Health inspection·March 27, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/22/24 at 3:10 p.m., Unlicensed Staff D stated he remembered that on 1/28/24 Unlicensed Staff A called him to Resident 1's room and asked for a mop because there was poop on the floor. Unlicensed Staff D stated he started mopping and Resident 1 started yelling at Unlicensed Staff A, He was talking crap to her asking why didn't she do her job, why did she call him (Unlicensed Staff D) to come do her job? Unlicensed Staff D stated Resident 1 got really aggressive and moved towards Unlicensed Staff A, acting like he was going to hit her, he was verbally calling her names and stuff. Unlicensed Staff D stated Unlicensed Staff A asked Resident 1, What are you going to do, [Resident 1 named]? Are you going to hit me? During an interview on 2/26/24 at 9:02 a.m., Licensed Nurse E stated she remembered that on 1/28/24 she heard Resident 1 and Unlicensed Staff A arguing, and then two nurses came to her office to inform her Resident 1 was in the hall and Unlicensed Staff A was in Resident 1's room and they were yelling at each other. Licensed Nurse E stated Resident 1 had this behavior of yelling and cussing at staff. Licensed Nurse E stated she heard Unlicensed Staff A tell another aide that Resident 1's behavior was like a toddler within ear shot of Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A swearing and yelling at Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A say to Resident 1 that she needed to take care of your roommate in your fucking room. Licensed Nurse E stated she did not intervene during these interactions between Resident 1 and Unlicensed Staff A. During an interview on 3/13/24 at 2:12 p.m., Licensed Nurse E stated that when Resident 1 and Unlicensed Staff A were arguing, nobody did anything. Licensed Nurse E stated that Resident 1 was yelling at Unlicensed Staff A for approximately 15 to 20 minutes before eventually Licensed Nurse F told Unlicensed Staff A she needed to walk away. Licensed Nurse E stated Resident 1 was pretty good about being redirected, but if you engage, he gets worse. Licensed Nurse E stated she took Resident 1 down to her office to file a grievance just to remove him from the situation, and that finally stopped it. When asked how the staff should have responded to Resident 1's behavior, Licensed Nurse E stated the charge nurse should have told them to stop and separated them. During an interview on 3/13/24 at 2:51 p.m., Unlicensed Staff A stated she remembered that on 1/28/24 Resident 1 was upset, verbally abusing me, displeased that he didn't get help going number two. Unlicensed Staff A stated that she looked at her nurse while this was happening, but she didn't do anything. Unlicensed Staff A stated Unlicensed Staff C helped her get a resident back to bed, then she helped Resident 1's roommate with his shower, and, [Resident 1] followed me, verbally abusing me. She stated Unlicensed Staff D came to clean up poop in Resident 1's room, and Resident 1 called her lazy for having Unlicensed Staff D do her job. Unlicensed Staff A stated she explained to Resident 1 that she cleaned it up, Unlicensed Staff D was just going over the area with a bleach mop, and then [Resident 1] shook his fist at me and threatened to punch me. Unlicensed Staff A verified Unlicensed Staff D was in the room at that time. Unlicensed Staff A stated she looked at the nurses sitting at the nurses' station (across from Resident 1's room) and they were all looking away. When asked if there was any management in the facility at the time of the incident, Unlicensed Staff A stated Licensed Nurse E was the management that day. Unlicensed Staff A stated she did not ask Licensed Nurse E to help with Resident 1 as she had not helped in the past. Unlicensed Staff A stated Licensed Nurse E sat at the nurses' station and watched the whole thing. Unlicensed Staff A stated that when Resident 1 wanted to file a grievance, Licensed Nurse E jumped in and offered to take Resident 1 to file the grievance. When queried, Unlicensed Staff A denied she had gotten training on how to manage Resident 1's behavior. Unlicensed Staff A stated she really believed he would have hit her, and I'm really scared of him, and I don't know what to do. Unlicensed Staff A stated she had cared for Resident 1 for one year without training on how to manage his aggression. When queried, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 2 of 8 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Unlicensed Staff A stated for 10 to 15 minutes Resident 1 yelled at her (on 1/28/24) and followed her from the linen closet to his room and down to the other end of the hall to another resident's room. Unlicensed Staff A stated that at one point she heard Unlicensed Staff C ask the nurses, Aren't you going to do anything? (about his aggression towards Unlicensed Staff A) and they said, No. During an interview on 3/14/24 at 3:53 p.m., Director of Nursing (DON) stated that unfortunately the staff were afraid Resident 1 would target them if they intervened when he got aggressive. DON stated her expectation was that staff would de-escalate him when he was aggressive towards staff. DON verified that Resident 1's care plan indicated management would intervene and stated that normally if she was there, she would go talk to him. DON verified Licensed Nurse E was the management staff in the facility on 1/28/24 and stated Licensed Nurse E did take Resident 1 to her office to file the grievance. DON verified his behavior put him at risk for abuse. When asked what the facility had done to address that risk, DON stated staff got abuse trainings, in-services, and videos. Documentation of staff trainings regarding Resident 1's behavior of verbal aggression was requested. DON stated she would look. Review of electronic correspondence from DON dated 3/26/24 indicated she was unable to find documentation of staff trainings specific to managing Resident 1's behavior prior to the 1/28/24 incident. Review of Resident 1's face sheet revealed an admission date of 5/7/2020, he was his own responsible party, and he had medical diagnoses including left-sided weakness and paralysis following a stroke (a blood clot or bleed in the brain), heart failure, chronic kidney disease, depression, and a blood clot in the lung, among others. Review of Resident 1's care plan indicated a focus area, initiated 7/13/23, The resident is verbally aggressive towards staff [related to] Ineffective Coping Skills, Mental/Emotional Illness, Poor impulse control. Interventions for this focus area, dated 7/13/23, included, The resident's triggers for verbal aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management 1 to 1 and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later, among others. Further review of Resident 1's care plan indicated a focus area initiated on 7/13/23, The resident has potential to be physically aggressive towards staff [related to] Anger, Depression, Poor impulse control. Interventions, dated 7/13/23, included, The resident's triggers for physical aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management, food and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later, among others. Review of facility policy and procedure Abuse – Prevention, Screening, & Training Program, last revised 7/2018, indicated, The facility does not condone any form of resident abuse . and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse . and mistreatment. Subsection titled Prevention indicated, The Facility assists or may rotate staff working with challenging or aggressive residents and allows staff to express frustration with their job or in working with behaviorally challenging residents. The Facility identifies, corrects, and intervenes in situations in which abuse . and/or mistreatment is more likely to occur. The Facility conducts resident . ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 3 of 8 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview, and record review, the facility failed to report potential abuse timely when a nurse witnessed a certified nursing assistant yell and cuss at a resident, Resident 1, and facility staff did not report the incident, or Resident 1's grievance about the incident, to the Department for three days. This failure resulted in a delayed suspension of a potentially abusive staff member and a delayed investigation into an allegation of abuse of a vulnerable resident. Findings: On 1/31/24, the Department received a report from the facility that indicated, During a meeting on 1/31/24 @ 3:30 pm the ombudsman had reported that they had received a report of potential abuse between this resident and a staff member. Immediately initiated an investigation and staff member suspended immediately. During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room. Resident 1 stated that on 1/28/24 he waited an hour for his aide to help him with toileting, and another aide finally came and got him to the bathroom. Resident 1 stated that later when he saw his aide, Unlicensed Staff A, he told her the other aides can't do all your work for you, you need to pick it up. Resident 1 stated, She (Unlicensed Staff A) got all mad. I told her to quit being so lazy, she said ' you're the one who's lazy, that's why you're in that wheelchair.' When asked how that made him feel, Resident 1 stated, It made me mad. I'm like a ticking time bomb. During an interview on 2/26/24 at 9:02 a.m., Licensed Nurse E stated she remembered that on 1/28/24 she heard Resident 1 and Unlicensed Staff A arguing, and she sent a text to the Director of Nursing to inform her of the argument. Licensed Nurse E stated two nurses also came to her office to inform her Resident 1 was in the hall and Unlicensed Staff A was in Resident 1's room and they were yelling at each other. Licensed Nurse E stated that she heard Unlicensed Staff A tell another aide that Resident 1's behavior was like a toddler within ear shot of Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A swearing and yelling at Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A say to Resident 1 that she needed to take care of your roommate in your fucking room. Licensed Nurse E stated she did not intervene during these interactions between Resident 1 and Unlicensed Staff A. During an interview on 3/13/24 at 2:12 p.m., Licensed Nurse E stated that when Resident 1 and Unlicensed Staff A were arguing on 1/28/24, nobody did anything. Licensed Nurse E stated usually no one intervened when Unlicensed Staff A started yelling because it did not help (she would continue to yell). When asked if staff yelling and cussing at a resident was potential verbal abuse, Licensed Nurse E stated, Yes. When queried, Licensed Nurse E stated she should have reported it to the Director of Nursing and filled out an SOC 341 (official document used to report alleged elder abuse, which is sent to the Department and the ombudsman's office). Licensed Nurse E stated she took Resident 1 down to her office to file a grievance to remove him from the situation, and that finally stopped the argument. During an interview on 3/14/24 at 4:35 p.m., Administrator verified he was the abuse coordinator. When queried about his expectation for reporting abuse, Administrator stated that in the case of the incident involving Unlicensed Staff A and Resident 1, they did not have the information about what happened (the alleged abuse) until the ombudsman told them about it, but if they do have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 4 of 8 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few information, it should be reported that day. Administrator verified that if a staff witnessed another staff yelling and cussing at a resident, that should have been reported. Review of facility document Resident Grievance/Complaint Investigation Report, dated 1/28/24, indicated Resident 1's name at the top and Licensed Nurse A's name as the staff member completing the form. Section titled Subject of Grievance/Complaint indicated, . when up in chair he came out and told [Unlicensed Staff A] she wasn't doing her job. This turned into an argument. He told her she was lazy. She told him he was lazy too and that's why he's stuck in a [wheelchair]. Review of facility policy and procedure Abuse - Reporting & Investigations, last revised 3/2018, indicated, The Facility will report all allegations of abuse . as required by law and regulations to the appropriate agencies. The Facility promptly reports and throroughly investigates all allegations of resident abuse, mistreatment . If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facilities [sic] policies. Subsection titled, Notification of Outside Agencies of Allegation of Abuse with No Serious Bodily Injury indicated, A. The Administrator or designated representative will notify within two (2) hours notify [sic], by telephone, CDPH, the Ombudsman and Law Enforcement. B. The Administrator or designated representative will send a written SOC341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 5 of 8 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on observation, interview, and record review the facility failed to provide behavioral management care according to the care plan of one of two sampled residents (Resident 1) when staff argued with Resident 1, who had a known behavior of verbal and physical aggression towards staff, and staff did not remove or redirect Resident 1 from the source of agitation. This failure resulted in Resident 1's behavior escalating and to continue his aggression for 10 to 20 minutes. Findings: During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room directly across from the nurses' station. Resident 1 stated that on 1/28/24 he was in bed and called for assistance to the bathroom. He stated he waited an hour for his aide, and another aide finally came and got him to the bathroom. Resident 1 stated that later that day he saw his aide, Unlicensed Staff A, and told her the other aides can't do all your work for you, you need to pick it up. Resident 1 stated, She (Unlicensed Staff A) got all mad. I told her to quit being so lazy, she said ' you're the one who's lazy, that's why you're in that wheelchair.' When asked how that made him feel, Resident 1 stated, It made me mad. I'm like a ticking time bomb. During an interview on 2/22/24 at 9:21 a.m., Licensed Nurse B stated she remembered the incident with Resident 1 and Unlicensed Staff A on 1/28/24. Licensed Nurse B stated she was at the nurses' station, Resident 1 was in the hallway in his wheelchair, and Unlicensed Staff A was in a room helping a resident. Licensed Nurse B stated Resident 1 started yelling at Unlicensed Staff A, and Unlicensed Staff A responded, If you would just let me finish helping your roommate, I could help you. Licensed Nurse B stated Resident 1 told Unlicensed Staff A, You need to get the fuck out of my room. Licensed Nurse B stated Resident 1 did that a lot, he gets in a mood and goes off on whoever. Licensed Nurse B stated Unlicensed Staff A could have stopped it (Resident 1's behavior) by not responding, but since she said that, it escalated it. It was an ugly scene. During an interview on 2/22/24 at 2:21 p.m., Unlicensed Staff C stated that on 1/28/24 she helped Unlicensed Staff A put a resident back to bed. Unlicensed Staff C stated that when they came out of the resident's room, Unlicensed Staff A had her hands full of dirty laundry and Resident 1's call light was on, so she (Unlicensed Staff C) went to help Resident 1 while Unlicensed Staff A took care of the laundry. Unlicensed Staff C stated Resident 1 started yelling and cussing at Unlicensed Staff A for not helping him, she told him she had been busy and apologized. Unlicensed Staff C stated Unlicensed Staff A went into another resident's room to help him and Resident 1 followed her and continued yelling and cussing at her. During an interview on 2/22/24 at 3:10 p.m., Unlicensed Staff D stated he remembered that on 1/28/24 Unlicensed Staff A called him to Resident 1's room and asked for a mop because there was poop on the floor. Unlicensed Staff D stated he started mopping and Resident 1 started yelling at Unlicensed Staff A, He was talking crap to her asking why didn't she do her job, why did she call him (Unlicensed Staff D) to come do her job? Unlicensed Staff D stated Resident 1 got really aggressive and moved towards Unlicensed Staff A, acting like he was going to hit her, he was verbally calling her names and stuff. Unlicensed Staff D stated Unlicensed Staff A asked Resident 1, What are you going to do, [Resident 1 named]? Are you going to hit me? During an interview on 2/26/24 at 9:02 a.m., Licensed Nurse E stated she remembered that on 1/28/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 6 of 8 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she heard Resident 1 and Unlicensed Staff A arguing, and then two nurses came to her office to inform her Resident 1 was in the hall and Unlicensed Staff A was in Resident 1's room and they were yelling at each other. Licensed Nurse E stated Resident 1 had this behavior of yelling and cussing at staff. Licensed Nurse E stated she heard Unlicensed Staff A tell another aide that Resident 1's behavior was like a toddler within ear shot of Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A swearing and yelling at Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A say to Resident 1 that she needed to take care of your roommate in your fucking room. Licensed Nurse E stated she did not intervene during these interactions between Resident 1 and Unlicensed Staff A. During an interview on 3/13/24 at 2:12 p.m., Licensed Nurse E stated that when Resident 1 and Unlicensed Staff A were arguing on 1/28/24, nobody did anything. Licensed Nurse E stated that Resident 1 was yelling at Unlicensed Staff A for approximately 15 to 20 minutes before eventually Licensed Nurse F told Unlicensed Staff A she needed to walk away. Licensed Nurse E stated Resident 1 was pretty good about being redirected, but if you engage, he gets worse. Licensed Nurse E verified she was the management in the facility on 1/28/24. Licensed Nurse E stated she took Resident 1 down to file a grievance just to remove him from the situation and that finally stopped it. When asked how the staff should have responded to Resident 1's behavior, Licensed Nurse E stated the charge nurse should have told them to stop and separated them. During an interview on 3/13/24 at 2:51 p.m., Unlicensed Staff A stated she remembered that on 1/28/24 Resident 1 was upset, verbally abusing me, displeased that he didn't get help going number two. Unlicensed Staff A stated that she looked at her nurse while this was happening, but she didn't do anything. Unlicensed Staff A stated Unlicensed Staff C helped her get a resident back to bed, then she helped Resident 1's roommate with his shower, and, [Resident 1] followed me, verbally abusing me. She stated Unlicensed Staff D came to clean up poop in Resident 1's room, and Resident 1 called her lazy for having Unlicensed Staff D do her job. Unlicensed Staff A stated she explained to Resident 1 that she cleaned it up, Unlicensed Staff D was just going over the area with a bleach mop, and then [Resident 1] shook his fist at me and threatened to punch me. Unlicensed Staff A verified Unlicensed Staff D was in the room at that time. Unlicensed Staff A stated she looked at the nurses sitting at the nurses' station (across from Resident 1's room) and they were all looking away. When asked if there was any management in the facility at the time of the incident, Unlicensed Staff A stated Licensed Nurse E was the management that day. Unlicensed Staff A stated she did not ask Licensed Nurse E to help with Resident 1 as she had not helped in the past. Unlicensed Staff A stated Licensed Nurse E sat at the nurses' station and watched the whole thing. Unlicensed Staff A stated that when Resident 1 wanted to file a grievance, Licensed Nurse E jumped in and offered to take Resident 1 to file the grievance. When queried, Unlicensed Staff A denied she had gotten training on how to manage Resident 1's behavior. Unlicensed Staff A stated she really believed he would have hit her, and I'm really scared of him, and I don't know whatto do. Unlicensed Staff A stated she had cared for him for one year without training on how to manage his aggression. When queried, Unlicensed Staff A stated for 10 to 15 minutes Resident 1 yelled at her (on 1/28/24) and followed her from the linen closet to his room and down to the other end of the hall to another resident's room. Unlicensed Staff A stated that at one point she heard Unlicensed Staff C ask the nurses, Aren't you going to do anything? (about his aggression towards Unlicensed Staff A) and they said, No. During an interview on 3/14/24 at 3:53 p.m., Director of Nursing (DON) stated that unfortunately the staff were afraid Resident 1 would target them if they intervened when he got aggressive. DON stated her expectation was that staff would de-escalate him when he was aggressive towards staff. DON verified that Resident 1's care plan indicated management would intervene and stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 7 of 8 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 055208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaview Rehabilitation & Wellness Center, LP 6400 Purdue Drive Eureka, CA 95503 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few normally if she was there, she would go talk to him. DON verified Licensed Nurse E was the management staff in the facility on 1/28/24 and stated Licensed Nurse E did take Resident 1 to her office to file the grievance. Review of Resident 1's face sheet revealed an admission date of 5/7/2020 with medical diagnoses including left-sided weakness and paralysis following a stroke (a blood clot or bleed in the brain), heart failure, chronic kidney disease, depression, and a blood clot in the lung, among others. Review of Resident 1's care plan indicated a focus area, initiated 7/13/23, The resident is verbally aggressive towards staff [related to] Ineffective Coping Skills, Mental/Emotional Illness, Poor impulse control. Interventions for this focus area, dated 7/13/23, included, The resident's triggers for verbal aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management 1 to 1 and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later among others. Further review of Resident 1's care plan indicated a focus area initiated on 7/13/23, The resident has potential to be physically aggressive towards staff [related to] Anger, Depression, Poor impulse control. Interventions, also initiated on 7/13/23, included, The resident's triggers for physical aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management, food and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later among others. Review of facility policy and procedure Behavior Management, last revised 1/2020, indicated, Purpose: To ensure the facility provides the necessary behavioral healthcare and services to residents in accordance with their comprehensive assessment and person-centered plan of care. Policy: The facility will ensure that when a resident displays a mental disorder, psychosocial adjustment difficulties (e.g. crying, yelling, hitting, etc.) . they will receive appropriate treatment to address the problem or attain the highest practicable mental and psychosocial wellbeing. Procedure: . C. In an effort to manage the behavioral problem(s) the IDT (interdisciplinary team) will: . iii. Use effective verbal and non-verbal communication techniques . vi. Avoid arguing or debating with the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055208 If continuation sheet Page 8 of 8