Seacrest Post-acute Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

could be a delay of care. During a concurrent interview and record review on 9/10/2025 at 1:47 p.m. with

the ADON, the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised February 2021, was reviewed. The P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a(an) accident or incident involving the resident. The ADON stated the resident being found outside the facility is considered an incident that should have been communicated to the physician.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Seacrest Post-Acute Care Center

1416 West 6th Street San Pedro, CA 90732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

other items off of trays and snack carts. Resident 1 stated the staff knew about Resident 2's behavior.

Resident 1 stated on 8/25/2025, Resident 2 grabbed his belongings from his table. Resident 1 stated he was so upset, he clenched his fist, waited for Resident 2 to walk back towards him, and attempted to punch Resident 2. During a review of facility hallway video footage with starting timestamp of 8/25/2025 7:23:45 p.m., the footage indicated:Received footage of [NAME]/[NAME] altercation from medical records. 8/25/2025 7:24:15 PM: Resident 1 makes left hand into a fist as Resident 2 and Staff Walk down the hallway toward Resident 1. 8/25/2025 7:24:20 PM: Resident 1 extends left fist and makes contact with the back of Resident 2 as Staff member and Resident 2 walk by. 8/25/2025 7:24:24 PM: Resident 2 uses right fist to punch left side of Resident 1's face making contact with Resident 1's glasses. During a review of the facilities P&P, titled Care Plans, Comprehensive Person-Centered, revised March 2022 the P&P indicated care plans are revised as information about the residents and the resident's conditions change. The P&P indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition. During a review of the facility's P&P, titled Safety and Supervision of Residents, revised July 2017 the P&P indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. The P&P indicated risk factors and environmental hazards include unsafe wandering. During a review of the facility's policy and procedure (P&P), titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support

the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including other residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Seacrest Post-Acute Care Center

1416 West 6th Street San Pedro, CA 90732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

lack of sleep. During a review of the facility's policy and procedure (P&P), Verification of Informed Consent for Psychotherapeutic Medications, revised May 2024, the P&P indicated the facility will obtain a written informed consent for treatment using psychotherapeutic drugs and consent renewal every six months.

During a review of the facility's P&P, titled Psychotropic Medication Use, revised July 2022. the P&P indicated psychotropic medication management includes indications for use, adequate monitoring for efficacy and adverse consequences, and preventing, identifying, and responding to adverse consequences.

The P&P indicated consideration of the use of any psychotropic medication is based on comprehensive

review of the resident which includes evaluation or the resident's signs and symptoms in order to identify underlying causes. The P&P indicated residents receiving psychotropic medications are monitored for adverse consequences.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Seacrest Post-Acute Care Center

1416 West 6th Street San Pedro, CA 90732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

review of the facility's policy and procedure (P&P), titled Safety and Supervision of Residents, revised July 2017, the P&P indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. The P&P indicated risk factors and environmental hazards include unsafe wandering.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Seacrest Post-Acute Care Center

1416 West 6th Street San Pedro, CA 90732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

hire, annually and as deemed necessary based on the facility assessment. During a concurrent interview and record review on 9/10/2025 at 4:02 p.m., LVN 1's employee file was reviewed. The DSD stated LVN 1's date of hire was 5/14/2025. The DSD stated LVN 1 has one competency checklist dated 9/2/2025. The DSD stated there are no other competency skill checklists in LVN 1's employee file. The DSD stated the medication competency checklist is completed by the Director of Nursing (DON) and completed upon hire and yearly after.During a review of the facility's P&P titled Administering Medications, revised April 2019, was reviewed. The P&P indicated medications are administered in accordance with prescriber orders. The P&P indicated medication administration times are determined by resident need and benefit, not staff convenience.

Event ID:

Facility ID:

If continuation sheet