report was not hers, while leadership and nursing staff acknowledged that nurses were responsible for monitoring labs, receiving critical values from the lab, notifying the physician via the message system or phone, and documenting this communication, which did not occur in this case.
A resident with multiple chronic conditions and identified fall risk slid from a recliner to the floor without injury, but staff failed to document the incident itself in the medical record, despite facility policies requiring charting of all significant condition changes and falls. An LPN entered a fall follow-up note based on shift report, yet no primary note describing the event was present. An RN later acknowledged witnessing the resident slowly slide from the chair to the floor and admitted this should have been documented. The DON and Administrator both stated that sliding from a chair is considered a fall and must be recorded, but the absence of documentation left the resident’s record incomplete and inaccurate.
A facility failed to provide appropriate respiratory care for a resident with COPD and respiratory failure. Staff did not clarify hospital discharge orders for pulse oximetry, leading to a lack of documentation and monitoring of oxygen usage and pulse oximetry readings. The resident's TAR did not include necessary orders, and staff did not consistently document oxygen saturations, despite expectations for spot checks.
A facility failed to maintain complete medical records for a resident who died, as staff did not document the death or notifications to the physician and family. The resident, with chronic conditions, was found without a pulse, and although the RN informed the physician and family, these actions were not recorded. Interviews confirmed the expectation for documentation, which was not met, violating the facility's policy.
The facility failed to ensure six NAs completed CNA training and obtained certification within four months of employment. NAs were observed working without certification, and interviews revealed no current training classes. The facility lacked a policy for CNA certification, contributing to the deficiency.
The facility failed to maintain an effective infection control program, as staff did not perform proper hand hygiene during personal care for two residents and lacked a policy for Enhanced Barrier Precautions (EBP). A resident with a wound did not have appropriate EBP signage, and staff did not consistently use gowns when providing care. Interviews revealed inconsistent understanding and implementation of EBP among staff.
Controlled substances, including Ativan Intensol and morphine sulfate, were found in an unlocked refrigerator in the medication room, contrary to the facility's policy requiring double-lock storage. Staff interviews revealed awareness of the locking requirement, but lapses occurred, leading to the deficiency.
A facility failed to report a verbal abuse allegation to the state within the required timeframe. During a smoke break, a resident threatened another resident, which was documented by an RN but not reported to the DHSS. The resident who made the threat has a history of behavioral issues, while the threatened resident has moderate cognitive impairment. Staff interviews indicated awareness of reporting requirements, but the Administrator was unaware of the incident.
The facility failed to investigate a verbal abuse allegation where a resident threatened another resident, saying, 'I will cut your throat.' Despite the facility's policy requiring immediate reporting and investigation of abuse, no documented investigation was conducted. The resident who made the threat has a history of behavioral issues, and staff interviews confirmed the incident was considered abusive. However, the administrator was unaware of the incident, and the required investigation was not completed.
A facility failed to monitor and manage a resident's edema, notify the physician of significant changes, and apply prescribed interventions. The resident, with multiple diagnoses, was not consistently wearing Tubi grips as ordered, and staff did not document physician notification of weight gain and changes in edema. Observations showed significant edema and possible cellulitis, with inconsistent application of interventions.
Two residents experienced unsafe transfers due to staff not adhering to care plans. One resident, with dementia and muscle weakness, was transferred without a gait belt, contrary to their care plan. Another resident, with hemiplegia and hemiparesis, was transferred using a gait belt despite not bearing weight, which was not specified in their care plan. Staff interviews revealed a lack of adherence to facility policies regarding safe transfers.
The facility failed to maintain proper hand hygiene during meal service, as staff were observed handling food and food contact surfaces with bare hands without sanitizing between tasks. This was contrary to the facility's hand hygiene policy and FDA guidelines, potentially leading to contamination.
A resident's alprazolam medication went missing after being signed for by an LPN, who failed to properly count and log the medication. The facility's investigation revealed that the medication was not delivered to the resident, and staff had to use the emergency kit to provide the medication. Despite efforts to locate the missing doses, the facility could not account for them, indicating a lapse in medication management procedures.
A CNA in a LTC facility failed to treat a resident with dignity and respect by placing their hand near the resident's mouth to muffle yelling during care. The resident, who had severe cognitive impairment, was known to yell during care. The CNA claimed the action was accidental, but the facility's investigation confirmed the resident was not treated appropriately. Staff interviews emphasized the importance of treating residents with dignity.
A resident's cell phone was misappropriated by a staff member, who gave it as a gift to another staff member's child. The resident, with moderate cognitive impairment, had their phone reported missing, and it was later confirmed to belong to the resident by the cellular provider. The involved staff member was terminated, and the incident was reported to authorities.
Inconsistent Documentation of Controlled Pain Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and consistent documentation of the administration of controlled pain medications on both the Medication Administration Record (MAR) and the Controlled Substance Record for multiple residents. Facility policy dated 06/01/18 required that medications classified as controlled substances be subject to special handling, storage, disposal, and recordkeeping, and that current controlled substance accountability records be kept in the MAR or designated book. The policy also stated that the medication regimens of residents with discrepancies should be reviewed to assure residents received all medications ordered and that therapeutic goals were met. Despite this, surveyors identified numerous instances where documentation on the MAR did not match the Controlled Substance Record for three residents receiving opioid analgesics. For one resident with chronic back and leg pain related to diabetic neuropathy, cervical disc degeneration, gout, and restless legs syndrome, the physician ordered hydrocodone-acetaminophen both as a scheduled and PRN medication. Review of this resident’s records showed repeated mismatches between the Controlled Substance Record and the MAR. On multiple dates in January and February, staff documented administration of hydrocodone-acetaminophen on the Controlled Substance Record without corresponding entries on the MAR, and on other occasions documented administration on the MAR without corresponding entries on the Controlled Substance Record. Some entries on the Controlled Substance Record included notes that the resident was out of the building, yet the MAR did not reflect administration at those times. There were also instances where times were missing or unreadable on the Controlled Substance Record while the MAR showed administration, further demonstrating inconsistent documentation. A second resident with major depressive disorder, difficulty in walking, and muscle weakness had an order for PRN oxycodone 5 mg for moderate to severe pain. For this resident, the Controlled Substance Record repeatedly showed documented administrations of oxycodone on numerous dates across January, February, and March, while the MAR lacked corresponding entries for those same administrations. Each listed date and time on the Controlled Substance Record had no matching documentation on the MAR, indicating a pattern of incomplete or absent MAR documentation despite recorded use of the controlled medication. A third resident with cognitive communication deficit, muscle weakness, chronic kidney disease, and a care plan requiring routine pain management for lower back pain had an order for PRN hydrocodone-acetaminophen. For this resident, the Controlled Substance Record documented multiple administrations of hydrocodone-acetaminophen on various dates in February and March, but the MAR did not show corresponding entries for those administrations. On each of the cited dates and times, staff signed out the narcotic on the Controlled Substance Record, yet there was no MAR documentation to match. During interviews, certified medication technicians and registered nurses stated that staff were expected to document pain medications on both the MAR and the controlled drug form, and that the two records should match. The administrator also stated she expected staff to document on the MAR and narcotic sheet and acknowledged that failure to sign the MAR made it easy to forget, characterizing the issue as a documentation problem.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination when it did not honor reasonable shower preferences for three residents. The report states the facility did not provide a policy related to showers, and staff did not document shower refusals or provide nursing progress note entries related to showers provided or refused for the residents reviewed. The Director of Nursing and Administrator both stated that residents should be kept clean, that resident shower preferences should be honored, and that staff should document refusals, but they were unaware that the three residents were not receiving showers twice per week in March and April 2026. Resident #6 was admitted with diagnoses including infection and inflammatory reaction due to an internal left knee prosthesis, COPD, dementia, and uninhibited neuropathic bladder. The resident’s MDS indicated cognitive intactness, wheelchair use, an indwelling catheter, and supervision or touching assistance for showering and other ADLs. Shower sheets showed showers on only a few dates in March and April 2026, and the care plan had a cancelled intervention stating the resident was totally dependent on staff to provide a bath per schedule and as necessary, with no current bathing information. During interview, the resident said he/she preferred showers at least twice per week, felt dirty because of the catheter and bowel incontinence, and was unsure when the last shower occurred. Resident #7 had severe cognitive impairment and required supervision or touching assistance for showering, while Resident #8 had severe cognitive impairment, used a walker and wheelchair, and required substantial to maximal assistance for showering and toileting hygiene. Their care plans called for staff assistance with bathing, including sponge baths when full showers could not be tolerated, but shower sheets showed only limited showers in March and April 2026 and no documentation of refusals. During observation and interview, Resident #7 appeared with oily hair and mild body odor and stated a preference for showers twice per week. The responsible party for Resident #8 reported the resident had been unshaved, had long toenails, was not having teeth brushed, and had been found in soiled clothing, and expected showers at least twice per week and clean clothing daily.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse when one resident with intellectual disabilities, deafness, non-speaking status, hemiplegia, and severe cognitive impairment repeatedly engaged in inappropriate behaviors toward other residents. The resident’s care plan documented behaviors such as touching the breast area, pulling at clothing, lifting a shirt, and needing redirection away from other residents, but the record also showed repeated incidents in which the resident wandered into other residents’ rooms, removed clothing in common areas, lay against a male resident, and continued to ignore boundaries despite staff redirection. The record and resident interviews showed that multiple residents experienced unwanted contact. One resident reported being fondled on the breasts by another resident, while facility documentation later reflected disagreement among staff about whether the touching had actually occurred. Another resident stated that the resident in question entered the room unclothed, lay on top of him/her, touched the upper chest area, and pulled at a central line, prompting the resident to request a room change. A third resident reported that the resident tried to bite around a pacemaker area and attempted to touch the left chest, causing discomfort and anger. A fourth resident also reported that the resident tried to sit on his/her lap, and staff observed the resident sitting on a male peer’s lap in the common area. Facility documentation showed that several of these events were not documented in the residents’ progress notes, including the allegations of inappropriate touching, the room change request, and the biting/touching incident. Staff interviews reflected that they understood unwanted touching and sexual contact between residents to be abuse and that such behaviors should be documented and reported, yet the record showed inconsistent reporting and documentation. The DON stated that multiple residents had reported kissing and breast touching involving two residents, and that the Administrator believed the residents were exaggerating and not telling the truth before an investigation was initiated.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to report multiple allegations of abuse immediately to facility management and to DHSS within the required two-hour timeframe. The deficiency involved four residents and included incidents of unwanted touching, sexual contact, and other resident-to-resident behaviors that staff documented or that were reported by residents, but were not reported to the state as required. The facility policy stated that resident abuse must be reported immediately to the Administrator and that allegations involving abuse or serious bodily injury must be reported no later than two hours after the allegation is made. Resident #1, who had intellectual disabilities, was deaf, non-speaking, and had left-sided hemiplegia, was involved in several incidents. Nursing notes documented that the resident was found removing clothing in a common area with other residents present, was repeatedly redirected for inappropriate touching of his/her body, was found laying against a male resident and returning to the back area to lay on a couch with males present, and was found in another resident’s room going through belongings and trying to get into the resident’s bed. The record showed nursing and management were notified in some instances, but there was no documentation that these allegations were reported to DHSS, and DHSS records showed no self-report for those events. Resident #2, who had CKD, dementia with anxiety, and mild cognitive impairment, was documented as fondling Resident #1’s breasts. Staff redirected the resident and removed Resident #1 from the area, but the record did not document notification of family, physician, DON, Administrator, or DHSS, and DHSS records showed no self-report. Resident #3, who had acute osteomyelitis, PVD, and COPD, reported that while rooming with Resident #1, he/she woke up to Resident #1 naked on top of him/her, touching his/her upper chest and pulling at his/her central line; the resident also reported witnessing Resident #1 and Resident #2 kissing in the dining room. Resident #4, who had hemiplegia/hemiparesis following cerebral infarction, a pacemaker, and dysarthria, reported that Resident #1 tried to bite him/her near the pacemaker and touched his/her left chest. These resident reports were not documented in the progress notes, and DHSS records showed the facility did not self-report the allegations.
Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to complete timely and thorough investigations of allegations of resident-to-resident abuse and failed to document steps taken to protect residents while investigations were underway. The facility policy stated that residents have the right to be free from abuse, that the Administrator will ensure a thorough investigation of alleged violations of individual rights, and that steps will be taken to prevent further abuse during an investigation. Survey review found no documented timely investigation or protective measures for multiple allegations involving residents. Resident #1, who had intellectual disabilities, was deaf, non-speaking, and had hemiplegia, was documented on several occasions engaging in inappropriate or sexualized behaviors with other residents, including disrobing in common areas, repeated inappropriate touching, lying against a male resident, entering another resident’s room and trying to get into the resident’s bed, and sitting on a male peer’s lap. The record showed no documentation of a timely or thorough investigation, and no documentation of steps taken to protect others related to the incidents on 04/14/26, 04/20/24, 04/21/26, and 04/22/26. Resident #2, who had CKD, dementia with anxiety, and mild cognitive impairment, was observed fondling Resident #1’s breasts, and staff removed Resident #1 from the area. Resident #3 reported that Resident #1 was naked, laying on top of him/her, touching his/her upper chest, and pulling at his/her central line, and also reported seeing Resident #1 and Resident #2 kissing in the dining room. Resident #4 reported that Resident #1 tried to bite around the area of a pacemaker and tried to touch the resident’s left chest. For these allegations, the facility had no documentation of a timely investigation or steps taken to protect other residents during an investigation.
Failure to Notify Physician of Critical Lab Results and Document Communication
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of critical laboratory results and to document such notification, as required by facility policy. The facility’s Significant Condition Change and Notification policy required licensed nurses to immediately contact the medical practitioner for emergencies, including abnormal lab values, and to document each attempt to notify the practitioner and the resident’s representative. The Charting and Documentation policy further required staff to document the date and time specimens were obtained and the date and time the physician was notified of lab results. Despite these policies, the medical record for one resident contained no documentation that the physician or family were notified of critical lab findings. The resident was admitted with multiple significant diagnoses, including type 2 diabetes mellitus, heart failure, essential HTN, hypokalemia, hyperlipidemia, and chronic kidney disease stage 3. Admission orders included a CBC, CMP, TSH, BNP, and valproic acid level. A lab report collected several days after admission showed critically low hemoglobin of 5.1 g/dL and hematocrit of 18.7%, both flagged in the critical range. The lab report bore an illegible signature on the final page without a date, and there was no documentation in the resident’s chart that the physician or family had been notified of these critical results, nor any indication in subsequent physician notes that the labs had been reviewed. Over the following months, multiple progress notes by the dietician documented that no labs were located in the electronic medical record, and physician notes on several visits showed no documentation of lab review. Eventually, nursing notes documented that the resident was acting outside baseline with low blood pressure, and the family requested transfer to the hospital, where emergency department labs again showed severely abnormal hemoglobin and hematocrit values. Interviews with RN staff, the Medical Director, the DON, and the Administrator confirmed that nurses were responsible for monitoring lab results, that the lab should call the facility with critical values, and that staff were expected to notify the physician and document this notification. The Medical Director stated she had not been informed of the critical results, the signature on the lab report was not hers, and there was no record of staff notification, confirming that the facility failed to follow its own policies for critical lab result communication and documentation.
Failure to Document Resident Sliding/Fall Event in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records when staff did not document an incident in which a resident slid from a recliner to the floor. Facility policies on Significant Condition Change and Notification and on Charting and Documentation required that all significant changes, including falls, be recorded in the resident record, with charting each shift for 72 hours as needed, and that all pertinent changes in condition be documented concisely, accurately, and completely. Resident #1, admitted with diagnoses including Type 2 diabetes mellitus, heart failure, HTN, hypokalemia, hyperlipidemia, and stage 3 chronic kidney disease, had a care plan identifying potential for falls due to weakness and medication side effects. The resident’s quarterly MDS indicated intact cognition, substantial/maximal assistance needs for toileting, showering, and personal hygiene, and no falls. On the date in question, an LPN documented a fall follow-up note stating the resident had no latent injuries from an earlier fall and that staff should continue to monitor, based on information received in shift report. However, there was no documentation in the medical record of the actual fall or incident itself. An RN later reported that while working that day, the resident did not “fall” but slid slowly out of a recliner onto the floor, did not hit the head, and had no injury, and acknowledged that this sliding event should have been documented. The DON and the Administrator both stated they considered sliding out of a chair to be a fall and expected staff to document such events in the progress notes and, per the DON, to notify the responsible party. Despite these expectations and policies, the resident’s record lacked documentation of the sliding/fall event, resulting in an incomplete and inaccurate medical record.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for a resident with chronic obstructive pulmonary disease (COPD) and respiratory failure. The staff did not clarify the hospital discharge orders for pulse oximetry, which included instructions for a non-monitored home continuous pulse oximeter for spot checks. The discharge orders specified that if the resident's pulse oximeter reading fell below 90%, the hospital or emergency services should be contacted immediately. However, the facility did not document an order regarding pulse oximeter monitoring or directions for when to notify the physician. The resident's Treatment Administration Record (TAR) did not include the physician's order for oxygen at two liters via nasal cannula PRN for shortness of breath, nor did it include monitoring for pulse oximeter readings. Interviews with staff revealed that the resident had a pulse oximeter at their bedside and checked their own oxygen saturations, but staff did not consistently document these readings. The staff assumed spot checks meant checking the resident's oxygen saturations each shift, but this was not clarified with the physician, and the checks were not documented on the TAR. The Director of Nursing and other staff members acknowledged that the hospital discharge order should have been clarified with the physician, and that the facility did not perform continuous pulse oximetry checks. The Director of Nursing expected staff to perform spot checks at least three times a day to ensure the resident's oxygen saturations were at 95% and to notify the physician if they were below this level. However, this expectation was not communicated or documented, leading to a failure in providing appropriate respiratory care for the resident.
Failure to Document Resident Death and Notifications
Penalty
Summary
The facility failed to maintain complete medical records for a resident who died at the facility. The deficiency was identified when staff did not document full details and notifications related to the resident's death. The facility's policy on charting and documentation requires staff to document all pertinent changes in a resident's condition, including details surrounding a resident's death, such as code status, CPR performance, symptoms, vital signs, and notifications to the physician and family. However, the nursing notes for the resident did not include documentation of the resident's death or notifications to the physician and responsible parties. The resident, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and chronic kidney disease, was found without a pulse or heartbeat by aides. A Registered Nurse (RN) was informed and subsequently messaged the physician and called the resident's family but failed to document these actions in the progress notes. Interviews with the RN, Director of Nursing (DON), and Administrator revealed an expectation for staff to document changes in condition and notifications, which was not met in this case. The lack of documentation was confirmed during interviews, highlighting a failure to adhere to the facility's documentation policy.
Failure to Ensure CNA Certification Within Four Months
Penalty
Summary
The facility failed to ensure that six nurse aides (NAs) completed a certified nurse aide (CNA) training program and obtained certification within four months of employment. The NAs in question, identified as NA B, NA G, NA J, NA K, NA L, and NA C, were all found to be working at the facility without having completed the necessary certification. NA B, for instance, was rehired in December 2024 and was observed providing direct care to residents without being enrolled in a CNA class. Similarly, NA G, NA J, NA K, NA L, and NA C were all scheduled to work in the facility for several months without being listed on the state agency CNA registry. Interviews with the CNA Instructor and the Administrator revealed that there were no current nurse aide training classes at the facility, and the last class had concluded in September 2024. The CNA Instructor noted that nurse aides should become certified within 120 days or be reclassified, and they should work with another CNA or licensed nurse staff. The Administrator acknowledged that nurse aides should not work on the floor if certification is not obtained within four months and mentioned plans to relocate staff if necessary. However, the facility lacked a policy for nurse aide certification or training, contributing to the deficiency.
Infection Control Deficiencies in Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene practices during personal care for two residents. In the case of Resident #46, staff members did not wash or sanitize their hands after removing gloves and before putting on new gloves while performing perineal care. Similarly, for Resident #38, staff members also failed to sanitize or wash their hands after glove removal during perineal care, which involved handling soiled incontinence briefs and applying barrier cream. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing infection transmission. Additionally, the facility lacked a policy for Enhanced Barrier Precautions (EBP), which are infection control measures designed to reduce the transmission of resistant organisms. This deficiency was observed in the care of Resident #5, who had a diabetic ulcer and required EBP due to the presence of a wound. Despite the need for EBP, there was no signage indicating the precautions, and staff members, including the Infection Control Specialist and a Registered Nurse, failed to don gowns when providing direct care to the resident's wound. Interviews with staff members revealed a lack of understanding and inconsistent practices regarding EBP. Some staff members acknowledged the need for EBP signage and the use of gowns and gloves for residents with wounds, yet these measures were not consistently implemented. The absence of a formal EBP policy and the failure to adhere to proper infection control practices contributed to the facility's deficiency in maintaining an effective infection prevention and control program.
Controlled Medications Found Unsecured in Facility
Penalty
Summary
The facility failed to ensure that all controlled medications were stored according to standards of practice, as observed during a survey. Specifically, controlled substances such as Ativan Intensol and morphine sulfate were found in an unlocked refrigerator in the medication room. The facility's policy requires that controlled substances be stored under double-lock conditions and accessible only to authorized personnel. However, during observations on two separate occasions, the refrigerator containing these controlled substances was found unlocked, with the lock placed beside it on the counter. Interviews with staff revealed that there was an awareness of the requirement to keep the narcotics refrigerator locked, but lapses occurred. A Certified Medication Technician (CMT) acknowledged having seen the refrigerator unlocked and stated they would inform the Director of Nursing (DON) if it was found unlocked. A Registered Nurse (RN) admitted to forgetting to lock the refrigerator after counting narcotics with an off-going nurse. These actions and inactions led to the deficiency, as the facility did not adhere to its own policy for the secure storage of controlled substances.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse/neglect policy by not reporting an allegation of verbal abuse to the State Survey Agency within the required two-hour timeframe. The incident involved two residents, where one resident threatened to cut the throat of another resident during a smoke break. Despite the threat being heard by other residents and documented by a Registered Nurse (RN), the facility did not report the incident to the Department of Health and Senior Services (DHSS) as required by their policy. Resident #7, who made the threat, has a history of schizoaffective disorder, generalized anxiety disorder, and other behavioral issues, including delusions and hallucinations. The resident's care plan noted behavior problems such as inappropriate actions towards caregivers and other residents. Resident #35, the recipient of the threat, has moderate cognitive impairment and uses a wheelchair. The incident was documented in a nursing note, but there was no evidence of the allegation being reported to the DHSS. Interviews with various staff members, including the RN who documented the incident, revealed that they were aware of the requirement to report such allegations to the state within two hours. However, the Administrator stated she was not aware of the incident or the progress note documenting the threat. This lack of communication and failure to follow the facility's reporting policy resulted in the deficiency noted in the report.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse/neglect policy effectively, resulting in a lack of documented investigation into an allegation of verbal abuse involving two residents. The policy mandates that any resident abuse must be reported immediately to the administrator, who is responsible for conducting a thorough investigation. However, in this case, the facility did not document any investigation into the incident where one resident threatened another resident by saying, 'I will cut your throat.' This threat was witnessed by other residents, but no written investigation was provided to the Department of Health and Senior Services. Resident #7, who made the threat, has a history of schizoaffective disorder, generalized anxiety disorder, and intermittent explosive disorder, among other conditions. The resident's care plan noted behavior problems, including inappropriate behaviors towards caregivers and other residents. Despite these documented issues, the facility did not follow through with the required investigation after the threat was made. The nursing note from the incident indicated that the threat was reported to the administrator and Director of Nursing via text message, but no further action was documented. Interviews with various staff members, including registered nurses, certified nurse assistants, and the administrator, revealed a consensus that the threat constituted abuse and should have been reported and investigated. However, the administrator stated that she was not aware of the incident and that the required investigation was not completed. This lack of action and documentation represents a failure to adhere to the facility's abuse prevention and prohibition policy, leaving the incident unaddressed and unreported to the appropriate authorities.
Failure to Monitor and Manage Edema in Resident
Penalty
Summary
The facility failed to routinely monitor and manage a resident's edema, notify the physician of significant changes in the resident's condition, and apply prescribed interventions. The resident, who had diagnoses including schizophrenia, dementia, diabetes mellitus, and chronic venous hypertension, was not taking a diuretic and had an order for Tubi grips to be applied to the lower legs as needed for edema. Despite this, staff did not consistently document the application of Tubi grips or notify the physician of the resident's weight gain and changes in edema status. The resident's care plan required monitoring and reporting of edema or weight gain over two pounds a day, as well as weekly inspections of the lower extremities for signs of edema. However, the facility's records showed a lack of documentation regarding the application of Tubi grips and physician notification of the resident's weight increase and new redness on the feet. Observations revealed the resident had significant edema, with swollen and red legs, and was not consistently wearing Tubi grips. Interviews with staff indicated a lack of consistent application of Tubi grips and inadequate communication with the physician regarding the resident's condition. The resident's legs were observed to be swollen, red, and sometimes hot to the touch, with signs of possible cellulitis. Despite these observations, there was no documentation of physician notification or consistent application of prescribed interventions, highlighting a deficiency in the facility's care and monitoring processes.
Unsafe Resident Transfers Due to Non-Adherence to Care Plans
Penalty
Summary
The facility staff failed to ensure a safe environment free from accident hazards by not completing a safe transfer for two residents. Resident #46, who has diagnoses including dementia, polyarthritis, anxiety, and muscle weakness, required substantial assistance for transfers as per their care plan, which specified the use of a gait belt. However, during an observed transfer, staff did not use the gait belt and instead lifted the resident by holding onto the back of their pants, contrary to the care plan instructions. This improper transfer method was acknowledged by the staff involved, who noted the resident's limited weight-bearing capacity and the resident's upset reaction to the gait belt. Resident #38, with diagnoses of hemiplegia and hemiparesis following a stroke, was also involved in an unsafe transfer. The resident's care plan indicated the need for staff assistance during transfers, but did not specify the use of a gait belt. During an observed transfer, staff used a gait belt and lifted the resident with most of the weight on the resident's arms, despite the resident's severely impaired cognition and upper/lower extremity impairment. Staff interviews revealed that the resident was a two-assist transfer and should not have been transferred using a gait belt, as the resident did not bear weight. Interviews with the facility's RN and Administrator highlighted that transfers should be documented in the care plan and that changes in a resident's condition should prompt a reassessment by therapy. The Administrator emphasized that if a resident is not bearing weight, a mechanical lift should be used, and staff should seek assistance if unsure about transfer procedures. Despite these guidelines, the observed transfers did not adhere to the care plans or facility policies, resulting in unsafe transfer practices for the residents involved.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service, as observed during a lunch meal service. Nurse Assistant (NA) B was seen touching a resident's clothing and then handling a straw and a cup without performing hand hygiene. NA B continued to interact with residents and serve drinks without sanitizing hands, violating the facility's hand hygiene policy and the FDA's 2022 Food Code, which prohibits bare hand contact with ready-to-eat foods. Similarly, NA C was observed assisting a resident with eating by holding a piece of chicken with bare hands, further breaching the standards of practice. Interviews with various staff members, including dietary aides, the dietary manager, and the infection control specialist, confirmed that staff were expected to perform hand hygiene between serving residents and to use gloves when assisting with eating. Despite this, the observations showed a lack of compliance with these protocols, as staff members did not consistently sanitize their hands or use gloves, leading to potential contamination of food and food contact surfaces.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when 30 doses of alprazolam, a medication used to treat anxiety, went missing. The medication was ordered for a resident diagnosed with anxiety disorder, but it was not properly accounted for upon delivery. The Licensed Practical Nurse (LPN) signed for the medication delivery from the pharmacy but did not individually count or verify the medications, leading to the medication not being logged into the narcotic book or found in the facility. The Director of Nursing (DON) conducted an investigation and discovered that the medication was not delivered to the resident as expected. The Certified Medication Technician (CMT) responsible for putting away medications did not receive the alprazolam and noted that the pharmacy sometimes failed to provide a narcotic count sheet. Despite searching the medication carts and room, the medication was not located. Interviews with staff revealed that the LPN did not follow proper procedures for checking in medications, and the medication was not properly secured. The resident reported not receiving the medication and that it was being pulled from the emergency kit instead. The facility's investigation included notifying the Department of Health and Senior Services and the local police department about the missing medication. Despite these efforts, the facility was unable to determine what happened to the alprazolam, highlighting a failure in the facility's medication management and safeguarding procedures.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The CNA placed their hand close to the resident's mouth in an attempt to muffle the sound of the resident yelling during care. This action was reported by another Nursing Assistant (NA) who was present during the incident. The NA stated that the resident was yelling, which was normal behavior for them, and the CNA responded by telling the resident to shut up and placing their hand near the resident's mouth. The resident involved had severe cognitive impairment and required maximum assistance from staff for various activities, including personal hygiene and mobility. The resident's care plan noted that they could become combative and yell out inappropriately at times. During the incident, the CNA claimed they were trying to block the sound to hear the NA better and accidentally touched the resident's chin with their glove. Despite the CNA's explanation, the facility's investigation concluded that the resident was not treated with dignity and respect. Interviews with other staff members, including the Director of Nursing (DON) and Business Office Manager (BOM), confirmed that the CNA's actions were inappropriate and did not align with the facility's policy on treating residents with dignity and respect. The staff members emphasized that residents should be treated like family and that it is never appropriate to place a hand in front of a resident's face to muffle sound. The incident highlighted a failure in maintaining the resident's right to a dignified existence and respectful treatment.
Failure to Protect Resident's Personal Belongings from Misappropriation
Penalty
Summary
The facility failed to protect a resident's personal belongings from misappropriation when a staff member had possession of the resident's cellular phone without consent. The resident, who had moderate cognitive impairment and was dependent on staff for various activities, had their phone reported missing by a family member. Despite staff efforts to locate the phone, it was not found initially. Another nurse assistant later reported suspicions that a colleague might have stolen the phone and given it as a gift to their child. The phone was eventually returned to the facility and confirmed to belong to the resident by the cellular provider. The nurse assistant suspected of taking the phone denied any involvement but was suspended pending investigation and subsequently terminated. The facility reported the incident to the Department of Health and Senior Services and the local police department. The deficiency highlights a failure in the facility's policy to prevent misappropriation of resident property and ensure that staff members with a history of such actions are not employed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Seneca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Higher Call Nursing Center | 12.1 mi | ★★★★★ | 3 | 0 |
| Medicalodges Neosho | 12.8 mi | ★★★★★ | 1 | 0 |
| Windridge Nursing And Rehabilitation Center | 14.2 mi | ★★★★★ | 1 | 0 |
| Miami Nursing Center, Llc | 14.2 mi | ★★★★★ | 14 | 2 |
| Maple Healthcare And Rehab | 14.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.