Health inspection·June 21, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was informed of the dosage changes for their psychotropic medications. Residents Affected - Few * The facility failed to ensure Resident 1 was informed of the decrease in dosage of amitriptyline (antidepressant medication) and sertraline (antidepressant medication). * The facility failed to ensure Resident 1's informed consent was obtained prior to administering the increase in dosage of amitriptyline and sertraline. These failures had the potential for Resident 1 not be informed of the medications and their potential side effects. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated July 2022 showed Residents are involved in the medication management process. Psychotropic medication management includes indications for use and dose. Medical record review for Resident 1 was initiated on 5/29/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 2/17/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report for May 2024 showed the following orders: - dated 4/14/24, for amitriptyline HCl oral tablet 25 mg one tablet by mouth at bedtime for depression, and to verify the informed consent obtained by the MD from the resident/RP after the explanation of the risks and benefits. - dated 4/14/24, for sertraline HCl oral tablet 75 mg one tablet by mouth one time a day for depression and to verify the informed consent obtained by the MD from the resident/RP after the explanation of the risks and benefits. Review of Resident 1's Order Summary Report for June 2024 showed the following orders: - dated 6/5/24, for amitriptyline HCl oral tablet 25 mg two tablets by mouth at bedtime for (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 056010 Printed: 05/15/2026 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 056010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 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)