Ahmc Seton Medical Center

In the surveyor’s words

From the most serious findings on record at Ahmc Seton Medical Center, in the surveyor’s own words.

• Actual harm, patternF584Feb 15, 2022

  Based on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable and homelike environment when: 1. The linoleum flooring in Room 403's bathroom were torn, cracked, and peeling off around the base of the toilet exposing the subfloor and had a pungent musty odor. 2. 20 of 41 resident bathroom flooring (Rooms 101, 105, 111, 201, 206, 208, 301, 302, 305, 306, 308, 309, 310, 311, 401, 403, 406, 407, 408 and 410) were damaged and discolored. 3. There was an evidence of stagnant, dark colored liquid in the shower room (number) 3 with pungent musty odor on the missing tiles. The pungent musty odor had caused Resident 91 to feel sick and want to throw up. […]

• Actual harm, isolatedF689Aug 15, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of the 26 sampled residents (Resident 97) bed/side rail was raised up while the resident was in bed. This failure resulted in Resident 97 falling out of bed and sustain a fracture (broken bone) through the right femur (thigh bone).During an observation on 8/11/25, at 10:04 AM, Resident 97 was asleep in bed. The right and left upper bed/side rails were raised.During an interview on 8/13/25, at 10:08 AM, Registered Nurse (RN) 4 stated that the bed/side rails were raised up when Resident 97 is in bed for positioning. RN 4 further stated Resident 97 leans to one side. […]

• Actual harm, isolatedF689May 16, 2025

  Based on observation, interview, and record review, four problems were identified regarding the facility's fall prevention program: 1. The facility did not regularly conduct a thorough investigation regarding the primary causes of falls for Resident 1. 2. The facility did not conduct a fall risk assessment for two of Resident 1's falls. 3. The facility continued using a tab alarm (an alarm that clips onto a resident's clothing) to alert staff for unassisted transfers for Resident 1 who has a history of unclipping the tab alarm from her clothing. The facility did not evaluate if a tab alarm was appropriate for Resident1 in decreasing her fall risks. 4. […]

• Actual harm, isolatedF686Feb 14, 2024

  Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer (PU) for one of 14 sampled residents (Resident 22) when interventions were not implemented to avoid skin breakdown for Resident 22. This deficient practice resulted in the development of Stage 2 PU for Resident 22. Definition/Stages for Pressure Ulcer/Pressure Injury (also called a bed sore, is an injury to skin and underlying tissue resulting from prolonged pressure on the skin. Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persists and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. […]

• Actual harm, isolatedF758Feb 14, 2024

  Based on interview and record review, the facility failed to ensure three of eight sampled residents (Residents 409, 70, and 86) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when the facility did not ensure: 1.Resident 409 a. was free from side effects due to the use of Haldol. Haldol is an anti-psychotic drug used to treat symptoms of psychosis. Symptoms of psychosis includes hallucinations (perceiving sights, sounds, smells, tastes, or touches that are not real), delusions (false beliefs), and dementia (loss of the ability to think, remember, learn, make decisions, and solve problems). b. Aggressive behaviors were managed via non-medication means such as modifying smoking rules. c. […]