Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Sena Kean Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident Council concerns were not addressed or communicated in a timely manner. Residents reported repeated issues with staff shutting off call lights before needs were met, not following the smoking plan, and meal trays being passed late, resulting in cold food. These concerns were raised in multiple council meetings over several months, but no timely resolution or update was shown.
Improper Storage of Supplemental Oxygen Tubing: A facility failed to maintain supplemental O2 equipment for four residents receiving respiratory services. Oxygen and nebulizer tubing were observed lying on the floor, hanging over portable tanks on wheelchairs, and in one case wrapped around a wheelchair wheel and requiring cutting to free it. An RN and LPN confirmed the tubing should be stored in a bag to keep it clean and dry, consistent with the facility policy.
Insufficient overnight nursing staffing contributed to a failure to clean multiple residents’ wheelchairs as required by facility policy. Observations showed wheelchairs with dried food, dried liquids, dust, dirt, and debris on the frames, wheels, arm rests, seats, cushions, and leg rests. An RN confirmed the condition, and the NHA stated the facility frequently lacked adequate staff on the overnight shift.
Confidential Resident Information Visible on Unattended Medication Carts: Two medication carts were observed unattended in hallway locations with computer screens displaying resident information visible to anyone passing by. An LPN acknowledged the lack of privacy on each cart, and the facility policy required screens to be shielded or cleared when unattended.
Unsecured medication carts left unattended. Two medication carts, the East A Cart and the [NAME] B Cart, were observed parked in hallways unlocked and unattended. Facility policy required medication compartments and carts to be locked when not in use, and an LPN confirmed one cart should have been locked while another LPN verified the East A Cart was not secured while he/she left to attend to a resident.
Two residents experienced actual harm when staff failed to follow care plans requiring two-person assistance for transfers and bed mobility. One resident suffered a femur fracture during a transfer performed by a single CNA, while another sustained a laceration above the right eyebrow after being rolled out of bed by one CNA instead of two, as required by their care plans and physician orders.
A resident with a history of left femur fracture and mobility issues was transferred by a CNA without the required two-person assist, contrary to physician orders and facility policy. During the transfer from a shower chair to a wheelchair, towels were placed under the resident's feet, leading to a slip and fall that resulted in a left hip/femur fracture. Staff interviews and documentation confirmed the transfer was not performed according to the care plan, resulting in actual harm.
A facility failed to follow a physician's order for a resident with a suprapubic catheter. Despite an order not to change the catheter, a nurse attempted to do so, removing the existing catheter and failing to insert a new one. This was confirmed by the Nursing Home Administrator and DON.
A facility failed to follow Enhanced Barrier Precautions during the care of a resident with a gastric tube. An LPN did not wear a gown, as required, and there was no signage or PPE available outside the resident's room. The deficiency was confirmed by the LPN and the Infection Preventionist, highlighting a lapse in infection control practices.
The facility failed to provide baseline care plan summaries to three residents or their representatives within 48 hours of admission, as required by policy. Despite having conditions such as COPD, hypertension, heart failure, hypothyroidism, hyperlipidemia, dementia, and dysphagia, the residents did not receive the necessary documentation outlining goals, medications, dietary instructions, and treatments. This deficiency was confirmed by a review of clinical records and an interview with the Regional Nurse Consultant.
A facility failed to ensure proper medication administration for a resident with chronic conditions, leaving medications unattended at the bedside. The resident reported that staff do not wait for them to take their pills, and a medication was found on the floor. An LPN was assisting other residents, and a nurse confirmed the breach of policy.
The facility failed to discard an outdated vial of Novolog Insulin on the West A Hall medication cart. The facility's policy requires checking expiration dates before administering medications and recording the opening date on multi-dose containers. A vial of Novolog Insulin, opened on 4/10/24, was found during an observation, exceeding the 28-day expiration period. An LPN confirmed the vial should have been discarded, violating facility policy and state regulations.
Resident Council Concerns Not Addressed or Communicated Timely
Penalty
Summary
The facility failed to ensure residents were updated in a timely manner regarding Resident Council concerns and failed to correct those concerns for a period of four months. Facility policy stated that the Resident Council is intended to provide residents, families, and resident representatives a forum to discuss concerns and suggestions for improvement, and that a Resident Council Response Form would be used to track issues and their resolution. The policy also stated that the department related to any issue would be responsible for addressing the concern, with QAPI review as applicable. Review of Resident Council minutes from February 2026 through April 2026 showed a pattern of concerns involving staff shutting call lights off without meeting residents' needs, failure to follow the facility smoking plan to assist residents who wanted to smoke, and dietary trays not being passed by nursing staff in a timely manner, resulting in cold food for residents. During a Resident Council meeting, interviews with residents who regularly attended the meetings indicated these concerns had been raised in several prior monthly meetings with no resolution. The residents stated that waiting until the next monthly Resident Council meeting was not a timely response to learn of facility resolutions, and no evidence was provided showing timely corrective actions or timely updates to residents regarding those concerns.
Improper Storage of Supplemental Oxygen Tubing
Penalty
Summary
The facility failed to appropriately maintain supplemental oxygen equipment for four residents reviewed for respiratory services: R54, R38, R92, and R60. A facility policy dated 1/12/26 stated that any tubing not in use would be placed in a bag to ensure it remained clean and dry. On 4/19/26, R38’s oxygen tubing was observed hanging on the portable oxygen tank attached to the back of the wheelchair without being placed in a bag, and the tubing for the resident’s respiratory nebulizer machine was lying on the floor. At 3:33 p.m., an LPN picked up R38’s nebulizer tubing from the floor and attached it to the nebulizer mask to administer an as-needed medicated nebulizer treatment. During that time, an RN confirmed that R38’s oxygen and nebulizer tubing should be stored in a bag and should be discarded. Also on 4/19/26, R54’s oxygen tubing was observed lying next to the bed on the floor and not in a bag, and an RN later confirmed that the tubing should be stored in a plastic bag to prevent contamination. On 4/20/26, R92’s oxygen tubing for the portable tank attached to the back of the wheelchair was observed hanging over the top of the portable tank, with a clear bag hanging on the concentrator. R60’s supplemental oxygen tubing for the portable tank was observed wrapped around the right wheel of the wheelchair and required cutting to release it. An LPN confirmed these observations and cut R60’s oxygen tubing from the wheel. On 4/21/26, R38’s oxygen tubing for the portable tank and R54’s oxygen tubing for the portable tank were again observed hanging over the top of the portable tanks on the backs of their wheelchairs. An RN confirmed these observations and stated that the oxygen tubing should be stored in a bag to prevent contamination.
Insufficient overnight nursing staffing left resident wheelchairs uncleaned
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, resulting in seven of 23 residents being affected: R15, R23, R28, R38, R54, R82, and R83. A facility policy dated 1/12/26 stated that wheelchairs are to be cleaned according to the resident's shower schedule on the 11:00 p.m. to 7:00 a.m. shift prior to the shower day. Observations on 4/19/26 and 4/20/26 showed that the wheelchairs used by these residents had copious amounts of dried food particles, dried liquids, dust, dirt, and debris on the frames, wheels, arm rests, seats, seat cushions, and leg rests. An RN confirmed the condition of the wheelchairs during interview, and the Nursing Home Administrator stated that the wheelchairs were to be cleaned on the overnight shift by nursing staff and that the facility frequently failed to maintain adequate staff on that shift, which could have contributed to the failure to clean the wheelchairs.
Confidential Resident Information Visible on Unattended Medication Carts
Penalty
Summary
The facility failed to maintain the privacy of confidential resident information during medication administration for two medication carts, West A Cart and East A Cart. A facility policy on Computer Terminals/Workstations dated 1/12/26 stated that computer terminals should be positioned or shielded so screens are not visible to the public or unauthorized staff, that only authorized users may access resident and facility information, and that users may not leave a workstation unattended unless the screen is cleared and the user is logged off. On 4/19/26 at 3:55 p.m., the West A medication cart was observed parked in the West A hallway and left unattended with the computer screen showing resident information visible to anyone passing in the corridor; during the observation, LPN Employee E1 acknowledged the lack of privacy. On 4/20/26 at 8:35 a.m., the East A medication cart was observed parked in the East A hallway and left unattended with the computer screen showing resident information visible to anyone passing in the corridor; during the observation, LPN Employee E5 acknowledged the lack of privacy.
Unsecured medication carts left unattended
Penalty
Summary
The facility failed to prevent the opportunity for potential unauthorized access to medications on two medication carts, the East A Cart and the [NAME] B Cart. A facility policy titled Medication Labeling and Storage dated 1/12/26 stated that compartments containing medications and biologicals are to be locked when not in use and that trays or carts used to transport such items are not to be left unattended if open or otherwise potentially available to others. On 4/19/26 at 3:51 p.m., the [NAME] B Medication Cart was observed parked in the [NAME] B hallway, unlocked and unattended, and an LPN confirmed at 3:55 p.m. that the cart should have been locked. On 4/20/26 at 8:35 a.m., the East A Medication Cart was observed parked in the East A hallway, unlocked and unattended, and an LPN verified that the cart was not secured while he/she left the cart to attend to a resident.
Failure to Follow Care Plans Results in Resident Harm
Penalty
Summary
The facility failed to protect two residents from neglect during care, resulting in actual harm. In the first incident, a resident with orders requiring transfer assistance from two staff members and a wheeled walker, and who was assessed as fully dependent for mobility, was transferred by a single CNA. During the transfer from a shower chair to a wheelchair, towels were placed under the resident's feet to keep them dry, but the resident stepped off the towels and slipped. The CNA attempted to lower the resident to the floor, but the resident sustained a left femur fracture. Documentation and staff interviews confirmed that the transfer was performed without the required second staff member, contrary to the resident's care plan and physician's orders. In the second incident, another resident, who was dependent on two staff for bed mobility due to cognitive impairment and physical limitations, was being rolled in bed by a single CNA during morning care. The CNA rolled the resident too far, causing the resident to fall out of bed from a height of approximately 18 inches. The resident sustained a laceration above the right eyebrow and forehead, which required sutures and further medical evaluation. The care plan, Kardex, and task documentation all indicated that two staff were required for bed mobility, but this was not followed. Both incidents were confirmed through facility documentation, clinical records, and staff interviews. The Director of Nursing and Nursing Home Administrator acknowledged that in both cases, staff failed to follow established care plans and physician orders requiring two-person assistance for transfers and bed mobility. These failures resulted in actual harm to the residents, including a femur fracture and a laceration requiring stitches.
Improper Transfer Results in Resident Fracture Due to Failure to Follow Two-Person Assist Policy
Penalty
Summary
A deficiency occurred when a resident, who had a history of left femur fracture, difficulty walking, atrial fibrillation, and asthma, was not transferred according to the facility's established policy and physician's orders. The resident's care plan and orders specified that transfers required the assistance of two staff members and, as needed, the use of a stand-up lift or walker. Despite these requirements, a CNA attempted to transfer the resident from a shower chair to a wheelchair with only one staff member present and placed towels under the resident's feet to keep them dry. During the transfer, the resident stepped off the towels, slipped, and fell to the floor. The CNA was able to support the resident's upper body and lower them to the ground, but the resident's lower body fell, resulting in significant pain and an inability to move the left leg. Assessment revealed the left lower extremity was bent and externally rotated, and the resident reported severe pain. The resident was subsequently sent to the emergency room, where a left hip/femur fracture was confirmed. Staff interviews and facility documentation confirmed that the CNA did not follow the resident's care plan or the facility's policy, which required two-person assistance for transfers. The incident was further corroborated by statements from other staff and the Director of Nursing, who verified that the transfer was performed improperly with only one staff member. This failure to follow established protocols directly resulted in actual harm to the resident.
Failure to Follow Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with a suprapubic catheter. The resident, who was admitted with diagnoses including anxiety, urinary retention, and bladder infections, had a physician's order dated 9/26/24, instructing staff not to change the suprapubic catheter. However, a nurse's note from 10/21/24 documented that a nurse attempted to change the catheter against these orders, removing the existing catheter and unsuccessfully attempting to insert a new one. This incident was confirmed during an interview with the Nursing Home Administrator and Director of Nursing on 11/09/24.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning Enhanced Barrier Precautions (EBP) during the care of a resident with a gastric tube. The facility's policy on Enhanced Barrier Precautions, implemented in April 2024, requires the use of gowns and gloves during high-contact resident care activities, especially for residents with indwelling medical devices like feeding tubes. However, during an observation of enteral tube feeding administration for a resident, it was noted that the LPN only wore gloves and did not use a gown, which is a requirement under EBP. Additionally, there was no signage indicating the need for EBP, nor was there any personal protective equipment (PPE) available outside the resident's room. The deficiency was confirmed through interviews with the LPN involved and the facility's Infection Preventionist, both acknowledging that EBP were not in place as required. The LPN admitted that both gloves and a gown should have been worn during the procedure, and the Infection Preventionist confirmed the absence of necessary precautions and PPE. This oversight indicates a failure to implement the facility's infection control policies effectively, particularly concerning residents with indwelling medical devices.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to three residents or their representatives within 48 hours of admission, as required by their policy. The policy mandates that a written summary of the baseline care plan, including goals and objectives, a summary of medications, dietary instructions, and treatments, be provided to the resident and/or their representative. However, for Residents R31, R103, and R105, there was no evidence that such summaries were shared. This was confirmed by a review of their clinical records and an interview with the Regional Nurse Consultant. Resident R31 was admitted with chronic obstructive pulmonary disease, hypertension, and heart failure, while Resident R103 had hypothyroidism, hypertension, and hyperlipidemia. Resident R105 was diagnosed with dementia, hypertension, and dysphagia. Despite these conditions, the facility did not provide the required baseline care plan summaries to these residents or their representatives, as evidenced by the lack of documentation in their clinical records and the confirmation from the Regional Nurse Consultant.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were consumed by Resident R55 during a medication administration review. The facility's policy on administering medications, dated 1/17/24, requires that medications be administered in a safe and timely manner, with staff remaining with the resident until each medication is swallowed. However, during an observation on 5/29/24, a medication cup filled with multiple unknown medications was found on Resident R55's bedside tray table without staff present. Resident R55, who has diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and disorientation, stated that staff do not wait for them to take their pills because it takes a while. Further observations revealed a small white unknown medication on the floor in front of Resident R55's bedside tray table, and the LPN responsible for administering the medications was assisting other residents down the hallway. During an interview, Registered Nurse Employee E1 confirmed the presence of the medication cup on the bedside table and acknowledged that medications should not be left at the bedside and that the nurse should stay with the resident until the medications are ingested. This incident is a violation of the facility's medication administration policy and the relevant state codes for pharmacy and nursing services.
Failure to Discard Outdated Novolog Insulin
Penalty
Summary
The facility failed to appropriately discard outdated medications, specifically a vial of Novolog Insulin, on one of the three medication carts reviewed, namely the West A Hall medication cart. The facility's policy on administering medications, reviewed on 1/17/24, requires that the expiration or beyond-use date on the medication label be checked prior to administration, and that the date of opening be recorded on multi-dose containers. According to the manufacturer's guidelines for Novolog Insulin, a vial may be kept at temperatures below 30 degrees Celsius (86 degrees Fahrenheit) for up to 28 days after initial use. However, during an observation of drug storage on 5/30/24, a vial of Novolog Insulin with an open date of 4/10/24 was found, which exceeded the 28-day expiration period. During an interview conducted at the time of the observation, an LPN confirmed that the Novolog Insulin vial should have been discarded as it was beyond the 28-day period after opening, yet it remained in the medication cart for resident use. This oversight was in violation of the facility's policy and the manufacturer's guidelines, as well as state regulations regarding management, pharmacy services, and nursing services.
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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 Smethport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Healthcare And Rehab | 0.7 mi | ★★★★★ | 3 | 0 |
| Bradford Ecumenical Home, Inc | 14.6 mi | ★★★★★ | 0 | 0 |
| Pavilion At Brmc, The | 15.7 mi | ★★★★★ | 8 | 0 |
| Bradford Manor Nursing And Rehab | 15.7 mi | ★★★★★ | 0 | 0 |
| The Pines Healthcare & Rehab Centers Olean Campus | 18.5 mi | ★★★★★ | 0 | 0 |
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