Seneca District Hospital D/P SNF

Based on interview and record review, this requirement was not met when the facility failed to obtain the services of a registered nurse for eight consecutive hours, seven days a week. This had the potential to adversely affect residents' care, which could lead to potential negative clinical outcomes.Findings:During a concurrent interview and record review on 12/10/25 at 8:29 a.m. with the Director of Nursing (DON), of the facility's Registered Nurse (RN) staffing/schedule documentation from the period of 4/1/25 to 4/30/25 and 5/1/25 to 5/31/25 the documentation indicated that no RN was scheduled to work 4/16/25, 4/17/25, 4/18/25, and 5/26/25 when the DON was off. The DON confirmed that RN coverage was provided by RN E (a nurse from the hospital side of the facility down the hallway) on 4/16/25, 4/17/25, and 4/18/25 and that RN coverage was provided by RN F (a nurse from the hospital side of the facility down the hallway) on 5/26/25. The DON indicated that if the Licensed Vocational Nurses (LVNs) needed help they could get an RN from the hospital down the hall. The DON indicated…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain infection control practices to prevent the transmission of infection when: 1. Staff failed to ensure proper hand hygiene and clean administration technique during the administration of eye drops to for one of 16 sample residents (Resident 8). 2. The facility failed to ensure the ice machine used by residents was maintained in a clean and sanitary condition, free from contamination. These deficient practices had the potential to put the residents at risk for unwanted infections, and negatively impact their quality of life.Findings: 1. During a review of the facility's policy and procedure titled, Medication Administration, dated 5/29/2025, indicated, that standard universal precautions, which include hand washing using soap and water or the hospital supplied hand antiseptic cleaner will be completed prior to and following all medication passes and after physical contact with residents. During a review of Resident 8's…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and revise care plans to meet the medical needs for two of eight residents sampled (Resident 7 and Resident 6) when:1. Resident 7's bladder incontinence (inability to hold urine) was not reflected on her care plan.2. Resident 6 had no care plan developed that addressed her heart condition.These failures had the potential to result in negative clinical outcomes for Resident 6 and Resident 7, by not receiving the care and services they needed.Findings: A review of the facility's Policy and Procedure titled, Comprehensive Care Policy effective 3/27/25, indicated the facility shall ensure a comprehensive care plan will be implemented for each skilled nursing facility resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. 6. The care plan will include the following information: b. All identified medical,…

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, the facility failed to ensure controlled medications (medications with high potential for abuse and addiction) verification process was accurately completed for one of four medication carts when the medication verification documentation was not signed with two (2) licensed nurses. This failure had the potential to cause the diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff, compromising the facility's ability to ensure safe and appropriate medication management for its patients. Findings: During a review of the facility's policy and procedure titled, Medication Administration, dated 5/29/2025, indicated, that controlled substances will be counted at the change of each shift by the licensed on-coming and off-coming nurses and that each nurse will be responsible for assuring the completion of the record. During a concurrent interview and record review on 12/10/25 at 11:27 am with Licensed Nurse (LN) B, the facility's narcotic reconciliation (the comparison of controlled…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of two residents sampled for dignity (Resident 1), was treated with dignity and respect when Houskeeper (HSK) A made comments to Resident 1 indicating he had sexy legs and a sexy face. This failure caused Resident 1 to feel uncomfortable and unsafe around HSK A. Findings: A review of the facility's policy titled Implementation of Patients' [NAME] of Rights dated 9/22/16, indicated Patient right number 10: to be treated with consideration, respect and full recognition of his/her dignity and individuality. 1. Members of the staff will display respect when speaking with, care for, or talking about patients as constant confirmation of their individuality and dignity as human beings. Staff members will address patients with respect at all times. A review of a Facility Reported Incident (a report written by the facility and sent to the California Department of Public Health (CDPH) dated 7/21/25, indicated On 7/18/25 the Housekeeping Manager (HSKM)…

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 interview and record review, the facility failed to follow their policies to ensure that Resident 1 was kept safe after he bought two electronic hand warmers to use when we went outside. This resulted in an avoidable accident when Resident one sustained two blisters on his left hand from using the warmers. Findings: In an interview with the DON (Director of Nurses) on 4/28/25 at 10 am, she stated that on 3/27/25, CNA1 (Certified Nursing Assistant) reported that Resident 1 had blisters on his hand that were not being addressed. The DON stated that she was unaware of the blisters and upon assessment of Resident 1's left hand she identified two blisters on his left palm, which measured 2.8 x 1 cm (centimeters) and 2 x 1.4 cm. Resident 1 told the DON that he had purchased lithium battery personal warmers that he attached to his body to keep him warm when he went outside. He stated that he had been using the warmers all winter. He further told the DON that usually there was a layer of clothing between the warmers and the skin, but on one occasion an unidentified staff member…

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, the facility failed to ensure that blood sugar testing equipment was dated when opened and that the glucometers (a machine used to test blood sugar), was calibrated (a control test to ensure the glucometer readings are accurate) when: a. Two vials of glucometer control test vials were not dated when opened, or when the solution was to be discarded. b. Two bottles of glucometer test strips were not dated when opened, or when they were to be discarded. c. Facility failed to perform quality control (QC) calibration checks daily on glucometers. These failures could lead to inaccurate blood sugar test results due to using outdated, inaccurate, and less effective testing equipment and supplies, which could result in negative clinical outcomes for the residents. Findings: A review of the facility's policies and procedures (P&P) titled, Glucose Testing Machine: Care and Use of, dated 6/19/24, indicated, before using the glucometer and testing a resident's blood sugar, facility staff would Verify that QC was performed and within expected…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe the meal preferences of one of eight sampled residents when Resident 9 was served brussel sprouts. This failure had the potential to reduce intake of nutrients, weight loss and have negative clinical outcomes. Findings: A review of the facility's undated policy and procedure titled, Skilled Nursing Facility Food Preferences, indicated, the facility would take into consideration resident food preferences. A review of an untitled and undated record indicated, Resident 9 was admitted to the facility on [DATE] with the diagnoses of type 2 diabetes (high blood sugar) and major depressive disorder (a sad mood). A review of the annual (yearly) Minimum Data Set (MDS, an assessment tool), dated 10/8/24, Section C, indicated, Resident 9 had a Brief Interview for Mental Status (an assessment that tested a resident's ability to recall information and memory. The test was scored from 0-15 where 0 meant the resident was not able to remember and…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect twelve (12) of twelve (12) residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) from abuse by a staff member when Licensed Nurse (LN) A, with willful intent, deprived residents of necessary medical care and treatment by withholding Resident one (1) through 12 ' s medications that were ordered by their Medical Doctor (MD). This occurred during the morning (am) shifts of 5/25/24 and 5/26/24. LN A was observed via video from a camera located above the nurse ' s station medication desk throwing medications in the garbage, putting medications in her scrub (uniform) pockets, and leaving some medications in drawers that were subsequently found by LN B. LN A documented that the medications observed being withheld, were administered to residents one through 12. This failure had the potential to cause significant physical harm, pain, and mental anguish by depriving residents of necessary medications that were ordered by their MD,…

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 the facility failed to record sanitizing temperatures for the dishwashing machine. This had the potential for staff to not recognize low, non-sanitizing temperatures and spread foodborne illness to residents and cause gastrointestinal (stomach and bowel) illness including nausea, vomiting and diarrhea with the potential for adverse clinical outcomes. Findings: On 12/11/23 at 10:30 AM, a review of the dishwashing temperature logs in the kitchen was conducted with the Certified Dietary Manager (CDM) and the Dishwasher (DW). In October 2023, 9 temperature recordings were missing, in November 2023, 5 temperature recordings were missing, and in December 2023, 2 temperature recordings were missing. The CDM and the DW both confirmed that there were missing temperature recordings on the Dishwasher Temperature Log, and that this could have a negative impact on the health and safety of the residents. On 12/12/23 9:17 AM, during an interview with the CDM she indicated that the dishwashing machine requires heat to sanitize dishes, utensils and…

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 interview and record review, this requirement was not met when the facility failed to obtain the services of a registered nurse for eight consecutive hours, seven days a week. This had the potential to adversely affect residents' care, which could lead to potential negative clinical outcomes (worsening condition). A review of the facility's Registered Nurse (RN) staffing/schedule documentation from the period of 10/1/23 to 10/31/23 indicated that the RN working as Director of Nursing (DON) was scheduled to work weekdays (Monday through Friday) leaving nine weekend days (10/1, 10/7, 10/8, 10/14, 10/15, 10/21, 10/22, 10/28, and 10/29/23) uncovered during this four-week time period. There were four days (10/26, 10/27, 10/30, and10/31/23) when the DON was on time off. During an interview on 12/12/23 at 3:16 PM, DON confirmed that an RN was not on duty for eight consecutive hours, seven days a week. DON stated, We are a very small town, RNs are difficult to recruit. The position is almost continuously posted, for 5-6 years we have had staffing waivers. DON acknowledged that an…

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.