Seal Beach Health And Rehabilitation Center

F-F584 - D ([NAME])

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the personal property was protected from theft or loss for one of three sampled residents (Resident 3). This failure had the potential for the resident's property to get lost or stolen.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 2 056010 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056010 B. Wing 08/21/2024

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

Seal Beach Health and Rehabilitation Center 3000 N Gate Road Seal Beach, CA 90740

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 0584 Findings:

Level of Harm - Minimal harm or Review of the facility's P&P titled Discharging the Resident revised 12/2016 showed to review the personal potential for actual harm effects inventory with the resident or responsible party and have them sign off what they have received all personal effects. Residents Affected - Few Closed medical record review for Resident 3 was initiated on 8/14/24. Resident 3 was admitted to the facility

on [DATE REDACTED], and discharged on [DATE REDACTED].

Review of Resident 3's Clothing and Possessions form dated 7/9/24, showed the resident had the following personal items upon admission: airlife machine, black charger, non-rinse cleanser, wipes, grey pants, foam wedge, grey basin, trousers, and hearing aids. However, further review of the Clothing and Possessions form showed under the discharge section, the signatures for the resident or responsible party and the staff who released the belongings were blank.

On 8/16/24 at 1231 hours, an interview and concurrent closed medical record review for Resident 3 was conducted with RN 1. RN 1 stated the process when discharging a resident from the facility would include going over the inventory list together to ensure nothing was missing and the form was signed by the resident or responsible party and the discharging nurse. When asked if all resident personal items were released to Resident 3 based on Resident 3's Clothing and Possessions form under the discharge section showing blank, RN 1 stated no. RN 1 verified the form did not show a signature from Resident 3 or the responsible party and the staff who released the belongings.

On 8/16/24 at 1515 hours, an interview, a concurrent closed medical record and facility P&P review for Resident 3 was conducted with the DON. The DON verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 2 056010