Seneca Health Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Nurse Aide #1 would have stayed with Resident #1, they could have prevented the fall. Certified Nurse Aide #1 should have pulled the emergency call cord in the bathroom and waited for someone to answer it and get them linen.During an interview on 10/29/2025 at 1:13 PM, the Medical Director stated they would have expected Certified Nurse Aide #1 to have reviewed Resident #1's care plan prior to providing care. They stated a fracture was a serious injury. The Medical Director stated, There was a possibility Certified Nurse Aide #1 could have prevented Resident #1's fall if they had not left the room, but Resident #1 could have fallen either way. During an interview on 10/29/2025 at 2:03 PM, the Director of Quality and Education stated they expected all certified nurse aides to review care plans prior to providing resident care. With the incident on 07/12/2025, Certified Nurse Aide #1 did not follow the care plan for Resident #1, and the resident sustained a fracture. During re-interview on 11/05/2025 at 9:56 AM, they stated after the fall they had determined this was an isolated incident based on trending of falls within the facility. Certified Nurse Aide #1 was re-educated on reading and following the plan of care. During a telephone interview on 10/29/2025 at 2:10 PM, Nurse Practitioner #1 stated they were informed on 07/12/2025 after the fall that Resident #1's left lower extremity was shorter than the right and had pain with passive range of motion.
They ordered x-rays of the left hip, femur, and pelvis and spoke with Resident #1's Health Care Proxy regarding possible surgical intervention. Nurse Practitioner #1 stated Resident #1 being left alone on the toilet was a break in their care plan that resulted in a fracture, which was a serious injury, and the serious injury caused harm to Resident #1. During an interview on 10/29/2025 at 2:45 PM, the Director of Nursing stated a break in a plan of care would be when staff does not follow the care plan. Their expectation was for all staff to read and follow residents' individualized care plans. Ultimately, Resident #1 had an intervention not to be left alone in the bathroom. Certified Nurse Aide #1 left them alone in the bathroom, the resident fell which resulted in a fracture. During an interview on 10/29/2025 at 2:56 PM, the Administrator stated
they expected the certified nurse aides to review resident care plans prior to providing care. Not following a resident's plan of care may be a break in their plan. The Administrator stated a broken bone would be a serious injury. The Administrator stated, it was an accident, not intentional.10 NYCRR 415.12(h)(2)
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SENECA HEALTH CARE CENTER in WEST SENECA, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WEST SENECA, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SENECA HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.