Seneca District Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at Seneca District Hospital D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF609Oct 8, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF727Dec 12, 2025

  Based 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.Findings:During a concurrent interview and record review on 12/10/25 at 8:29 a.m. with the Director of Nursing (DON), of the facility's Registered Nurse (RN) staffing/schedule documentation from the period of 4/1/25 to 4/30/25 and 5/1/25 to 5/31/25 the documentation indicated that no RN was scheduled to work 4/16/25, 4/17/25, 4/18/25, and 5/26/25 when the DON was off. […]

• No harm, potential for more than minimal, widespreadF600Jun 4, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF880Dec 12, 2025

  Based 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.Findings: 1. […]

• No harm, potential for more than minimal, patternF550Sep 5, 2025

  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. […]