A list of the most recent deficiencies for Seminary Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-31 | 2024-02-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-03 | 2024-01-08 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-03 | 2024-01-08 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-05 | 2023-06-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-06-05 | 2023-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-05 | 2023-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-01 | 2023-06-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-01 | 2023-06-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-01 | 2023-06-08 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-06-05 | 2023-06-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-17 | 2023-04-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-17 | 2023-04-18 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-25 | 2022-06-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-25 | 2022-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-13 | 2022-05-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-13 | 2022-05-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-25 | 2022-05-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-24 | 2021-11-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-12 | 2021-04-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-12 | 2021-04-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-04 | 2021-04-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-04 | 2021-03-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-05 | 2021-03-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-05 | 2021-03-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-03-05 | 2021-03-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-05 | 2021-03-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-04 | 2021-03-05 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-03-04 | 2021-03-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-03-04 | 2021-03-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-04 | 2021-03-05 | N |
