Seneca District Hospital D/P SNF

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the residents' right to be free from physical abuse and verbal abuse by Certified Nursing Assistant (CNA) 2 for two of two residents (Resident 1 and 2) sampled for abuse when:1. CNA 2 roughly turned, slapped, and held down Resident 1's hands and arms during patient care. This resulted in Resident 1 receiving a skin tear to her left wrist on 10/1/25 at 9:30 pm and caused Resident 1 to yell and scream at CNA 2 whenever she was in the room. The treatment of Resident 1 by CNA 2 had the potential to have caused the bruise that was discovered on Resident 1's left arm on 10/1/25. This failure resulted in psychosocial harm for Resident 1. Resident 1 would scream and use profanity toward CNA 2 upon her entering the room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report physical and verbal abuse, and an injury of unknown origin within two hours to the state and federal entities (California Department Public Health, CDPH, the Ombudsman, [a person appointed by the government who ensures that residents are treated fairly and that their rights are protected], and the Sheriff's office) for two of two residents (Resident 1 and 2) reviewed for abuse, when:1. On 10/1/25 at 9:30 pm, Certified Nursing Assistant (CNA) 1 witnessed CNA 2 roughly turning, slapping and holding down Resident 1's hands and arms and causing a skin tear to Resident 1's left wrist during patient care. CNA 1 did not report the abuse of Resident 1 to state and federal entities and waited until 10/2/25 at 3:45 pm, (18 hours later) before reporting abuse to Licensed Nurse (LN) A.2. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]