Health inspection·September 5, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **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) notified DON (Director of Nursing) that the LTC (Long Term Care) charge nurse (LN B) had concerns that the housekeeper (HSK A) working in LTC that day was saying inappropriate comments to a male resident (Resident 1). The charge nurse (LN B) stated that he overheard the housekeeper, (Name) HSK A, tell the male resident, (Name) Resident 1, that he had a sexy face. The charge nurse also said that he has witnessed multiple occasions where the housekeeper has referred to (Name) Resident 1, as sexy or make other provocative comments about his body. A review of the facility's final investigation report dated 7/21/25, indicated the DON spoke with (name) Resident 1 in the DON office on 7/18/25 at approximately 1:30 pm. (Name) Resident 1 stated the housekeeper (HSK A), frequently makes inappropriate comments to him. He stated that she often says things like you have sexy legs and other provocative comments about him being sexy. DON asked (name) Resident 1 if these comments made him feel uncomfortable and he shrugged his shoulders and nodded his head. He stated he tries to let these comments roll off his shoulder, but they are occurring more frequently now. A review of Resident 1's face sheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that include unsteady gait, confusion, mild cognitive (the ability to remember and make decisions) impairment, and history of alcohol abuse. A review of Resident 1's Minimum Data Set (MDS, a clinical assessment) dated 7/4/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a cognitive evaluation ranging from 00- impaired cognition to 15- cognition intact) evaluation performed and scored 15. During an interview on 8/15/25 at 1:17 pm, Resident 1 indicated that HSK A would come into his room and while cleaning his room she would make comments about his legs being sexy. Resident A stated he felt uncomfortable and unsafe around HSK A and would try and avoid her. During an interview on 9/5/25 at 10:18 am, LN B stated he had witnessed HSK A telling Resident 1 that he had sexy legs, a sexy face, and other provocative comments about his body since February 2025. LN B stated he should have reported this sooner but did not think it was an issues because Resident 1 was always laughing and smiling during the interactions. During an interview on 9/5/25 at 11:15 am, DON Page 1 of 2 555022 555022 09/05/2025 Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020

F 0550 Level of Harm - Minimal harm or potential for actual harm stated that she was unaware that HSK A was making these comments to Resident 1 since February and it should have been reported to her at that time. DON stated that HSK A was hired on 6/17/24 and discharged from employment to the facility on 7/25/25. DON confirmed that Resident 1 was not treated with dignity and respect and was made to feel uncomfortable when HSK A made these comments. Residents Affected - Some 555022 Page 2 of 2