Seneca Hill Manor INC

Based on record review and interviews, the facility failed to report timely, verbal and physical abuse for one (1) of three (3) residents (Residents #1) reviewed, resulting in the alleged perpetrator having continued access to residents. Specifically, on 04/02/2026 at approximately 5:30 PM, Certified Nurse Aide #2 alleged they witnessed Certified Nurse Aide #1 handling and speaking to Resident #1 roughly during care. On 04/02/2026, Certified Nurse Aide #1 continued to have access to residents and worked until the end of their shift at 10:00 PM. Certified Nurse Aide #2 did not report the incident until 04/03/2026 at approximately 2:30 PM. Resident #1 was not assessed until 04/03/2026 at approximately 8:00 PM. Findings include: The 05/2023 facility policy, Resident Abuse documented in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source or misappropriation of resident property, are reported immediately, but not more than two (2) hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews during the recertification survey conducted 10/3/2024-10/9/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 4 residents (Residents #25, #53, and #86) reviewed. Specifically, Resident #86 was not provided timely toileting assistance; Resident #53 was not provided nail care, facial hair care, or a weekly shower as planned; and Resident #25 was not provided their offloading boots (used to lessen pressure on the feet) as planned. Findings include: The facility policy, Positioning of the Resident, revised 10/12/2023, documented all residents who could not independently position themselves would be positioned by nursing staff to reduce risk for development of pressure areas; heels would be elevated and offloaded with a pillow, or booties as ordered when lying in bed; and positioning systems included heel protectors. The facility policy, Toileting Schedule for Residents, revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews during the recertification survey conducted 10/3/2024-10/9/2024, the facility did not ensure performance reviews for certified nurse aides were completed at least once every 12 months for 2 of 2 Certified Nurse Aides (Certified Nurse Aides #1 and #2) reviewed. Specifically, Certified Nurse Aides #1 and #2 did not have performance evaluations documented at least once every 12 months. Findings included: The facility Certified Nurse Aide job description dated 6/11/2020, documented the certified nurse aide reported to the Nurse Manager and was responsible for providing individual and comprehensive resident care in accordance with and under the supervision of licensed personnel. Personnel files for Certified Nurse Aides #1 and #2 did not include documented evidence of performance evaluations completed at least once every 12 months. During an interview on 10/8/2024 at 1:34 PM, Certified Nurse Aide #11 stated they had been employed by the facility for 2 years and never had a performance evaluation. They thought they were supposed to be completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview during the abbreviated Survey (NY00310806), the facility did not implement a person-centered care plan with measurable objectives, time frames, and appropriate interventions for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 was identified at risk for falls and no fall prevention interventions were included on their care plan. The resident was left unattended in the bathroom and was found on the floor with a minor injury. Findings include: The Comprehensive Resident-Centered Care Plan Policy, revised 7/2022, documented: - the interim/baseline care plan will be developed within 48 hours of admission, including any specialized services. - The Resident Care Profile (RCP) will be developed, will support the resident plan of care, and will be placed in each resident's closet door for review by all licensed and non-licensed staff, including but not limited to certified nurse aides (CNA). - Care plan meetings will be held, and resident care plans will be updated to reflect pertinent changes and/or updates in resident care status. -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview during the abbreviated survey (NY00326356), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents reviewed (Resident #2). Specifically, Resident #2 was admitted to the facility with a cholecystostomy tube (tube that drains fluid from the gallbladder) and there was no documentation: - a treatment was ordered to the cholecystostomy insertion site until the surgical provider ordered one 13 days after admission. - Parameters were specified for cholecystostomy drainage to determine when the medical provider should be notified of inadequate drainage. - The resident was assessed after the cholecystostomy tube was removed to determine if a treatment order was needed at the insertion site. - A plan of care was implemented to monitor the resident after the tube removal. Findings include: The 4/2020 facility's Biliary (bile, bodily fluid that aides in digestion) Drain Care Policy documented the purpose of the policy was to instruct nursing staff on how to care for biliary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review during the recertification survey conducted 9/29/22-10/4/22, the facility failed to ensure staff were educated on the policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 3 of 3 resident units (Units 1, 2, and 3). Specifically, facility staff were not aware of the policy to properly reheat resident food brought from outside the facility and did not have access to an internal probe thermometer to properly measure food temperatures after reheating. Finding include: The facility policy Resident Food Prepared Outside the Facility dated 10/2016, documented family and/or friends were allowed to bring food /beverages prepared outside the facility to the facility for a resident's dining pleasure. If the food needed to be reheated, it must be reheated to a minimum of 165 degrees F (Fahrenheit). The kitchen would provide a thermometer to the dining room as needed. When interviewed on 10/3/22 at 12:19 PM, the Food Service Director stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview during the recertification survey conducted 9/28/22-10/4/22, the facility failed to ensure each resident was offered influenza and pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 5 residents (Residents #39 and 16) reviewed. Specifically, there was no documented evidence Resident #39 was offered, declined, or educated on the pneumococcal immunization, or Resident #16 was offered, declined, or educated on the influenza immunization. Findings include: The undated facility policy Influenza-Pneumonia Vaccine Immunization Program documented residents would be provided with instruction and education relative to Influenza/Pneumovax (pneumococcal vaccine) and aspects of the facility vaccination program. All education provided would be documented on the Resident Consent/Declination Form and/or nurse's notes for validation. The undated facility policy Influenza: Prevention, Early Detection and Control documented all residents were to receive the influenza vaccine on an annual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview during the recertification survey the facility did not ensure each resident is treated with respect and dignity to promote maintenance or enhancement of his or her quality of life for 2 of 2 residents (Residents #83 and #110) reviewed for dignity. Specifically, Residents #83 and #110 were not provided a dignified dining experience. Findings include: The facility policy Feeding the Dependent Resident dated 1/2014 documented any personnel assisting a resident should try to assume a seated position next to the resident and the manner of assisting should be unhurried. Personnel are responsible for feeding residents assigned to them as needed and it is the responsibility of the nurse to ask for assistance if they have more than one resident to feed. 1) Resident #83 was admitted with diagnoses including cerebral infarction and hemiplegia following a stroke. The 12/9/19 Quarterly Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance for eating. The January 2020 physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview during the recertification survey, the facility did not ensure residents had the right to be free from physical restraints not required to treat the resident's medical symptoms for 1 of 1 resident (Resident #4) reviewed for restraints. Specifically, Resident #4 had a wheelchair seat belt in place without a physician order for a restraint, a current restraint assessment or parameters for use of the seat belt. Findings include: The facility policy Restraints revised 12/12/17 documented: The facility will try all alternative available interventions before applying a restraint to a resident. In the event a restraint is utilized, ongoing reassessment will be completed to ensure continued need for the restraint, and to ensure the restraint is the least- restrictive device appropriate for the resident. Determination regarding the initial need for the restraint will be completed by the interdisciplinary care plan team (IDCP) and will be reviewed quarterly, annually, and with all significant changes. Once the restraint decision has been made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review during the recertification survey, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 5 of 11 residents (Residents #25, 45, 62, 100, and 313) observed for medication administration. Specifically, licensed practical nurses (LPNs) #1 and 2 were observed not performing hand hygiene between Residents #25, 45, 62, 100 and 313 during medication pass observations. Findings included: The facility policy Medication Administration Guidelines dated 11/16/17 does not include guidelines/instructions for hand hygiene during medication administration. The facility policy Hand Hygiene (undated) documented hand hygiene is the primary means of avoiding spreading of infection and should be completed before and after direct contact with a resident, after removing gloves, and after handling soiled dressings. During a medication administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.