Health inspection·October 8, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. 2. CNA 2 intentionally placed a pillow over Resident 2's face and verbally told her to shut up. This had the potential for Resident 2 to experience fear and anxiety when CNA 2 was doing her cares and a decline in her mental and emotional wellbeing.This failure had the potential to result in negative psychosocial outcomes for Residents 1 and 2.Findings:A review of the facility's policy and procedures (P&P) titled Abuse Prevention and Reporting revised 3/27/25, indicated [Facility's name] shall ensure an abuse-free environment for the residents of the Skilled Nursing Facility (SNF) by establishing an effective abuse prevention program and shall report suspected or known resident abuse per all state and federal regulations. The P&P defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. d. Mental abuse includes, but is not limited to, humiliation, harassment and threats of punishment or deprivation. e. Physical abuse includes, but not limited to, hitting, slapping, pinching, and kicking. i. verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms aimed at residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability.A facility reported incident, dated 10/3/25 at 10:54 am, by the Director of Nursing (DON), indicated CNA 1 had witnessed CNA 2 verbally and physically abuse Resident 1, and yell at and put a pillow over Resident 2's face on 10/1/25 during the night shift.1. A review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with diagnoses that included Alzheimer's dementia (a progressive, irreversible brain disorder that causes memory loss, confusion, and a decline in mental ability) and acute back pain. Resident 1 was unable to make her own health care decisions.During a review of Residents 1's Quarterly Minimum Data Set (MDS, a data driven clinical assessment) dated 7/30/25, section C -(Cognitive patterns, the ability to think clearly, reason and remember) indicated a Brief Interview for Mental Status (BIMS, a test for memory and thinking ability with scores from 00 having severe cognitive impairment to a score of 15 memory intact) was conducted, and Resident 1 scored a 4 indicating severe cognitive impairment. Section E- (Behavior assessment) indicated Resident 1 did not exhibit physical or verbal behavioral symptoms (i.e. hitting, pushing, screaming or cursing) directed toward others and did not have episodes of refusing care. Section GG-Functional Abilities indicated Resident 1 was dependent on staff for Page 1 of 7 555022 555022 10/08/2025 Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few toileting. Section H -Bowel and Bladder indicated Resident 1 was incontinent (having no control with) bowel and bladder and wore briefs (disposable underwear that collects urine and feces) that required the staff to change.A review of Resident 1's Nursing Narrative Note dated 10/1/25 at 5:00 pm, by Licensed Nurse (LN) D, indicated .a new bruise appeared on her left forearm 9 cm (centimeters, a measurement) x 3 cm.A review of Resident 1's Nursing Narrative Note dated 10/1/25 at 11:50 pm, by LN B, indicated that CNA 1 notified LN B that Resident 1 had received a skin tear to her left forearm measuring 1.5 cm (cm- a measurement of length) x 3 cm skin tear during patient cares on 10/1/25 at 9:30 pm.During a concurrent interview with the DON and email review on 10/3/25 at 2:30 pm, DON stated she had read an email on 10/3/25 in the morning from LN A indicating CNA 2 was abusing residents. The email dated 10/2/25 at 6:58 pm, by LN A indicated: This staff (CNA 1) reported to me that they have witnessed [CNA 2's name] be verbally abusive towards multiple residents and physically abusive to [Resident1's name]. While I was completing wound care on [Resident 1's name] skin tear, this staff member stated to me that they feel like the skin tear was caused by [CNA 2's name] being too rough when completing care. I asked them to elaborate. This staff member stated that [CNA 2's name] often yelled at [Resident 1's name] and other residents when they (CNA 2) got frustrated and was rough when completing care on residents. This staff member also stated that [CNA 2's name] takes [Resident 1's name] hands and often slams them against her chest and slaps her arms and legs around. This staff [CNA 1] member also stated that they [CNA 1] try to complete rounds by themselves, especially [Resident 1's name] so that she isn't yelled at or hit again or any resident. This staff member also stated that other staff has expressed the same concern and witness[witnessed] her yelling and being rough with other residentsDuring a concurrent observation and interview in the DON's office with Resident 1 and the DON on 10/3/25 at 3:20 pm, Resident 1's left forearm was observed in the DON's office to have a bandage wrapped around the left hand and up to half of the left forearm. The DON removed the bandage, and a purple and reddish bruise was noted on the top of her forearm about 3 to 4 inches (approximately 9 cm) long and a skin tear was on the bruised area. The DON said a bruise was discovered on Resident 1's left forearm on the morning of 10/1/25 (before the skin tear happened), but it had never been investigated to find out how it had happened. DON said that it was not normal for Resident 1 to get bruises and should have been investigated. Due to Resident 1's declined cognition level she was unable to identify how she received the bruise or skin tear when asked.During an interview with LN A on 10/3/25 at 3:29 pm, LN A stated that on 10/2/25 in the evening, CNA 1 told him that on 10/1/25 at 9:30 pm, CNA 2 took Resident 1's hands and slapped them on her chest and slapped her arms and caused a skin tear to Resident 1's left wrist because of the rough treatment. LN A said that he sent an email to his DON about the reported abuse.During a phone interview with CNA 2 on 10/6/25 at 11:02 am, CNA 2 stated that when she changed Resident 1's briefs Resident 1 would put her (Resident1's) hands down into her briefs and get them dirty with feces and urine. CNA 2 continued to say that to prevent Resident 1 from getting her hands dirty, CNA 2 would cross Resident 1's arms and put them on her chest and press down on them to keep her from reaching into her soiled brief. CNA 2 said sometimes she swears at me Sometimes I push her arms away and she just keeps trying, we (her and another CNA) have to work kind of fast with her. There might have been a few incidents when I pushed her too hard. CNA 2 said that on 10/1/25 during the changing of the brief of Resident 1, she noticed a skin tear on Resident 1's left hand after she had rolled Resident 1 towards her.During a phone interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated that during the night shift on 10/1/25, she and CNA 2 worked together, conducting rounds that involved checking and changing residents' briefs. CNA 1 described instances since the beginning of September 2025 where CNA 2 removed blankets abruptly and 555022 Page 2 of 7 555022 10/08/2025 Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few handled residents roughly. CNA 1 reported that CNA 2 grabbed Resident 1's hands and arms, pushing them against Resident 1's chest hard to keep Resident 1 from reaching into her dirty briefs. CNA 1 stated that Resident 1 would yell and swear at CNA 2 and call her names and say, she is mean. CNA 1 stated that Resident 1 had never called her names or swore at her before but only did this when CNA 2 was in the room with her. CNA 1 said she observed an increase in the assertiveness of CNA 2's behavior during the week of 10/1/25. CNA 1 stated that on 10/1/25 at 9:30 pm, CNA 1 witnessed CNA 2 grab Resident 1's arms and roll her quickly, resulting in a skin tear. CNA 1 stated I was so afraid, and I know I should have said something that night. I knew it was wrong. I went into work early on 10/2/25 at about 3:45 pm and told LN A. I should have known to have reported it (the abuse) right away, but I was scared.During an interview with LN C on 10/8/25 at 4:01 pm, LN C indicated that he worked the night shift and at times would change Resident 1's briefs. LN C stated that Resident 1 had never sworn or yelled at him while he provided care.2. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, chronic (on going) pain, joint pain of the leg, and anxiety disorder. Resident 2 was unable to make her own health care decisions.A review of Resident 2's Quarterly MDS dated [DATE], section C indicated a BIMS was conducted, and Resident 2 scored a 9 indicating moderate cognitive impairment. Section E indicated Resident 2 had daily behaviors that included yelling and screaming and making disruptive sounds. Section GG- indicated that both legs were impaired, Resident 2 was unable to feed herself, required maximal assistance (helper does more than half the effort) with going to the bathroom, upper and lower body dressing, personal hygiene (washing and drying face), and rolling from left to right while in bed. Resident 2 was unable to stand or transfer in and out of bed without total assistance from staff. Section H indicated Resident 2 was incontinent with bowel and bladder and wore briefs that required the staff to change.During an interview with the DON on 10/3/25 at 2:30 pm, the DON indicated that on 10/3/25 at 9:03 am, CNA 1 had notified her by phone that on 10/1/25 Resident 2 was yelling during care, and CNA 2 placed a pillow over Resident 2's face.During an observation and interview with Resident 2 in her room on 10/3/25 at 2:58 pm, Resident 2 was observed in her room lying on her back in her bed and facing the ceiling. Resident 2 had three pillows placed behind and to both sides of her head. The covers were pulled up to her chest. Resident 2 was talking continually and not making any sense. Resident 2 did not answer questions that were asked of her she just continued to say words that did not make sense. During a phone interview with CNA 2 on 10/6/25 at 11:02 am, CNA 2 confirmed that she worked the night of 10/1/25 through morning of 10/2/25. CNA 2 stated that Resident 2 talked a lot and would yell. CNA 2 said that Resident 2's continual talking and yelling was overwhelming for her. CNA 2 said that she got frustrated when Resident 2 yelled. CNA 2 confirmed that at one time a pillow had fallen on Resident 2's face.During a phone interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated CNA 2 always says shut up, knock it off, and stop screaming to Resident 2. I noticed CNA 2 saying these things to Resident 2 since the beginning of September 2025. On 10/1/25 at 10:30 pm, we were changing Resident 2's brief while she was in bed. Resident 2 was screaming, and CNA 2 intentionally put a pillow over Resident 2's face and said, try screaming, stop screaming [Resident 2's name]! Resident 2 was unable to remove the pillow by herself, so I removed it. CNA 1 continued to say that when they were done changing and positioning Resident 2, CNA 2 threw blankets over Resident 2's face. CNA 1 said I was so afraid, and I know I should have said something that night. I knew it was wrong. I should have reported it right away, but I was scared. CNA 1 said she notified the DON on 10/3/25 at 9:03 am.A review of the facility staffing dated 9/30/25 and 10/1/25, indicated:*CNA 2 worked night shift on 9/30/25 from 4:00 pm to 4:30 am and provided care for Resident 555022 Page 3 of 7 555022 10/08/2025 Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020

F 0600 1 and Resident 2.*CNA 1 and CNA 2 worked the night shift together on 10/1/25 from 4:00 pm to 4:30 am and provided care for Resident 1 and Resident 2. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555022 Page 4 of 7 555022 10/08/2025 Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. On 10/1/25 at10:30 pm, CNA 1 witnessed CNA 2 intentionally placing a pillow over Resident 2's face and verbally tell her to shut up. CNA 1 did not report this to state and federal entities and waited until 10/3/25 at 9:03 am (35 hours later), to notify the Director of Nursing (DON).3. On 10/2/25 at 3:30 pm, CNA 1 reported to LN A the witnessed abuse (roughly turning, slapping and holding down Resident 1's hands and arms and causing a skin tear) of Resident 1 by CNA 2 on 10/1/25 at 9:30 pm. LN A did not report the suspected abuse to state and federal entities.4. At the beginning of August 2025 LN B overheard unidentified staff talking about how CNA 2 was rough with residents during patient cares and LN B did not notify anyone.5. On 10/1/25 at noon, a bruise of unknown origin was discovered on Resident 1's left arm by LN B, and it was not reported to the state and federal entities and there was no investigation to determine the cause of the bruise.6. The facility's Policy and Procedure (P&P) titled Abuse Prevention and Reporting revised 3/27/25, did not correctly indicate the CDPH and Ombudsman should be notified within two hours of known abuse.Refer to F600The failure to report these events immediately to a supervisor and within two hours to the appropriate state and federal entities allowed for the continued abuse, mental anguish, a skin tear and bruising for Resident 1 and verbal and physical abuse for Resident 2. Findings:During a record review of the facility's checklist titled Unusual Occurrence Alleged Abuse Reporting SNF Checklist (undated), indicated Unusual Occurrence is defined as: Any incident or event, especially one which happens without being designed or expected as an unusual occurrence or the ordinary occurrences of life. The checklist indicated that the person reporting the allegation is ultimately responsible for making sure the Sheriff, CDPH, and Ombudsman are verbally notified within 2 hours.1. During a record review of Resident 1's admission record, printed 10/3/25, indicated Resident 1 was admitted on [DATE] with diagnoses that included Alzheimer's dementia (a progressive, irreversible brain disorder that causes memory loss, confusion, and a decline in mental ability) and acute back pain. Resident 1 was unable to make her own health care decisions.During a review of Residents 1's Quarterly Minimum Data Set (MDS, a data driven clinical assessment) dated 7/30/25, section C -(Cognitive patterns, the ability to think clearly, reason and remember) indicated a Brief Interview for Mental Status (BIMS, a test for memory and thinking ability with scores from 00 having severe cognitive impairment to a score of 15 memory intact) was conducted, and Resident 1 scored a 4 indicating severe cognitive impairment. Section E- (Behavior assessment) indicated Resident 1 did not exhibit physical or verbal behavioral symptoms (i.e. hitting, pushing, screaming or cursing) directed toward others and did not have episodes of refusing care. Section GG-Functional Abilities indicated Resident 1 was dependent on staff for toileting. Section H -Bowel and Bladder indicated Resident 1 was incontinent (having no control with) bowel and bladder and wore briefs (disposable underwear that collects urine and feces) that required the staff to change.During an interview with CNA 1 on 10/8/25 555022 Page 5 of 7 555022 10/08/2025 Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020

F 0609 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. at 3:16 pm, CNA 1 stated that during patient care for Resident 1 she had witnessed CNA 2 grab Resident 1's hands and arms and push them into Resident 1's chest. CNA 1 continued to say CNA 2 turned Resident 1 roughly and quickly when they were changing her brief. CNA 1 stated she had witnessed this treatment of Resident 1 by CNA 2 since September 1, 2025, but on 10/1/25 it was the worst she had seen. CNA 1 indicated that on 10/1/25 at 9:30 pm, Resident 1 obtained a skin tear when CNA 2 grabbed Resident 1's arm and rolled her roughly. CNA 1 indicated she reported the rough treatment of Resident 1 by CNA 2 to LN A on 10/2/25 at 3:45 pm (18 hours after the incident.) CNA 1 confirmed that she should have reported it right away.2. During a record review of Resident 2's admission record, printed 10/3/25, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, chronic (on going) pain, joint pain of the leg, and anxiety disorder. Resident 2 was unable to make her own health care decisions.During a record review of Resident 2's Quarterly MDS dated [DATE], section C indicated a BIMS was conducted, and Resident 2 scored a 9 indicating moderate cognitive impairment. Section E indicated Resident 2 had daily behaviors that included yelling and screaming and making disruptive sounds. Section GG- indicated that both legs were impaired, Resident 2 was unable to feed herself, required maximal assistance (helper does more than half the effort) with going to the bathroom, upper and lower body dressing, personal hygiene (washing and drying face), and rolling from left to right while in bed. Resident 2 was unable to stand or transfer in and out of bed without total assistance from staff. Section H indicated Resident 2 was incontinent with bowel and bladder and wore briefs that required the staff to change.During an observation and interview with Resident 2 laying on her bed in her room on 10/3/25 at 2:58 pm, Resident 2 was lying on her back, facing the ceiling. Resident 2 had three pillows placed behind and to both sides of her head. The covers were pulled up to her chest. Resident 2 was talking continually and not making any sense. Resident 2 did not answer questions that were asked of her. Resident 2 continued to say words that did not make sense. During a phone interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated CNA 2 always says shut up, knock it off, and stop screaming to Resident 2. I noticed CNA 2 saying these things to Resident 2 since the beginning of September 2025. On 10/1/25 at 10:30 pm, we were changing Resident 2's brief while she was in bed. Resident 2 was screaming, and CNA 2 put a pillow over Resident 2's face and said, try screaming, stop screaming [Resident's name]! Resident 2 was unable to remove the pillow by herself, so I removed it. CNA 1 continued to state that when they were done changing and positioning Resident 2, CNA 2 threw blankets over Resident 2's face. CNA 1 said I was so afraid, and I know I should have said something that night. I knew it was wrong. I should have reported it right away, but I was scared. CNA 1 said she notified the DON on 10/3/25 at 9:03 am. (35 hours after the incident)3. During an interview on 10/3/25 at 2:30 pm, DON stated she opened and read an email from LN A the morning of 10/3/25 at 8:00 am. DON said the email indicated CNA 1 had witnessed CNA 2 abuse residents. DON said LN A had sent the email to her on 10/2/25 at 6:58 pm.During an interview with LN A on 10/3/25 at 3:29 pm, LN A stated that on 10/2/25 in the evening, CNA 1 told him that CNA 2 took Resident 1's hands and slapped them on her chest and slapped her arms and caused a skin tear to Resident 1's left wrist because of the rough treatment. LN A stated, Since I did not witness the abuse, I am not the one to fill out an abuse report. LN A confirmed that he sent an email to his DON about the reported abuse but did not call anyone or fill out any forms.During an interview with DON on 10/3/25 at 4:20 pm, DON stated that witnessed or suspected abuse at any time should be reported to herself immediately, CDPH, Ombudsman and the Sherrif office within two hours and this was not done by LN A or CNA 1, and it should have been.4. During an interview with LN B on 10/3/25 at 3:03 pm, LN B stated that at the beginning of August 2025 she heard two unidentified CNA's talking 555022 Page 6 of 7 555022 10/08/2025 Seneca District Hospital D/P Snf 130 Brentwood Dr Chester, CA 96020

F 0609 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. about how CNA 2 was very verbally aggressive or dominate with her speech with residents. LN B stated she did not report this to anyone.5. During an interview on 10/3/25 at 3:03 pm, LN B said she noticed a bruise on Resident 1's left forearm on 10/1/25 in the morning. LN B stated the bruise measured 9 centimeters (cm, a measurement of length) X 3 cm. LN B stated she did not know how the bruise happened and did not do an investigation concerning the bruise but just assumed she had hit the bed rail.During an interview on 10/3/25 at 3:07 pm, DON confirmed that Resident 1 had a obtained a bruise on her left forearm that was unwitnessed. DON stated that she assumed it came from Resident 1 hitting her arm on the bed railing but that there had been no investigation done to determine this. DON confirmed that the bruise should have been reported to the state and federal agencies, and an investigation should have been carried out to determine root cause.During a concurrent observation and interview with Resident 1 and the DON in the DON's office on 10/3/25 at 3:20 pm, Resident 1's left forearm was observed to have a bandage wrapped around the left hand and up to half of the left forearm. The DON removed the bandage, and a purple and reddish bruise was noted on the top of her forearm about 3 to 4 inches (approximately 9 cm) long and a skin tear was on the bruised area. The DON indicated it was not normal for Resident 1 to get bruises.6. During a concurrent interview with the DON and policy review on 10/6/25 at 2:21 pm, the facility's P&P titled Abuse Prevention and Reporting revised 3/27/25 was reviewed. The P&P did not indicate that all suspected Abuse was required to be reported to the CDPH within 2 hours. The DON confirmed that their policy was incorrect and needed to be revised to indicate that all suspected abuse was to be reported to the CDPH, local Sheriff's office and the Ombudsman within 2 hours. 555022 Page 7 of 7