Health inspection·October 24, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries for two of six sampled residents (Residents 2 and 3). Residents Affected - Few * The facility failed to complete the discharge skin assessment for Resident 2's coccyx Stage 2 pressure injury. * The facility failed to ensure Resident 3's low air loss mattress was plugged in for Resident 3 who had an unstageable pressure injury to the sacrum. These failures had the potential for not providing the necessary care and services for Residents 2 and 3. Findings: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown Clinical Protocol revised 4/2018 showed the nurse shall document and report the following including current treatments, including support surfaces. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. Review of the facility's P&P titled Prevention of Pressure Injuries revised 4/2020 showed support surfaces and pressure redistribution: select appropriate surfaces based on the resident's risk factors, in accordance with currently clinical practice. 1. Closed medical record review for Resident 2 was initiated on 10/17/24. Resident 2 was admitted to the facility on [DATE], and discharged on 10/5/24. Resident 2 had developed a Stage 2 pressure injury on 9/23/24. Review of Resident 2's H&P examination dated 9/13/24, showed Resident 2 did not have the capacity to make medical decisions. Review of Resident 2's eInteract Change in Condition Evaluation V5.1 dated 9/23/24, showed a new change in condition for the Stage 2 pressure injury located on the coccyx. Review of Resident 2's Skin and Wound Evaluation 7.0 dated 9/30/24, showed Resident 2 had the Stage 2 pressure injury located on the sacrum, measuring 3.5 cm (length) x 2.6 cm (width). (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 10/24/2024 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)