Health inspection·August 21, 2024

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. Findings: (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 2 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's P&P titled Discharging the Resident revised 12/2016 showed to review the personal effects inventory with the resident or responsible party and have them sign off what they have received all personal effects. Closed medical record review for Resident 3 was initiated on 8/14/24. Resident 3 was admitted to the facility on [DATE], and discharged on 8/11/24. 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) Previous Versions Obsolete Event ID: Facility ID: 056010 If continuation sheet Page 2 of 2