Seacrest Post-acute Care Center

During a review of Resident 319's admission Record, the admission Record indicated, Resident 319 was admitted to the facility on [DATE] with diagnoses including multiple myeloma (blood cancer), difficulty walking, muscle weakness, dementia (a progressive state of decline in mental abilities).

During a review of Resident 319's History & Physical (H&P) dated 11/27/24, the H&P indicated, Resident 319 does not have the capacity to understand and make decision.

During a review of Resident 319's Minimum Data Set (MDS- a resident assessment tool) dated 12/3/24, the MDS indicated Resident 319's cognition (ability to think, understand, learn, and remember) is severely impaired.

The MDS indicated that Resident 319 needs substantial/maximal assist (helper does more than half the effort) with Activities of Daily Living (ADLs- activities such as toileting and personal hygiene a person performs daily).

During an observation on 2/25/24 at 11:25 a.m., in Resident 319's room, Resident 319's call light was wrapped around the siderail of his bed with the siderail in down position Resident 319 was not able to reach his call light.

During a concurrent observation and interview on 2/26/25 at 9:05 a.m., with the Director of Staff Development (DSD) in Resident 319's room.

Observed Resident 319's call light was wrapped around the siderail of his bed with the siderail in down position.

The DSD stated Resident 319 was not able to reach his call light.

The DSD stated call light should be within reach. DSD stated the call light provides help and support that is needed and that is how Resident 139 communicates with the staff.

The DSD stated there could be a medical emergency or resident could fall out bed.

During an interview on 2/27/25 at 5:07 p.m., with the Director of Nursing (DON), the DON stated the call light is a devise to help residents call for assistance and should be within reach for the resident.

The DON stated residents could fall and hurt themselves when call lights were not within reach.

During a review of the facility's policy & procedure (P&P) titled Answering the Call Light dated 9/2022, indicated Staff need to be sure that the call light is plugged in and functioning at all times.

Staff need to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of Resident 38's Care Plan dated 2/27/2025, the care plan indicated Resident 38 is

passes, appointments, and additional reasons why not to participate when time allows.

The Care Plan goals indicated for Resident 38 to participate in RNA program per medical doctor (MD) order and will allow some services within her allotted time prior to departing the facility.

The Care Plan interventions indicated to educate Resident 38 on risk and benefits of refusal of services and report observations of decline. RNA to supervise patient using recumbent cycle for 20 min 5 times a week.

RNA to perform ambulation using platform walker five times a week once a day as tolerated.

Offer RNA service early morning prior to pick up times.

Offer RNA services once resident returns from appointment.

During a concurrent observation and interview on 2/25/25 at 11:55 a.m. in Resident 38's room. Resident 38's right shin had redness. Resident 38 stated she wears a brace that fits in her right shoe when she walks. Resident 38 stated about 3 weeks ago when she took off her brace, she noticed some redness and swelling on her right shin and ever since then she has not been doing her RNA exercises.

During an interview on 2/27/24 at 12:27 p.m., with RNA 1, RNA 1 stated Resident 38 just started refusing to walk in February because she says that her right leg has pain and does not want to try and walk.

During a concurrent interview and record review on 2/27/25 at 2:39 p.m. with the Director of Nursing (DON), Resident 38's RNA TAR dated 2/1/2025 and care plan for noncompliant with RNA program dated 2/27/2025 were reviewed.

The DON stated that care plans need to be specific, measurable, attainable, realistic and time bound.

The DON stated that Resident 38 had been refusing care for about three weeks and that Resident 38's care plan should have been initiated on the reason of Resident 38 refusal when the concern was identified.

The DON stated she does not think Resident 38's care plan was appropriate for Resident 38's identified concerns (right leg pain).

During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated

treat a specific condition.

The P&P indicated, Psychotropic medication management includes a. indications of use.

Residents who have not used psychotropic medication are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.

During a review of the facility's P&P titled, Medication Regimen Reviews, dated 05/2019, the P&P indicated, an 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice . not supported by medical evidence .It may also include the use of medication without indication, without adequate consequences.

During a review of the facility's document titled, Job Description Unit/Shift Nursing Supervisor, the documented indicated, The primary purpose of your job position is to assist .in accordance with current applicable federal, state and local standards, guidelines and regulations .quality patient care can be maintained at all times.

Cross reference F-F758

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a concurrent observation and interview on 2/28/2025 at 12:44 p.m., with Registered Nurse Supervisor (RNS), in Resident 29's room, RNS stated all nursing staff were responsible for making sure dentures were cleaned. RNS stated she follows up with the CNAs to make sure resident's dentures were being cleaned and to make sure resident have a denture cup. RNS stated CNAs had an in-service for dentures and oral care. RNS stated she failed to check if Resident 29's dentures were cleaned. RNS stated Resident 29 does not have denture tablets at the bedside to clean dentures. RNS stated the family, or the facility supplies the resident with tablets for denture cleaning.

During a review of the facility's policy and procedure (P&P) titled, Dentures, Cleaning and Storage, dated revised 3/2028, the P&P indicated, The purposes of this procedure are to cleanse and freshen the resident's mouth, to clean the resident's dentures, to prevent infections of the mouth, to protect the resident's dentures from breakage when dentures are out of the resident's mouth, and to store dentures at bedtime .Store dentures whenever they are not in the resident's mouth .The following equipment and supplies will be necessary when performing this procedure .Toothpaste or denture cleaner .Disposable denture cup/container (with cover) .Clean the dentures by brushing them with a denture cleaner or toothpaste .Rinse dentures thoroughly.

Fill the denture cup one-half (1/2) full of fresh water and one-half (1/2) full of mouthwash.

Place dentures into the denture cup.

Take the denture cup and emesis basin to the bedside table.

Leave dentures in the cup until the resident is ready to replace them in his or her mouth .Leave the denture cup, with the cleaning solution, on the resident's bedside stand.

Put it within easy reach of the resident. Be sure the denture cup is properly labeled with the resident's name and room number.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

Summary Report indicated Resident 318 had order for ceftriaxone (antibiotic- treats bacterial

to rotate IV site every 72 hours and as needed for soilage and complications (sign of infection, edema, phlebitis).

During a review of Resident 318's Care plan titled Resident 318 has an IV antibiotic and is at risk for infection or other complications such as pain, phlebitis, and embolism dated 2/20/2025, The Care Plan goal indicated resident will be free from complications.

The Care Plan interventions indicated to change IV peripheral (catheter placed in a vein near the surface of the skin) heplock (a way to access a vein without having an IV running) every three days may extend with medical doctors (MD) order.

Change IV peripheral hep lock gauze dressing every day.

During an observation on 2/25/2024 at 12:15 p.m. in Resident 20's room, observed Resident 20 had an IV heplock in her right wrist with no date and time label on the dressing.

During an observation on 2/25/2024 at 1:26 p.m., in Resident 318's room, observed Resident 318 had an IV in his left forearm wrapped with kerlix (gauze dressing) with no date and time label on the dressing.

During a concurrent observation and interview on 2/26/2025 at 8:35 a.m., with Registered Nurse Supervisor (RNS) in Resident 20's room, Resident 20 had an IV catheter in her right wrist. RNS stated Resident 20 was not receiving IV therapy at this time. RNS stated IV catheter should have been removed after Resident 20's IV therapy was completed on 2/5/2025. RNS stated IV sites are a potential source for infection.

During a concurrent observation and interview on 2/26/2025 at 8:45 a.m., with RNS in Resident 318's room, Resident 318 had an IV catheter in his left forearm wrapped with a kerlix dressing with no time or date on the dressing. RNS unwrapped IV site, IV site was dated 2/14/2025 and was placed at the general acute care hospital (GACH). RNS stated IV site should be rotated every 72 hours. RNS stated you can leave IV site in longer than 72 hours but we would have to monitor and document daily to ensure there are no signs and symptoms of infection, IV line was flushing well and no infiltration (leakage of medication or solution from the catheter into the surrounding tissues instead of the vein).

RNS stated IV sites are a potential source for infection.

During an interview on 2/27/2025 at 5:07 p.m., with the Director of Nursing (DON), the DON stated the IV site needs to be rotated every 72 hours because veins are fragile.

The DON stated IV catheters must be removed after the course of therapy was completed.

The DON stated it could lead to infection and complications because there is an opening in the skin.

During a review of the facility's policy & procedure (P&P) titled Peripheral IV Catheter (PIVC) and Site Selection, the P&P indicated to select PICV's based on prescribed therapies, duration of treatments, availability of peripheral access sites, diagnosis, and potential complications.

Use PICV's for duration of less than four days when criteria are met for compatibility of therapy.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During an interview on 2/27/2025 at 4:29 p.m. with the DON, the DON stated she had not conducted

facility reinforces this during the in-services.

The DON stated, ideally it is important to use arm as your site of blood pressure.

The DON stated in the scenario for Resident 368, the resident had one part of shunt because of dialysis, there should be BP check on the side opposite of the shunt.

The DON stated, the side where IV line was placed could be used as long as it did not block the infusion flow.

The DON stated the facility staff should not have been taking BP at the forearm.

The DON stated if the BP was taken where edema was present, it could cause blood clot or present an inaccurate blood pressure and would not be able to manage the BP regimen.

During a review of the facility's policy and procedure (P&P) titled, Blood Pressure, Measuring, dated 09/2010, the P&P indicated, Preparation: Review the resident's care plan to assess for any special needs of the resident General Guidelines: A blood pressure reading is represented as a ratio or fraction.

The top number (the systolic pressure) measures the blood pressure during the contractions of the heart (systole) .The bottom number (the diastolic pressure) measures .at rest (diastole).

The P&P indicated, Steps in the procedure: expose the resident's arm by rolling the sleeve up about 5 inches above the elbow.

Wrap the blood pressure cuff evenly around the upper arm, approximately one (1) inch from the elbow.

Note: The cuff should fit snugly, but not so tightly that the resident is uncomfortable. If the cuff is placed too loosely, you will get a false high blood pressure reading.) The P&P indicated, Reporting: Notify the supervisor if the resident refuses the treatment.

During a review of the facility's P&P titled, Hypertension - Clinical Protocol, dated 11/2018, the P&P indicated, Assessment and Recognition - Blood pressure should be measured correctly, including use of a properly sized cuff, in both arms, and where possible, in the upright position.

The P&P indicated, In addition, the nurse shall assess and document/report the following: all current medications, especially antihypertensive therapy.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During an observation on 2/25/2025 at 11:15 a.m., near Nurses Station One, the staffing information was posted and dated 2/25/2025.

During a concurrent interview and record review on 2/28/2025 at 2:42 p.m., with Director of Staff Development (DSD), the facility's CMS Daily Nurse Staffing Form and the Nursing Staffing Assignment and Sign-In-Sheet, dated 2/5/2025, 2/8/2025, 2/19/2025, 2/20/2025, and 2/22/2025 were reviewed.

The Nursing Staffing Assignment and Sign-In-Sheet indicated one staff call off on 2/5/2025, 2/8/2025, 2/19/2025, 2/20/2025 and 2/22/2025.

The DSD stated staffing was posted daily in the front of Nurses Station One.

The DSD stated she does not update or change the posted staffing.

The DSD agreed that the sign in signatures on the Nursing Staffing Assignment and Sign in Sheet does not match the posted staffing and should be updated due to discrepancies.

The DSD stated quality of care suffers without accurate posted staffing.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of Resident 367's MDS, dated [DATE], the MDS indicated Resident 367's cognition was severely impaired.

The MDS indicated, Resident 367 needed supervision level assistance from the facility staff for ADLs such as eating and oral hygiene, moderate assistance for upper body dressing and personal hygiene, and dependent on facility staff for toileting, lower body dressing and putting on/taking off footwear.

During an observation on 2/26/2025 between 9:15 a.m. and 9:32 a.m., LVN 3 prepared six medications for Resident 367 to be administered. LVN 3 stated physician orders indicated one capsule of Vitamin D3 125 mcg, but LVN 3 did not have capsule formulation in stock. LVN 3 stated he would need to clarify with physician if tablet formulation would be okay to administer.

During a review of Resident 367's Physician Order Summary Report, dated 2/26/2025, the Physician Order Summary report indicated but not limited to the following physician order: Cholecalciferol oral capsule 125 mcg (5000 UT), give 1 capsule by mouth one time a day for supplement, order date 2/11/2025, start date 2/12/2025.

During a concurrent interview and record review on 2/26/2025 at 1:43 p.m. with LVN 3, the administration details for cholecalciferol (Vitamin D3) 125 mcg, dated 2/26/2025 was reviewed.

The document indicated cholecalciferol (Vitamin D3) 125 mcg was administered and documented as administered at 1:36 p.m. LVN 3 stated he was able to clarify cholecalciferol order with physician and administered it to Resident 367 at 11:00 a.m. which was two hours later than the scheduled time of 9:00 a.m. LVN 3 stated medication should be administered and documented as administered in timely manner for its intended effect.

During an interview on 2/27/2025 at 4:08 p.m. with the Director of Nursing (DON), the DON stated facility staff should have separated chewable aspirin from other medications to be swallowed and resident should have been instructed to chew the chewable formulation of aspirin for it to be effective and to prevent stroke and blood clots.

The DON stated facility staff should have clarified Vitamin D3 order with physician before medication administration to prevent delays in medication administration to ensure a certain level of medication.

During a review of the facility's P&P titled, Medication Administration - General Guidelines, dated 11/2021, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by to do so.

Medications are administered in accordance with written orders of the attending physician.

Medications are administered without unnecessary interruptions.

The P&P indicated, Medications are administered within 60 minutes of scheduled time, except . mealtimes).

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of MRR dated 2/11/2025, the review indicated the consultant pharmacist failed to identify Resident 22 was receiving quetiapine without a corresponding medical diagnosis of a psychiatric disorder.

The consultant pharmacist instead indicated Resident 22 was taking an atypical antipsychotic medication with a potential to cause type II adult-onset diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hyperlipidemia (high levels of fat particles in the blood) and recommended to conduct periodic labs.

During a review of Resident 22's Medication Administration Record (MAR), dated 1/24/2025 to 1/31/2025, the facility administered quetiapine 25 mg daily at 9:00 p.m. for a total of eight times.

During a review of Resident 22's MAR, dated 2/1/2025 to 2/26/2025, the facility administered quetiapine 25 mg daily at 9:00 p.m. for a total of six times.

During an interview on 2/28/2025 at 10:26 a.m. with Quality Assurance Licensed Vocational Nurse (QA LVN), QA LVN stated Resident 22 was receiving quetiapine for schizophrenia because of hallucinations. QA LVN stated the MDS did not indicate diagnosis of schizophrenia or other psychiatric disorders. QA LVN stated the IDT notes indicated the meeting was held with Resident 22 and Resident 22's daughter. QA LVN stated Resident 22 should not be on quetiapine without a corresponding diagnosis. QA LVN stated quetiapine would be considered as an unnecessary drug for Resident 22 and placed her at risk for altered mental status, allergy, shortness of breath, respiratory distress, dizziness, vomiting, hypotension (low blood pressure) and fever. QA LVN stated Resident 22 also had dementia and stated the administration of quetiapine without medical diagnosis could affect Resident 22's function negatively.

During a review of the facility's policy and procedures (P&P) titled, Medication Regimen Reviews, dated 05/2019, the P&P indicated, The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.

The P&P indicated, The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication .other medication errors, including those related to documentation.

The P&P indicated, An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice . not supported by medical evidence .It may also include the use of medication without indication, without adequate consequences.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

7/2022, the P&P indicated, Residents will not receive medications that are not clinically indicated to

these medications unless the medication is determined to be necessary to treat a specific condition

Cross reference F-F756

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a concurrent interview and record review on 2/26/2025 at 1:43 p.m. with LVN 3, the administration details for cholecalciferol (Vitamin D3) 125 mcg, dated 2/26/2025 was reviewed.

The document indicated cholecalciferol (Vitamin D3) 125 mcg was administered and documented as administered at 1:36 p.m. LVN 3 stated he was able to clarify cholecalciferol order with physician and administered it to Resident 367 at 11:00 a.m. which was two hours later than the scheduled time of 9:00 a.m. LVN 3 stated medication should be administered and documented as administered in timely manner for its intended effect.

During an interview on 2/27/2025 at 3:57 p.m. with the Director of Nursing (DON), the DON stated when insulin was removed from the refrigerator and opened, facility should label it with an open date because they could only be stored up to 28 days.

The DON stated with the opened date, facility staff could determine whether the insulin was expired or safe to be administered to resident.

The DON stated if the insulin was not dated with open date, there was a risk that it could be expired and increased the risk of glycemic reactions (the effect of food or meal has on blood sugar) such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) if administered to resident.

The DON stated facility staff should have separated chewable aspirin from other medications to be swallowed and resident should have been instructed to chew the chewable formulation of aspirin for it to be effective and to prevent stroke and blood clots.

The DON stated facility staff should have clarified Vitamin D3 order with physician before medication administration to prevent delays in medication administration to ensure a certain level of medication.

During a review of the facility's P&P titled, Medication Administration - General Guidelines, dated 11/2021, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by .to do so.

Medications are administered in accordance with written orders of the attending physician.

Medications are administered without unnecessary interruptions.

The P&P indicated, Medications are administered within 60 minutes of scheduled time, except . mealtimes).

During a review of the facility's P&P titled, Medication Storage in the Facility, dated 08/2019, the P&P indicated, medications and biologicals are stored safely, securely .following manufacturer's recommendations or those of the supplier.

During a review of the facility's P&P titled, Medication Labeling and Storage, dated 02/2023, the P&P indicated, The facility stores all medications .under proper temperature, humidity and light controls.

The P&P indicated, Labeling of medications and biologicals .is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.

The medication label includes, at a minimum: a. medication name . expiration date, when applicable .and precautions.

Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During an interview on [DATE] at 3:13 p.m. with the Director of Nursing (DON), the DON stated it was important to keep the medications in refrigerator at the temperature range of 36°F to 46°F to keep the medications safe and effective.

The DON stated she had ordered two new refrigerators to replace the old refrigerators.

The DON stated if the medications that were not stored at manufacturer recommended temperatures were administered to facility residents, it would increase risk for residents' harm, and adverse events such as hypoglycemia, hyperglycemia, infection, and hospitalization.

During a review of the facility's P&P titled, Medication Storage in the Facility - Storage of Medications, dated 08/2019, the P&P indicated, medications and biologicals are stored safely, securely .following manufacturer's recommendations or those of the supplier.

The P&P indicated, Medications requiring refrigeration or temperatures between 2°C (36°F) and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring.

During a review of the facility's P&P titled, Medication Labeling and Storage, dated 02/2023, the P&P indicated, The facility stores all medications .under proper temperature, humidity and light controls.

The P&P indicated, Labeling of medications and biologicals is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.

The medication label includes, at a minimum: a. medication name . expiration date, when applicable and precautions.

Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During an observation on 2/25/2025 at 10:15 a.m., in the dishwashing area, DA1 was requested to check the dish machine sanitizer concentration (chlorine sanitizer). DA1 attempted to pick up the QUAT sanitizer test strips (QUAT another type of sanitizer) to test the sanitizer concentration in the dish machine. [NAME] 2 stopped DA1 and asked to look for the other test strip that is purple in color. [NAME] 2 stated DA1 is new and forget which test strip to use. DA1 stated she cannot find any other test strips.

During an interview on 2/25/2025 at 10:20 a.m., with DA1, DA1 stated she cannot find the test strip to check the sanitizer. DA 1 stated she does not know where the test strip container was.

During a concurrent interview and review with DA 1, reviewed the dish machine sanitizer log. DA1 stated it was her signature on the dish machine sanitizer log for morning shift. DA1 then stated she used the last test strip.

During an interview on 2/25/2025 at 10:25 a.m., with DA 1 and DS, DS stated DA 1 should report to him when the test strip container was finished.

During an observation on 2/25/2025 at 10:35 a.m., in the kitchen, observed DA 3 provided new test strips borrowed from a nearby sister facility to check the dish machine sanitizer.

During an observation on 2/25/2025 at 10:40 a.m., in the dish machine area, DA 1 did not know how to check the dish machine sanitizer concentration. DA 1 did not know the normal range for the dish machine sanitizer concentration.

During a review of facility's policy and procedure (P&P) titled Dishwashing (dated 2023) indicated, A chlorine log for low temperature machines will be kept and maintained by the dishwashers to assure that the dish machine is working correctly.

This log will be completed each meal prior to any dishwashing .The chlorine should read 50-100 PPM on dish surface in final rinse.

The proper chlorine level is crucial in sanitizing the dishes.

During a review of facility dishwashers job description indicated, Job knowledge: Ability to operate dish machine, handle cleaning supplies and equipment, sort, stack and store clean dishes; knowledge of sanitary requirements, rules and regulations.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of the 2022 U.S.

Food and Drug Administration Food Code titled Frozen Food Code 3-501.11 indicated, Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms.

Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. 4.During an observation on 2/25/2025 at 10:45 a.m., in the kitchen food preparation area, observed [NAME] (Cook1) was preparing lunch and cleaned the counter using kitchen cloth stored in a solution inside a red bucket.

During a concurrent observation and interview with [NAME] 1, [NAME] 1 stated the kitchen cloth was stored in the sanitizer red bucket. [NAME] 1 stated after wiping and washing counter with soap and water, [NAME] 1 used the cloth in the sanitizer to sanitize food contact surfaces. [NAME] 1 was asked to test the sanitizer effectiveness inside the red bucket. [NAME] 1 immersed a test strip in the bucket and compared the color change to the test strip container.

The test strip resulted in sanitizer not effective. [NAME] 1 replaced the sanitizer solution and retested.

The sanitizer test strip resulted in sanitizer not effective again. [NAME] 1 stated when sanitizer was prepared in the morning it was always tested. [NAME] 1 stated she did not prepare the sanitizer solution in the container. [NAME] 1 stated when the test strip results in sanitizer not effective it means there was no sanitizer, and the counters were not sanitized.

During an interview on 2/25/2025 at 11:00 a.m., with [NAME] 2, [NAME] 2 stated she filled the buckets with the sanitizer solution using the faucet that directly dispenses the QUAT sanitizer solution (Quat sanitizer-Quaternary Ammonium a type of sanitizer used in the kitchen). [NAME] 2 stated that she filled the buckets for the staff at 5:15 a.m. [NAME] 2 stated that she changes the solution three times a day and as needed when the solution was visibly soiled or cloudy. [NAME] 2 stated she should test the sanitizer solution effectiveness using the test strip before distributing to the stations. [NAME] 2 stated she did not check it this morning. [NAME] 2 stated when there was no sanitizer then the counters were not being sanitized and it can cross contaminate the food, making residents sick.

During a review of facility's P&P titled Quaternary Ammonium Log Policy (no date) indicated, The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution.

The quaternary solution, used for sanitizing clean work surfaces in the kitchen, will be made according to the instruction on the product or dispensing device.Food and nutrition worker will place the solution in the appropriate bucket .and will test the concentration of the sanitation solution.

The concentration will be tested at least every shift or when the solution is cloudy.

The solution will be replaced when the reading is below 200 parts per million (PPM- a unit used to express the concentration of a substance in a solution).

The replacement solution will be tested prior to usage

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

D.

After touching a resident E.

After touching the resident's environment F.

Before moving from work on a soiled body site to a clean body site on the same resident G.

Immediately after glove removal

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, revised

of antibiotics in our residents .When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available signs and symptoms, when symptoms were first observed, resident's hydration status, current medication list, allergy information, infection type, any orders for warfarin and results of last INR, last creatinine clearance or serum creatinine, if available, and time of the last antibiotic dose.

During a review of the facility's P&P titled, Surveillance for Infections, date revised 9/2017, the P&P indicated, Infections that will be included in routine surveillance include those with clinically significant morbidity or mortality associated with infection ( e.g., pneumonia, UTIs, C.difficile) .

Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible.

The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data.

The infection control committee and/or QAPI committee may be involved in interpretation of the data.

The surveillance should include a review of any or all of the following information to help identify possible indicators of infections laboratory records skin care sheets infection control rounds or interviews verbal reports from staph infection documentation records temperature logs, pharmacy records antibiotic review and transfer log/summaries. If laboratory reports are used to identify relevant information, the following findings merit further evaluation, positive blood cultures positive wound cultures that do not just represent surface colonization, positive urine cultures (bacteriuria) with corresponding signs and symptoms that suggest infection .

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

The facility failed to ensure bedrooms room [ROOM

Findings

During the initial the initial tour on 2/26/2025 at 10:00 a.m., to the facility, room [ROOM NUMBER] and 34 housed five residents per room.

During a record review of Client Accommodations Analysis form, provide by the facility Maintenance Supervisor (MS) rooms [ROOM NUMBERS] occupied by five residents.

During a review of Room Waiver letter dated 2/28/2025 provided by the Administrator (Admin) indicated, all residents and caregivers have ample space in mobility with walkers and wheelchairs.

Residents can get in and out of their rooms with ease and facility staff are able to give care of administering treatment or medications to the residents inside the room.

The floor size of room [ROOM NUMBER] was 500.73 sq. ft (100.14 sq. ft per bed), and room [ROOM NUMBER] was 534.42 sq. ft (106.88 sq. ft per bed).

This exceeds the required 80 sq. ft per bed requirement.

During the survey observations from 2/25/2025 to 2/28/2025, the other resident's room were observed with sufficient space to move around freely within the room, and the nursing staff had enough space to provide care.

There was space for the beds, side tables, dressers, and resident care equipment.

There were no adverse effects noted to the residents' privacy, health, and safety, which could have been compromised by the size of the rooms.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

The facility failed to ensure 8 of 17 residents rooms met the 80 square feet (sq. ft.-unit of measurement) per residents in multiple resident rooms.

This failure had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Findings

During the initial the initial tour on 2/26/2025 at 10:00 a.m., to the facility, Rooms 20, 21,22, 23, 25, 26, 27, and 32 rooms did not meet the requirement of 80 sq. ft. per residents.

During a record review of Client Accommodations Analysis form, provide by the facility Maintenance Supervisor (MS) Rooms 20, 21, 22, 23, 25, 26, 27 and 32 rooms did not meet the requirement of 80 sq.ft per residents.

During a review of Room Waiver letter dated 2/28/2025 provided by the Administrator (Admin) indicated, all residents and caregivers have ample space in mobility with walkers and wheelchairs.

Residents can get in and out of their rooms with ease and facility staff are able to give care of administering treatment or medications to the residents inside the room.

During the survey observations from 2/25/2025 to 2/28/2025, the other resident's room were observed with sufficient space to move around freely within the room, and the nursing staff had enough space to provide care.

There was space for the beds, side tables, dressers, and resident care equipment.

There were no adverse effects noted to the residents' privacy, health, and safety, which could have been compromised by the size of the rooms.

results.

055070 02/28/2025

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of Resident 54's Admission Record, the Admission Record indicated, Resident 54 was admitted to the facility on [DATE] with diagnoses including type 2 Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), type 2 DM with foot ulcer (open wound that does not heal), type 2 DM with diabetic polyneuropathy (damage affecting peripheral nerves) and long term (current) use of insulin.

During a review of Resident 54's Minimum Data Set (MDS -resident assessment tool), dated [DATE], the MDS indicated, Resident 54's cognition (ability to think, understand, learn, and remember) was intact.

The MDS indicated, Resident 54 needed clean-up assistance from facility staff for Activities of Daily Living (ADLs) such as eating, oral hygiene, upper body dressing and personal hygiene, supervision level assistance for toileting, showering and lower body dressing, and moderate assistance from facility staff for putting on/taking off footwear.

055070

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055070 B.

Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

During a review of Resident 29's Care Plan, titled Oral/Dental Care, dated 3/8/2023, the Care Plan indicated goal of adequate oral/dental hygiene will be maintained.

The Care Plan indicated Resident 29 will be provided good mouth care.

During a review of Resident 29's Minimum Data Set (MDS-a resident assessment tool), dated 2/2/2025, the MDS indicated, Resident 29 had the ability to express ideas and wants.

The MDS indicated Resident 29 had the ability to make self-understood.

The MDS indicated Resident 29 usually had the ability to understand others.

The MDS indicated Resident 29 needed partial to moderate assistance from nursing staff with inserting and removing dentures into and from the mouth and managing dentures soaking and rinsing with use of equipment.

The MDS indicated Resident 29 was dependent on nursing staff for putting on and taking off footwear.

The MDS indicated Resident 29 needed substantial to maximal assistance from nursing staff with toileting, showering, dressing, lying, sitting, standing, walking, and transferring to the toilet chair and bed.

During a review of the facility's in-service, titled Dentures and Oral Care, dated 2/13/2024, the in-service indicated a summary lecture on denture cup with water storage, denture tablets provided by the families and the facility, providing daily oral care after meals, and as needed, oral care process and preventing bad breath and decaying gum issues.

During an interview on 2/26/2025 at 10:46 a.m., with Resident 29's family member (FM), Resident 29's FM stated she had an issue with oral care and dentures not being cleaned and placed in denture cups.

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 4, in Resident 29's room observed Resident 29 had a sign on his wall that indicated Please remove lower dentures and disinfect with tablets at night. CNA 4 stated Resident 29 has lower dentures placed on the wall of his bed. CNA 4 stated dentures are cleaned in the sink before and after eating. CNA 4 stated Resident 29 does not have a denture cup, or the tablets used for cleaning the dentures at the bedside.

055070

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055070 B.

Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732