Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seneca District Hospital D/p Snf during CMS and state inspections, most recent first.
RN Coverage Not Scheduled as Required: Facility RN staffing records showed no RN scheduled for several shifts when the DON was off, and the DON confirmed coverage was instead provided by RNs from the hospital side of the facility down the hall. The DON stated LVNs could get help from an RN from the hospital side and noted the facility would need to apply for the federal waiver for RN coverage.
Infection control practices were not followed during eye drop administration for a resident with aphasia, CVA, HTN, memory loss, and hypertensive retinopathy. An LPN gave ophthalmic drops without hand hygiene, changing gloves, or cleaning the eye, and the DON confirmed proper technique was required. The facility also had an ice machine with visible white and black buildup inside the dispenser, and the Maintenance Director stated that area had never been cleaned despite the manufacturer’s cleaning instructions.
Failure to update care plans for urinary incontinence and cardiac needs: Two residents had unmet care plan documentation. One resident with dementia, urinary frequency, and later bladder incontinence had no revised bladder care plan after a decline in continence, despite CNA reports that she needed toileting more often than every 2 hours. Another resident with atrial fibrillation and HTN had no cardiac care plan, and the DON confirmed one should have been developed.
Controlled medication verification documentation was not accurately completed for one of four medication carts when the narcotic count record was not signed by two LNs during multiple shift changes. Facility policy required controlled substances to be counted at each shift change by the on-coming and off-coming licensed nurses, but the record showed several missing entries. An LN and the DON both confirmed that controlled medication reconciliation is expected at the end and beginning of each shift and documented.
Two residents with cognitive impairment were subjected to physical and verbal abuse by a CNA, including rough handling that resulted in injury and the intentional placement of a pillow over a resident's face. Staff delayed reporting the incidents, and the DON did not investigate unexplained injuries as required by policy.
Staff failed to promptly report suspected physical and verbal abuse, as well as an injury of unknown origin, involving two residents with cognitive impairments. Incidents witnessed by a CNA were not reported to the DON or authorities within the required timeframe, and a nurse failed to investigate or report a bruise of unknown origin. The facility's policy did not specify the two-hour reporting requirement, and multiple staff did not follow proper reporting procedures.
A resident with mild cognitive impairment and a history of alcohol abuse was subjected to repeated inappropriate comments by a housekeeper, who made remarks about the resident's appearance. These comments were witnessed by an LTC charge nurse over several months but were not reported to the DON. The resident reported feeling uncomfortable and unsafe, indicating a failure to uphold the resident's right to dignity and respect.
A resident sustained two blisters on the hand after using personal electronic hand warmers that were not properly inspected or approved according to facility policy. The devices were found to become excessively hot and required a protective barrier, but this information was not documented or communicated to nursing staff. On one occasion, a staff member placed the warmer directly on the resident's skin, resulting in injury.
The facility failed to properly label and calibrate glucometer equipment, leading to potential inaccuracies in blood sugar testing. Two vials of control test solutions and two bottles of test strips were not dated when opened or when to be discarded, as confirmed by a nurse. Additionally, daily quality control checks on glucometers were not consistently performed, with multiple missing entries noted in the maintenance records.
A resident with documented dislikes for brussel sprouts was served them due to a failure in updating the food dislike list. The oversight was noted when the resident expressed dissatisfaction during a meal service, and the Licensed Nurse admitted to forgetting to remove the disliked item. The Registered Dietician confirmed the resident's preferences were documented but not updated in the dietary staff's list.
The facility did not have a registered nurse (RN) on duty for eight consecutive hours on weekends, as required. The Director of Nursing (DON) worked only on weekdays, leaving six weekend days without RN coverage. Despite this, no complaints or concerns were reported by residents or staff, and the facility had a federal waiver to reduce RN hours, which was recommended for continuation.
A nurse in an LTC facility was observed withholding medications from twelve residents, despite documenting their administration. Video evidence showed the nurse discarding medications and concealing them, affecting residents with various medical conditions. The facility's policies on abuse prevention and medication administration were not followed, leading to substandard quality of care.
RN Coverage Not Scheduled as Required
Penalty
Summary
The facility failed to obtain the services of an RN for eight consecutive hours, seven days a week. During a concurrent interview and record review with the DON, the facility’s RN staffing/schedule documentation for 4/1/25 to 4/30/25 and 5/1/25 to 5/31/25 showed that no RN was scheduled to work on 4/16/25, 4/17/25, 4/18/25, and 5/26/25 when the DON was off. The DON confirmed that RN coverage on 4/16/25, 4/17/25, and 4/18/25 was provided by RN E from the hospital side of the facility down the hallway, and that RN coverage on 5/26/25 was provided by RN F from the hospital side of the facility down the hallway. The DON also stated that if the LVNs needed help, they could get an RN from the hospital down the hall, and indicated that the facility would need to apply for the federal waiver for RN coverage.
Infection Control Lapses During Eye Drop Administration and Ice Machine Maintenance
Penalty
Summary
Infection prevention and control practices were not implemented during medication administration for one resident who was admitted with aphasia, a CVA, high blood pressure, memory loss, and hypertensive retinopathy. The resident had an order for Dorzolamide-Timolol ophthalmic drops, 1 drop to the left eye twice daily. During observation, a nurse administered the eye medication without performing hand hygiene, without changing gloves, and without ensuring the resident’s eye was clean before placing the drops. The nurse confirmed that hand hygiene should have been performed and that the eye should have been cleaned before the medication was given. The facility also failed to maintain the resident ice machine in a clean and sanitary condition. The ice machine service manual required the machine to be cleansed with a scale remover mixed with water every 6 months. During observation, the Maintenance Director confirmed a visible white and black substance was present along the interior surface of the ice machine dispenser and stated the ice came into direct contact with that substance during dispensing. The Maintenance Director also stated that area of the machine had never been cleaned.
Failure to Update Care Plans for Urinary Incontinence and Cardiac Needs
Penalty
Summary
The facility failed to develop and revise care plans to meet the medical needs of two residents. Resident 7 was admitted with diagnoses including dementia, urinary frequency, and high blood pressure. Her MDS dated 7/10/25 showed a BIMS score of 9 and indicated she was always continent of her bladder, but a later MDS dated 10/08/25 showed she was occasionally incontinent. During interview, a CNA stated Resident 7 was toileted every two hours but needed to go more frequently. The MDS nurse confirmed Resident 7 had declined in urinary continence and the care plan had not been revised to reflect that change. The DON also confirmed the bladder care plan had not reflected her current status and should have been revised to include incontinent episodes. Resident 6 was admitted with diagnoses including atrial fibrillation and hypertension. Her MDS, completed by the DON, showed a BIMS score of 12 indicating moderate cognitive impairment. During concurrent interview and record review of her care plan, the DON confirmed there was not a cardiac care plan developed for Resident 6 and stated there should have been one.
Incomplete Controlled Medication Reconciliation Documentation
Penalty
Summary
Controlled medication verification documentation was not accurately completed for one of four medication carts when the narcotic reconciliation record was not signed by two licensed nurses during multiple shift changes. During review of the facility policy titled Medication Administration, it was noted that controlled substances are to be counted at each shift change by the on-coming and off-coming licensed nurses, and each nurse is responsible for ensuring the record is completed. A concurrent review of the narcotic end-of-shift record on the medication cart showed missing documentation on 8/13/25, 9/17/25, 10/14/25, 10/20/25, 10/28/25, 11/11/25, and 12/2/25. An LN confirmed the documentation was incomplete and that controlled medication reconciliation must be completed and documented at the change of each shift. The DON also confirmed that controlled medication is expected to be reconciled at the end and beginning of each shift and that confirmation is documented.
Failure to Protect Residents from Physical and Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by a Certified Nursing Assistant (CNA 2). CNA 2 was observed and reported to have handled one resident with excessive force during personal care, including roughly turning, slapping, and holding down the resident's hands and arms. This resulted in a skin tear and a bruise on the resident's left forearm. The resident, who had severe cognitive impairment due to Alzheimer's dementia and was dependent on staff for toileting and incontinent care, began to yell and scream at CNA 2 whenever she was present, a behavior not previously exhibited with other staff. Documentation and interviews confirmed that the injury occurred during care provided by CNA 2, and that the resident's behavioral change was specific to interactions with this CNA. Another resident, also with Alzheimer's dementia and moderate cognitive impairment, was subjected to verbal abuse and inappropriate physical actions by CNA 2. During care, CNA 2 intentionally placed a pillow over the resident's face and told her to "shut up" while she was yelling. The resident, who was unable to remove the pillow herself due to significant physical limitations, was also subjected to CNA 2 throwing blankets over her face. CNA 1, who witnessed these actions, reported that CNA 2 frequently used harsh language and rough handling with this resident and others, particularly when frustrated by their behaviors. The facility's policy required an abuse-free environment and prompt reporting of suspected or known abuse. However, the initial report of the incidents was delayed, as CNA 1 did not immediately report the abuse out of fear. The DON acknowledged that a bruise found on the first resident prior to the skin tear was not investigated, despite it being unusual for the resident. Multiple staff interviews corroborated the pattern of rough and abusive behavior by CNA 2, as well as the failure to immediately report and investigate these incidents as required by facility policy.
Failure to Timely Report Suspected Abuse and Injuries
Penalty
Summary
The facility failed to report multiple incidents of suspected physical and verbal abuse, as well as an injury of unknown origin, to the appropriate state and federal authorities within the required two-hour timeframe. Certified Nursing Assistant (CNA) 1 witnessed another CNA (CNA 2) roughly handling, slapping, and restraining a resident during care, resulting in a skin tear. Despite witnessing this on several occasions, CNA 1 delayed reporting the incident for 18 hours, only notifying a Licensed Nurse (LN A) the following day. Additionally, CNA 1 observed CNA 2 placing a pillow over another resident's face and verbally telling her to be quiet, but did not report this for 35 hours, eventually informing the Director of Nursing (DON). Both incidents were not reported to the California Department of Public Health (CDPH), the Ombudsman, or the Sheriff's office within the mandated timeframe. Further review revealed that LN A, after being informed of the abuse, did not report the suspected abuse to the required authorities, instead only sending an email to the DON. The DON confirmed that neither LN A nor CNA 1 followed the correct reporting procedures. Another nurse (LN B) overheard staff discussing CNA 2's rough treatment of residents but did not report these concerns. LN B also discovered a bruise of unknown origin on a resident's arm but did not investigate or report the injury, assuming it was accidental. The DON later confirmed that no investigation was conducted to determine the cause of the bruise and that it should have been reported. The residents involved had significant cognitive impairments and were dependent on staff for care, with one resident unable to make her own health care decisions and another exhibiting moderate cognitive impairment and behavioral symptoms. The facility's policy and procedure on abuse prevention and reporting did not specify the requirement to notify CDPH and the Ombudsman within two hours of suspected abuse. The DON acknowledged that the policy was incorrect and needed revision. The failure to report these incidents promptly allowed for continued abuse and unaddressed injuries among vulnerable residents.
Failure to Ensure Resident Dignity Due to Inappropriate Staff Comments
Penalty
Summary
A deficiency occurred when a housekeeper (HSK A) made repeated inappropriate and provocative comments to a male resident, including remarks about his legs and face being 'sexy.' These comments were witnessed by a charge nurse (LN B) on multiple occasions since February, but were not reported to facility leadership at the time. The resident, who had a history of unsteady gait, confusion, mild cognitive impairment, and alcohol abuse, was assessed as cognitively intact. He reported feeling uncomfortable and unsafe around HSK A and tried to avoid her due to the frequency of these comments. The facility's policy requires staff to treat residents with dignity and respect at all times, and to address them with consideration and recognition of their individuality. Despite this, the inappropriate behavior continued for several months without intervention. The charge nurse admitted to not reporting the incidents earlier, believing the resident was not negatively affected because he appeared to be laughing and smiling during the interactions. The Director of Nursing (DON) confirmed that the resident was not treated with dignity and respect as required by facility policy.
Failure to Follow Electrical Equipment Safety Policy Leads to Resident Injury
Penalty
Summary
The facility failed to follow its own policies regarding the inspection and safe use of new electrical equipment, resulting in an avoidable accident involving a resident. The resident purchased two electronic hand warmers for personal use when going outside. According to the facility's policy, all new electrical equipment must be inspected by the Environmental Services department, and if deemed unsafe, should not be used. The Director of Plant Operations recalled being shown the devices by two CNAs and determined that the devices became too hot and required a protective barrier between the device and the skin, as stated in the manufacturer's instructions. However, this assessment was not documented, and neither the resident nor the Director of Nursing was informed. The devices were not formally approved or labeled as inspected, as required by policy. The deficiency was further compounded when a staff member, whose identity was not disclosed, placed the warmer directly on the resident's left hand without a protective barrier, resulting in two blisters measuring 2.8 x 1 cm and 2 x 1.4 cm. The blisters were discovered by a CNA and subsequently assessed by the DON, who was previously unaware of the injury. The resident reported that he typically used a layer of clothing as a barrier but that this protocol was not followed on the occasion that led to the injury. The lack of adherence to the facility's policy and failure to communicate findings regarding the safety of the devices directly contributed to the resident's injury.
Plan Of Correction
Education prepared for staff by LTC DON regarding electrical equipment and resident safety, including the Arrival of New Electrical equipment policy for review. All staff are to review and sign acknowledgement. The policy MAIN-043 Arrival of New Electrical Equipment will be added to the admission packet. The DON will inform new residents and their responsible parties of the policy and they will sign an acknowledgement of understanding. Director of Plant Operations will amend her existing QA Patient Care Equipment Inspections to include Personal Equipment. The Director of Plant Operations will monitor all equipment to ensure the equipment has been inspected and approved for use during the Safety Hazard/Injury Prevention Inspection that is conducted at least monthly.
Deficiency in Glucometer Labeling and Calibration
Penalty
Summary
The facility failed to ensure proper labeling and calibration of blood sugar testing equipment, which could lead to inaccurate test results. Specifically, two vials of glucometer control test solutions and two bottles of glucometer test strips were not dated when opened or when they were to be discarded. This oversight was confirmed by Licensed Nurse A, who acknowledged that the control test vials and test strips should have been dated according to the manufacturer's recommendations. The manufacturer's guidelines indicated that control test vials should be discarded three months after opening, and test strips should be discarded six months after opening, or by the expiration date, whichever came first. Additionally, the facility did not perform daily quality control (QC) calibration checks on the glucometers as required. The Equipment Maintenance Record, reviewed by LN A, showed multiple missing entries for QC checks across several months, indicating that the night shift staff did not consistently perform these checks. The Chief Nursing Officer confirmed the absence of opened or discarded dates on the glucometer supplies and acknowledged the missing QC checks, which were supposed to be conducted nightly.
Failure to Observe Resident Meal Preferences
Penalty
Summary
The facility failed to adhere to the meal preferences of a resident, identified as Resident 9, who was served brussel sprouts despite having a documented dislike for them. This oversight was observed during a meal service when a Licensed Nurse (LN) checked the meal trays to ensure they matched the residents' dietary needs and preferences. However, Resident 9 was visibly upset upon receiving the meal, expressing dissatisfaction and stating that they had repeatedly communicated their dislike for brussel sprouts. The tray card, which should have indicated the resident's dietary preferences, confirmed the dislike for brussel sprouts, but the LN admitted to forgetting to remove them from the meal. Further investigation revealed that the dietary staff had a document listing resident food dislikes, which was supposed to guide meal preparation. This document, however, was not updated to reflect Resident 9's preferences until after the incident occurred. The Registered Dietician (RD) confirmed that the resident's food preferences, documented prior to the incident, clearly indicated a dislike for brussel sprouts. The failure to update the food dislike list in a timely manner led to the resident being served an unwanted meal, highlighting a lapse in the facility's adherence to its policy of considering resident food preferences.
Deficiency in RN Coverage on Weekends
Penalty
Summary
The facility failed to meet the requirement of having a registered nurse (RN) on duty for eight consecutive hours, seven days a week. During the review of the facility's RN staffing schedule for November 2024, it was found that the Director of Nursing (DON), who is an RN, was scheduled to work only on weekdays, leaving six weekend days without RN coverage. Additionally, there were two weekdays when the DON was off, further contributing to the lack of RN presence. Interviews with the Chief Nursing Officer (CNO) and the DON confirmed the absence of RN coverage on weekends, although an RN from a nearby acute hospital could be called if needed. Despite the lack of RN coverage on weekends, interviews with residents and staff did not reveal any complaints or concerns about staffing issues. The facility had previously requested a federal waiver to reduce the required RN hours from 56 to 40 per week, which was in place and due for renewal. The survey team did not find any negative outcomes related to the continuation of this waiver and recommended its continuation.
Nurse Withholds Medications from Residents
Penalty
Summary
The facility failed to protect twelve residents from abuse by a staff member, specifically a Licensed Nurse (LN) who willfully deprived them of necessary medical care and treatment. This occurred when LN A withheld medications ordered by the residents' Medical Doctor during morning shifts on two consecutive days. Video evidence showed LN A throwing medications in the garbage, putting them in her scrub pockets, and leaving some in drawers, despite documenting that the medications were administered to the residents. The residents affected had various medical conditions, including atrial fibrillation, heart failure, hypertension, psychosis, dementia, cancer, COPD, depression, quadriplegia, malnutrition, cerebrovascular accident, coronary artery disease, chronic respiratory failure, osteoporosis, and diabetes mellitus. The Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) scores indicated varying levels of cognitive impairment among the residents, ranging from cognitively intact to severely impaired. The failure to administer medications as ordered had the potential to cause significant physical harm, pain, and mental anguish, depriving residents of necessary medical care to maintain their well-being. The facility's policies on abuse prevention and medication administration were not followed, as evidenced by the actions of LN A. The Chief Nursing Officer and Director of Nursing confirmed the incident after reviewing video footage, which showed LN A's deliberate actions to withhold medications. Although no residents were transferred to the hospital or showed symptoms of problems due to the incident, the deficiency resulted in substandard quality of care for the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plumas District Hospital Dp/snf | 29.1 mi | — | 13 | 0 |
| Lassen Nursing & Rehabilitation Center | 31.4 mi | ★★★★★ | 30 | 0 |
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