Seneca Health Care Center
SENECA HEALTH CARE CENTER in WEST SENECA, NY — inspection on November 5, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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