Seminary Manor

In the surveyor’s words

From the most serious findings on record at Seminary Manor, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 29, 2026

  Based on interview and record review the facility failed to prevent employee to resident mental abuse for one (R1) resident out of seven reviewed for abuse. This failure caused R1 to feel blindsided, dumbfounded, and embarrassed. Findings include:The facility policy, Abuse Prohibition and Reporting (elder Justice Act), revised 11/28/19, documents not in its entirety, To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms.Shift coordinators and shift nurses, will be instructed to be aware of inappropriate staff behavior and take the necessary procedure for correction of… […]

• Actual harm, isolatedF689Sep 18, 2025

  Based on observation, interview and record review the facility failed to provide staff supervision during toileting for a resident that was assessed as requiring toileting assistance (R2), one of three residents reviewed for falls, in a sample of 3. This failure resulted in R2 being left unsupervised, falling from a toilet resulting in a head laceration, extensive bruising and fractured ribs. FINDINGS INCLUDE:R2's facility Resident Face Sheet documents that R2 was admitted to the facility on [DATE] with the following diagnoses: History of Falls, Displaced Fracture of Greater Trochanter of Left Femur, Need for Assistance with Personal Care, Weakness, Generalized Anxiety Disorder, Exudative Age-Related Macular Degeneration, right eye, Osteoarthritis, Asthma and Chronic systolic (congestive)… […]

• Actual harm, isolatedF686Feb 11, 2025

  Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions to prevent pressure ulcer development and worsening, conduct a pressure ulcer risk assessment once a week for four weeks after admission, obtain a treatment for a newly identified pressure ulcer, and accurately and thoroughly assess pressure ulcers weekly for two of three residents (R1 and R2) reviewed for facility acquired pressure ulcers in the sample of five. […]

• Actual harm, isolatedF695Feb 11, 2025

  Based on record review and interview, the facility failed to monitor the level of Oxygen in a portable Oxygen tank for a resident diagnosed with Congestive Heart Failure, ensure a continuous Oxygen supply was administered as ordered by the Physician, and failed to perform an assessment after a resident went without Oxygen and experienced respiratory distress and a low pulse oximetry reading for one of three residents (R1) reviewed for Oxygen use in the sample of five. These failures resulted in R1 being without oxygen for 20 minutes on one occurrence and 10 minutes on second occurrence, which caused R1 to experience chest pain, shortness of breath, feelings of being smothered and imminent death. […]

• Actual harm, isolatedF690Jan 3, 2024

  Based on observation, interview, and record review the facility failed to immediately notify the physician to obtain a treatment for a UTI (Urinary Tract Infection) for one of three residents (R1) reviewed for UTI's in the sample of three. These failures resulted in R1's UTI being left untreated for 12 days and R1 experiencing increased moaning, pain, and discomfort. This resulted in R1 being sent to the emergency room and admitted to the local hospital for four days to receive treatment with intravenous antibiotics for the diagnosis of Sepsis secondary to a UTI. Findings include: The facility's Lab/Diagnostics Policy dated 11-28-17 documents, Policy: It is a policy of the facility to provide means of quality diagnostic lab services for the residents. […]