Health inspection·November 7, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 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 These failures could lead to inaccurate blood sugar test results due to using outdated, inaccurate, and less effective testing equipment and supplies, which could result in negative clinical outcomes for the residents.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 limits. A review of the undated document titled, SNF Meeting (notes regarding education reviewed and provided to facility staff during a staff meeting), indicated, facility staff were perform daily glucometer QC checks. The document indicated, The test solution and strips must have an outdate placed on the outside. Expiration date for the control solution is three (3) months from opening, test strips are six (6) months from opening. During a concurrent observation, interview, and record review on 11/6/24 at 2:30 pm, located at the glucometer storage area in the nurse's station, with Licensed Nurse (LN) A, two bottles of glucometer control test vials, two bottles of glucometer test strips, and the Equipment Maintenance Record, dated 6/1/24 through 11/5/24 were reviewed and reflected the following; a. LN A stated, when the control test vials were opened, the expectancy was that LN dated the control test vials with the date it was opened and the date they were to be discarded. LN A confirmed, both control test vials were not dated with the opened or discarded dates and should have been. LN A reviewed the manufacturer's recommendations (MR) titled, Nova StatStrip Glucose Control Solution, dated, 1/1/22, and stated the MR indicated, 'the control test vials were to be discarded three months after opening or the expiration date, which ever date was sooner.' b. LN A stated, when the glucometer control test strips were opened, the expectancy was that LN dated the control test strips with the date they were was opened and the date they were to be discarded. LN A confirmed, both bottles of control test strips were not dated with the opened or discarded dates and should have been. LN A reviewed the MR titled, StatStrip Glucose Hospital Test Strips, dated 1/1/22, and stated, the MR indicated the glucometer test strips were to be discarded six months (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555022 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 after opening or the expiration date, which ever date was sooner. Level of Harm - Minimal harm or potential for actual harm c. LN A reviewed the Equipment Maintenance Record, dated 6/1/24 through 11/5/24 and stated the night shift was to perform a QC check on the glucometer every night. LN A confirmed multiple missing entries located on the, Equipment Maintenance Record, eight for the month of June, 12 for the month of July, six for the month of August, three for the month of September, 9 for the month of October, and one in the first 5 days of November. The Equipment Maintenance Record, included instructions to discard control solutions 3 months after opening. Residents Affected - Some On 11/6/24 at 2:45 pm, during an observation and interview, the Chief Nursing Officer (CNO), confirmed two bottles of glucometer control test vials and two bottles of glucometer test strips did not have opened or discarded dates and should have. CNO reviewed the, Equipment Maintenance Record, dated 6/1/24 through 11/5/24, and confirmed there were multiple missing quality calibration checks for the glucometers, and stated the night shift was responsible for performing the glucometer QC test every night. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555022 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 15 meant the resident had intact memory) and scored a 14. During a concurrent observation and interview on 11/4/24 at 12:04 pm, Licensed Nurse (LN) B was observed outside of the resident dining area checking resident lunch trays. LN B stated, when meal trays come out, LNs checked the meal trays to ensure the residents received the correct diet, food preferences, and resident food allergies. During the observation, LN B checked all the lunch trays prior to the residents being served. During a concurrent observation, interview, and record review, on 11/4/24 at 12:09 pm, LN B provided Resident 9 with her lunch tray. When the lid was removed from the lunch plate, Resident 9's smile changed to a frown, she appeared upset, with eyebrows scrunched together. Resident 9 cursed loudly and, having a dislike of brussel sprouts stated, I tell them all the time and I keep getting them. Resident 9's tray card (a card that indicated a resident's diet, allergies, and dislikes) was reviewed and indicated Resident 9 had a dislike of brussel sprouts. LN B apologized to Resident 9 and stated, I forgot to have the brussel sprouts removed. During a concurrent observation, interview, and record review, on 11/6/24 at 11:49 am, the dietary staff was observed plating resident lunches. A document that contained resident food dislikes was observed, taped to a cupboard door near the tray line (where food was placed on plates). The document indicated, Resident 9 did not like brussel sprouts. [NAME] affirmed remaking the resident dislike food list a few days ago and forgetting to add Resident 9's dislike of brussels sprouts to the list. [NAME] stated, the x, indicating a dislike of brussel sprouts was added to the document on 11/4/24 after lunch was served. During a concurrent interview and record review on 11/6/24 at 2:42 pm, Resident 9's Food Preferences, dated 9/28/23, was reviewed with the Registered Dietician (RD). The RD stated, the 'Food Preferences' indicated Resident 9 did not like brussel sprouts and confirmed, Resident 9 was served brussel sprouts at lunch on 11/4/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555022 If continuation sheet Page 4 of 4