Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sea Cliff Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow its own care planning policy by not implementing required monitoring for bedrail entrapment for two residents whose care plans called for safety checks every shift, with no documentation in the medical record that such monitoring occurred and an LVN confirming it was not done. The facility also did not develop a care plan for a resident with intergluteal/perianal MASD despite an active treatment order, as confirmed by an RN. In addition, another resident’s care plan inaccurately documented the location of a midline catheter as being in the right upper arm when it was actually in the left upper arm, a discrepancy verified by nursing staff and acknowledged by the DON.
A resident who had difficulty swallowing medication was not properly assessed or monitored after the incident, and the care plan was not updated to reflect the change in condition. Additionally, warfarin sodium was not administered as ordered due to missing laboratory results and lack of follow-up, and meal intake documentation was incomplete.
A resident with severe cognitive impairment was given crushed iron and tamsulosin medications by an LVN after experiencing difficulty swallowing whole pills. Facility policy and national guidelines indicate these medications should not be crushed, but the LVN proceeded to do so without consulting appropriate references. The DON was made aware of the incident.
A resident with severe cognitive impairment developed new swallowing difficulties, including coughing when taking medication and sips of water. Although the medication was subsequently crushed, the care plan was not reviewed or updated to reflect these changes, contrary to facility policy. The DON confirmed the care plan should have been revised.
A resident was found self-administering multiple medications at bedside without a required assessment, physician's order, or care plan documentation. Staff confirmed that the resident was not authorized to have medications unattended and that facility policy requiring IDT assessment and documentation was not followed.
A facility failed to maintain an effective infection control program, with issues in laundry room cleanliness, inaccurate infection reporting, and improper use of PPE. Staff did not consistently sanitize equipment or perform hand hygiene, and a feeding tube was not disinfected after falling on the floor. These deficiencies were confirmed by staff and the DON.
The facility failed to follow its protocols for enteral feeding and medication administration for three residents. Nurses administered medications via GT by pushing instead of using gravity, and did not check tube placement and residuals as required. These actions were confirmed by the DON and had the potential to cause complications.
A resident requiring continuous oxygen therapy did not receive it as ordered, as the nasal cannula was found hanging on a feeding tube stand instead of being in place. A nurse confirmed the oversight, and the DON acknowledged the findings. The resident was dependent on staff for daily activities and had a physician's order for continuous oxygen to maintain saturation levels above 90%.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses for 157 residents. Observations included improperly thawed chicken without a pull date, a dirty frying pan, improper storage of dry bulk food, wet meal preparation equipment, lack of backflow prevention in floor drains, and unsanitary storage of cleaning equipment.
A facility failed to ensure accurate completion and review of nutritional assessments for a resident, leading to an oversight of significant weight gain. The RD did not participate in or verify the MDS Nutritional Status assessment, which was incorrectly coded by the DSS, resulting in inaccurate documentation of the resident's nutritional status.
The facility failed to ensure two residents under hospice care received scheduled hospice aide visits as required. Despite physician orders for biweekly visits, documentation showed missed visits for both residents. Interviews confirmed the absence of required signatures from hospice staff, indicating visits were not completed. The DON acknowledged the need for hospice staff to sign visit logs, but facility nurses were not documenting visits unless orders were received from the hospice doctor.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident was treated for pneumonia without meeting McGeer's criteria, and the physician was not notified for reevaluation. Another resident was treated for an infection related to elevated WBCs, but symptoms did not meet the criteria, and the physician was not informed.
The facility failed to properly clean and sanitize its ice machine according to the manufacturer's instructions, posing a risk of contamination. The Maintenance Assistant was confused about the cleaning process, using incorrect amounts of cleaner and sanitizer, and the instructions were difficult for him to understand. This failure could potentially lead to food contamination and health issues for residents.
The facility failed to meet pharmaceutical service needs by leaving medications unattended, not replacing an opened CII E-kit within 72 hours, improperly disposing of a refused Percocet tablet, and discarding medication wastes inappropriately. These actions were against the facility's policies, potentially leading to medication misuse and unavailability of emergency medications.
A facility was found to have a 20% medication error rate during an observation, involving two residents. Errors included not measuring heart rate before administering blood pressure medications, incorrect aspirin dosage, and improper form of multivitamins. Additionally, the facility failed to follow enteral tube medication administration procedures, not flushing the GT with the required water amount. Interviews confirmed these practices did not align with physician orders and facility policies.
The facility failed to properly label and store medications, including megestrol acetate without a shake well label, Katerzia stored at room temperature instead of refrigerated, and an opened Levemir insulin vial without an open date. Additionally, expired Tempa-DOT thermometers were found in Medication Room A. These deficiencies were acknowledged by the staff and the DON.
The facility failed to maintain accurate medical records for several residents, including errors in POLST forms, incomplete documentation of treatments and medications, and inaccuracies in meal consumption records. Staff interviews confirmed these lapses, which were acknowledged by the DON.
The facility failed to accurately code the MDS for two residents regarding significant weight changes. One resident experienced a weight loss of over 5% in a month, while another had a 14% weight gain, yet these changes were not reflected in their MDS assessments. The errors were confirmed by the MDS Coordinator, with the dietary department responsible for the assessments.
A resident experienced an unwitnessed fall, and the facility failed to conduct timely neurological assessments as per their policy. The assessments were supposed to occur every hour after the initial evaluations, but one scheduled assessment was missed, leading to a delay in care. The DON confirmed the oversight during a review.
Two residents in an LTC facility were involved in a physical altercation, where one resident scratched the other's face, prompting a defensive bite. Both residents sustained injuries, and the facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse. Medical records indicated cognitive impairments in both residents, and staff observations confirmed the altercation.
A facility failed to create a care plan for a resident who repeatedly refused medications, despite having a policy that mandates comprehensive, person-centered care plans. The resident's medical records documented instances of medication refusal, but no care plan was developed to address this issue, as confirmed by the DON.
The facility did not comply with State law as two CNAs were observed without their name badges, wearing visitor stickers instead. Both CNAs acknowledged the importance of wearing badges for resident identification. The DON confirmed the facility had run out of temporary badges and stressed the importance of staff identification for residents and visitors.
The facility failed to provide necessary care for two residents, leading to deficiencies in medication administration and timely medical response. A resident did not receive Marinol as ordered, and the physician was not notified of the lapse. Another resident experienced stroke symptoms, but the physician was not notified until over six hours later. Interviews with staff confirmed the lack of timely communication and assessment, potentially impacting the residents' health.
A facility failed to order and administer a resident's aspirin and atorvastatin according to hospital discharge orders. The resident, admitted with CVA, pneumonia, and potential stroke, did not receive the prescribed medications. Interviews with staff confirmed the oversight, and the DON acknowledged the failure in the medication reconciliation process.
Failure to Develop and Implement Accurate, Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans consistent with its own policy and residents’ assessed needs. The facility policy required the IDT to develop comprehensive care plans with measurable objectives and timeframes, and to implement baseline care plans within 48 hours of admission. For one resident with moderately impaired cognition who used bilateral half side rails, the care plan identified a risk for entrapment and required monitoring of the resident’s safety for entrapment every shift. However, review of the medical record showed no documented evidence that this monitoring occurred, and an LVN confirmed that the intervention to monitor for entrapment every shift had not been implemented or documented in the MAR or progress notes. A second resident, cognitively intact and using a bariatric bed with built-in bilateral half side rails, also had a care plan identifying risk for entrapment/bodily injury and requiring monitoring of safety for entrapment every shift. Medical record review similarly failed to show documentation that this monitoring was performed. During interview and concurrent record review, the same LVN verified that the resident’s care plan intervention to monitor for entrapment every shift was not implemented as ordered. In both cases, the care plan interventions related to bedrail entrapment risk were not carried out or documented as required. The facility also failed to develop appropriate care plans for two additional residents’ identified conditions. One resident had a physician’s order to cleanse intergluteal cleft extending to perianal MASD with soap and water, pat dry, and apply barrier cream each day shift, but the medical record contained no care plan addressing this MASD; an RN confirmed the absence of such a care plan. Another resident had a documented midline IV access in the left upper arm, but the care plan referenced IV medication and a midline catheter in the right upper arm instead. An RN verified that the midline was actually in the left upper arm and that the care plan inaccurately identified the right upper arm. The DON was informed of and acknowledged these findings for the involved residents.
Failure to Monitor Change in Condition and Administer Ordered Medication
Penalty
Summary
The facility failed to provide necessary care and services for a resident who experienced difficulty swallowing medications. After the resident coughed and choked when given a whole medication tablet with water, the nurse crushed the remaining medications and informed speech therapy (ST) of the change in condition. However, there was no documented evidence that the resident was assessed or monitored following this event, nor were care and safety measures provided as required by facility policy. The resident's care plan was not reviewed or revised to address the new swallowing problem, and meal intake documentation was incomplete for the day of the incident. Additionally, the facility did not administer warfarin sodium, an anticoagulant, as ordered by the physician. The medication was unavailable because the pharmacy required recent laboratory results, which had not been obtained or ordered. The nurse responsible acknowledged that the medication was not given and that follow-up with the pharmacy and physician was not completed due to being occupied with another emergency. The resident's medical record did not contain a physician's order for the necessary blood tests (prothrombin time and INR) required for warfarin dosing. Interviews with staff confirmed these lapses in care and documentation. The Director of Nursing (DON) verified that the resident was not monitored after the change in condition and that the warfarin sodium was not administered as ordered. The DON also confirmed the absence of a care plan update and the lack of orders for required laboratory tests, as well as incomplete documentation of the resident's meal intake.
Improper Crushing and Administration of Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed and administered an iron tablet to a resident, despite facility policy stating that only medications which may be crushed should be altered in this way. The facility's policy requires nursing staff to use available references to determine which medications are safe to crush. According to the National Library of Medicine, iron tablets are enteric coated and should not be crushed, as the coating is intended to protect the stomach. The resident in question had a physician's order for iron 25 mg and tamsulosin hydrochloride 0.4 mg, both of which were administered on the day of the incident. The resident, who had severe cognitive impairment as indicated by a BIMS score of three, began coughing and choking after the LVN attempted to administer the whole pill with water. In response, the LVN crushed all of the resident's medications, including those that should not be crushed according to reference materials. The Director of Nursing (DON) was informed and acknowledged these findings during the investigation.
Failure to Revise Care Plan for Swallowing Difficulties
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised to reflect the resident's current care needs and interventions following a change in condition. Specifically, after the resident experienced difficulty swallowing medication and coughed when taking sips of water, the care plan was not updated to address these new swallowing problems. The facility's policy required documentation of changes in condition and updates to the care plan as indicated, but this was not followed in this case. Medical record review showed that the resident had severe cognitive impairment, as indicated by a BIMS score of three, and was observed to cough after attempting to swallow a whole medication tablet with water. The medication was subsequently crushed, but the care plan was not revised to reflect this intervention or the resident's new swallowing difficulties. The Director of Nursing confirmed that the care plan should have been updated to address the resident's change in condition.
Failure to Assess and Document Resident's Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed with a medication cup containing multiple medications at their bedside and proceeded to self-administer these medications without the presence of a licensed nurse. The resident's medical record did not contain an assessment, physician's order, or care plan addressing the ability to self-administer medications. The facility's policy requires that the interdisciplinary team (IDT) assess the safety of self-administration, clarify physician orders to include "may keep at bedside," and document these determinations in the care plan, none of which were completed for this resident. Interviews with facility staff, including an LVN and the DON, confirmed that the resident was not supposed to have medications unattended at the bedside and that the required assessment and documentation were missing. The medications involved included blood pressure medications, blood thinners, and supplements. The DON verified that the resident's records lacked the necessary assessment, physician's order, and care plan problem for self-administration of medications, in direct violation of facility policy and federal requirements.
Plan Of Correction
Corrective Action for those residents identified as being affected by this deficiency: Resident 3 was assessed by the DON if he wishes to self-administer medications on 7/24/2025 and resident declined. Identification of other residents having the potential to be affected by this same deficiency: All residents have the potential to be affected by the same deficiency. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. How the facility will monitor its performance to make sure that solutions are sustained: Documented findings of the audit will be forwarded to the QAPI committee monthly for at least 4 weeks beginning September 2025 for review and action planning as indicated or as the QAPI committee determines compliance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the laundry and clean linen rooms, conditions were not maintained to ensure a clean area free from potential contamination. Puddles of water were observed on the floor, adhesive residue on the clean linen folding table, and signs of damage and discoloration on the walls and cabinets, which could lead to mold formation. These conditions were verified by the Maintenance Director, who acknowledged the potential for mold and contamination. The facility's infection surveillance and reporting were also found to be inadequate. Resident 144's infection was not reported on the facility's monthly infection control log, and infections for Residents 127 and 159 were incorrectly listed as meeting McGeer's Criteria. The Infection Preventionist (IP) confirmed these discrepancies, indicating a failure in accurately identifying and reporting infections, which is crucial for preventing potential outbreaks. Additionally, there were multiple instances of staff failing to adhere to proper infection control practices. Two licensed nurses did not wear appropriate personal protective equipment (PPE) during medication administration for residents on enhanced barrier precautions (EBP). Furthermore, the same nurses did not sanitize blood pressure cuffs and stethoscopes before and after use, and hand hygiene was not consistently performed during medication administration. In one instance, a nurse did not disinfect a feeding tube after it fell on the floor before reattaching it to a resident's gastrostomy tube (GT). These lapses in infection control practices were confirmed through interviews with the involved staff and the Director of Nursing (DON).
Failure to Follow Enteral Feeding and Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding enteral feeding and medication administration for three residents. Two licensed nurses administered medications to residents via gastrostomy tubes (GT) by pushing the medications through the tube instead of allowing them to flow by gravity, as per the facility's policy. This was observed during medication pass observations for two residents, where one nurse admitted to using the incorrect method initially and then switched to the gravity method. The Director of Nursing (DON) confirmed that medications should be administered by gravity, with gentle pushing only if there is resistance. Additionally, one licensed nurse did not check the tube placement and residual volume before administering medications to a resident, which is required by the facility's policy. This oversight was acknowledged by the nurse during an interview and confirmed by the DON, who stated that checking tube placement and residual volume is necessary to ensure safe medication administration. Furthermore, another resident's enteral feeding was initiated without verifying the GT placement and checking gastric residuals, as required by the facility's policy. The nurse involved admitted to not performing these checks, and the DON confirmed the importance of these procedures to prevent complications. These failures in following established protocols had the potential to lead to complications related to GT care and management.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident who required continuous oxygen therapy. The facility's policy on oxygen administration, revised in February 2023, mandates that oxygen therapy be administered by a licensed nurse as ordered by the physician. However, during an observation on February 11, 2025, it was noted that the resident's nasal cannula tubing was not in place on the resident but was instead hanging on the feeding tube stand, despite the oxygen being set at two liters per minute. A registered nurse (RN) confirmed the observation and acknowledged that the nasal cannula should have been on the resident's nose to ensure continuous oxygen administration. The Director of Nursing (DON) also verified and acknowledged these findings during an interview and medical record review. The resident, who was dependent on staff for activities of daily living, had a physician's order for continuous oxygen to maintain oxygen saturation levels above 90%.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, posing a risk for foodborne illnesses among the 157 residents who consumed food prepared in the kitchen. During an inspection, it was observed that frozen meat was not thawed safely, as seven bags of thawed raw chicken in the walk-in refrigerator lacked a pull date, making it impossible to determine when they were placed there. Additionally, a frying pan with heavy black residue was found, indicating it was not clean or in good working condition, and should have been discarded. Further observations revealed that dry bulk food was not stored properly, with a plastic scoop left in a powdered thickener container. Meal preparation equipment was not air-dried, as evidenced by a wet blender stored with its lid on. Two floor drains lacked backflow prevention, as the drainage pipes of the juice machine and walk-in refrigerator did not have an air gap. Lastly, cleaning equipment was not stored in a sanitary manner, with a broom found on the floor in the utility closet, contrary to guidelines requiring maintenance tools to be stored off the floor to prevent pest harborage.
Failure to Accurately Complete Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the Registered Dietitian (RD) completed or reviewed the Minimum Data Set (MDS) Nutritional Status assessment and the quarterly nutritional assessment for accuracy for one of the residents, identified as Resident 87. The California Business and Professions Code 2586 requires Registered Dietitians to conduct nutritional and dietary assessments. However, the RD did not participate in completing or verifying the accuracy of the MDS Section K assessment, which was incorrectly coded by the Dietary Services Supervisor (DSS). The MDS Coordinator confirmed that the assessment was incorrectly coded, and the RD acknowledged that she was not involved in the process. Resident 87 experienced a significant weight gain of 17 pounds, or 13%, over six months, which was not accurately reflected in the assessments. The quarterly nutritional assessment completed by the DSS inaccurately indicated that the resident's weight was stable, despite the significant weight gain. The RD verified that the assessments were not accurate and that she was not involved in reviewing them, which posed a risk to the resident's nutritional needs being unmet.
Failure to Provide Scheduled Hospice Visits
Penalty
Summary
The facility failed to provide necessary hospice care services for two residents, identified as Residents 16 and 93, who were under hospice care. Resident 16, diagnosed with heart failure, was admitted under Hospice A with a physician's order for hospice aide (HA) visits twice a week. However, from January to February 2025, there were no documented HA visits conducted twice a week as required. Specifically, during the week of February 9 to February 15, 2025, there was no evidence of a scheduled HA visit on February 11, 2025. The hospice visit sign-in sheets lacked entries or signatures from hospice staff for the scheduled visits, and the facility's licensed nurse was expected to contact the hospice provider if visits were not completed. Similarly, Resident 93, diagnosed with cerebral atherosclerosis, was admitted under Hospice B with a similar requirement for HA visits. From December 2024 to February 2025, there were multiple weeks where no HA visits were documented, despite being scheduled. Interviews with the Licensed Vocational Nurse (LVN) and the Hospice Case Manager confirmed the absence of documented visits, as hospice staff were required to sign the calendar and visit description log to confirm their visits. The Director of Nursing (DON) acknowledged that hospice staff must sign the hospice calendar or visit log to confirm completed visits, but facility nurses were not required to document visits unless orders were received from the hospice doctor.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for two nonsampled residents. Resident 127 was prescribed antibiotics for pneumonia, but a review of the medical records indicated that the symptoms did not meet the McGeer's criteria for a true infection. Despite this discrepancy, the resident's physician was not notified to reassess the necessity of the antibiotic treatment. Similarly, Resident 159 was prescribed antibiotics for an infection related to elevated white blood cells, which was initially thought to meet the McGeer's criteria. However, upon further review, it was found that the symptoms did not align with the criteria for a true infection. The facility's Infection Preventionist (IP) confirmed the absence of a McGeer's criteria tool for such infections and acknowledged that the physician was not informed about the need to reevaluate the antibiotic use.
Improper Cleaning of Ice Machine
Penalty
Summary
The facility failed to maintain its essential equipment, specifically the ice machine, in safe operating conditions. The ice machine was not cleaned and sanitized according to the manufacturer's instructions, which could potentially lead to contamination of food and illnesses among residents. The facility's policy required monthly cleaning of the ice machine's internal components, but the Maintenance Assistant (MA) did not follow the correct procedure. The MA mixed five ounces of cleaner with an unspecified amount of water and ran it through the machine, then soaked the parts in bleach, which was not in accordance with the manufacturer's guidelines. During an observation and interview, the MA admitted to not knowing the exact amount of water used in the cleaning process and was confused about the instructions, which were in English and difficult for him to understand. The Maintenance Director confirmed the MA's confusion and acknowledged the discrepancy between the cleaning process used and the manufacturer's instructions. This failure to adhere to proper cleaning procedures posed a risk of the ice machine not functioning as intended, potentially leading to contamination and health issues for the residents who consumed food prepared in the kitchen.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to ensure the provision of pharmacy services met the needs of the residents in accordance with the facility's policies and procedures. During a medication administration observation, a licensed nurse left medications unattended on a resident's bedside table multiple times while retrieving supplies, which was against the facility's policy that requires medications to be secured or taken with the nurse if the line of vision cannot be maintained. This oversight had the potential for misuse of medications by residents, staff, or visitors. Additionally, the facility did not replace an opened CII E-kit within the required 72-hour timeframe, as per the facility's policy. The CII E-kit, which contained controlled medications, was opened and not replaced in a timely manner, potentially leading to the unavailability of emergency medications when needed. Furthermore, a tablet of Percocet was removed from the CII E-kit and not disposed of properly after a resident refused it, contrary to the facility's policy that requires refused or held doses to be destroyed. Moreover, a staff member improperly disposed of non-scheduled medication wastes by discarding them into a regular trash bin instead of using the designated drug disposal system. This action was observed during the preparation for medication administration, where the nurse failed to identify which medications were prepared and subsequently discarded the remaining medications into the trash. This practice was not in line with the facility's policy, which mandates the use of a drug disposal system to prevent misuse and environmental harm.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a cumulative error rate of 20% during a medication administration observation. Six medication errors were identified out of 30 opportunities involving two residents. For one resident, the errors included not measuring the heart rate before administering blood pressure medications, administering the incorrect dosage of aspirin, and providing a tablet form of multivitamins instead of the prescribed liquid form. The Licensed Vocational Nurse (LVN) involved did not adhere to the physician's orders, which required checking both systolic blood pressure and heart rate before administering certain medications. Additionally, the facility's policies and procedures for enteral tube medication administration were not followed. The LVN did not flush the resident's gastrostomy tube (GT) with the required amount of water before and after medication administration, nor between each medication, as per the physician's orders. This was observed during the administration of medications to two residents, where the LVN used less water than prescribed and did not flush the GT between medications, potentially leading to tube clogging. Interviews with the LVN and the Director of Nursing (DON) confirmed the discrepancies between the observed practices and the facility's policies. The DON acknowledged that the licensed nurses should have adhered to the physician's orders and the facility's procedures, including the specific instructions for medication administration and GT flushing. These failures in following established protocols contributed to the high medication error rate observed during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications according to the manufacturer's instructions and the facility's policies and procedures. An amber bottle of megestrol acetate oral suspension was found without the necessary label instructing nurses to shake the container well before use. This omission was acknowledged by LVN 10, who confirmed that the information was crucial for the proper preparation of the medication. The Director of Nursing (DON) also confirmed that suspension medications require adequate shaking to ensure uniform preparation. Additionally, a bottle of Katerzia oral suspension, which requires refrigerated storage, was found stored at room temperature in Medication Cart 2. LVN 10 acknowledged that the medication was improperly stored and suggested that it might have been left in the cart after use. The DON confirmed that medications should be stored according to the manufacturer's instructions and returned to the refrigerator after use. Furthermore, an opened vial of Levemir insulin was found without an open date in Medication Cart 1, making it impossible to determine its expiration. LVN 9 confirmed that insulin vials should be discarded 28 days after opening. The DON reiterated the importance of dating insulin vials upon opening. Lastly, three boxes of expired Tempa-DOT thermometers were found in Medication Room A, which the Central Supply Staff confirmed should have been removed. The DON stated that staff should check expiration dates and dispose of expired supplies.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for 12 out of 33 sampled residents. This included errors in the Physician Orders for Life-Sustaining Treatment (POLST) forms, such as missing physician signatures for two residents and incorrect documentation of advanced directives and health care agents for another resident. Additionally, there was a lack of documentation of staff review and confirmation of POLST information with a resident's responsible party. Further deficiencies were noted in the documentation of treatment administration records (TARs) and medication administration records (MARs). For instance, one resident's treatment for xerosis and pruritus was not documented as completed, and another resident's low air loss mattress monitoring was not recorded for a specific shift. There were also inaccuracies in documenting meal consumption, with one resident's intake being overestimated in the records compared to actual observations. The facility's failure to maintain accurate records extended to the documentation of vital signs, pain levels, and medication administration for several residents. This included missing entries for monitoring COVID-19 symptoms, administering medications, and providing nonpharmacological interventions for pain. Interviews with staff confirmed these documentation lapses, which were acknowledged by the Director of Nursing.
Inaccurate MDS Coding for Weight Changes
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which could impact their individualized care plans. Resident 25 experienced a significant weight loss of more than 5% in a month, as evidenced by a decrease from 153 lbs to 139.6 lbs over a period of one month. Despite this, the MDS was inaccurately coded to indicate no significant weight loss. The MDS Coordinator confirmed the error, noting that the dietary department was responsible for completing the nutrition assessment. Similarly, Resident 87's MDS was inaccurately coded regarding weight gain. The resident's weight increased from 114 lbs to 130.8 lbs, a 14% increase, yet the MDS did not reflect this change. The MDS Coordinator verified the incorrect coding, which was completed by the Dietary Services Supervisor (DSS). These inaccuracies in the MDS coding could lead to residents not receiving appropriate care plans tailored to their nutritional needs.
Failure to Conduct Timely Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the highest practicable well-being for a resident who experienced an unwitnessed fall. The facility's policy and procedure for neurological evaluations, revised on 3/28/23, required assessments every 15 minutes for one hour, then every 30 minutes for four hours, then every hour for two hours, and then every shift for 72 hours. However, after the resident's fall on 1/18/25, the required hourly neurological assessments were not completed as scheduled. Specifically, the first hourly assessment was conducted at 0155 hours on 1/19/25, but the subsequent assessment due at 0255 hours was missed, with the next assessment occurring two hours later at 0355 hours. During an interview on 2/13/25, the Director of Nursing (DON) confirmed that the neurological assessments should have been conducted according to the specified frequency on the flowsheet. The DON reviewed the resident's Neurological Assessment Flowsheet and acknowledged that the scheduled assessment for 0255 hours on 1/19/25 was not completed. This oversight in following the established protocol for post-fall neurological evaluations had the potential to delay necessary care for the resident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from physical abuse, resulting in an altercation between them. Resident 2 allegedly called Resident 1 a derogatory name and scratched her face, prompting Resident 1 to bite Resident 2's hand in self-defense. This incident was observed by staff, who found Resident 1 with Resident 2's hand in her mouth. Both residents sustained injuries, with Resident 1 having a scratch on her face and Resident 2 having a bite mark on her hand. The facility's policies and procedures on abuse prevention and resident rights were reviewed, revealing that the facility is responsible for ensuring residents are free from abuse and neglect. Despite these policies, the altercation between the residents occurred, indicating a failure in oversight and monitoring. The facility's investigation confirmed the abuse incident, with both residents admitting to their involvement in the altercation. Medical records showed that Resident 1 had moderate cognitive impairment, while Resident 2 had severe cognitive impairment. Both residents were assessed following the incident, with Resident 1 having dried scratches on her face and neck, and Resident 2 having a deep laceration on her hand. Staff interviews corroborated the residents' accounts of the incident, confirming that Resident 1 acted in self-defense after being scratched by Resident 2.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was refusing to take medications. The facility's policy requires the interdisciplinary team to create a person-centered care plan with measurable objectives and timeframes to address the medical, nursing, and psychosocial needs identified in the comprehensive assessment. Despite this policy, the medical records for the resident showed multiple instances of medication refusal, with notes indicating the resident was shouting and calling out. However, there was no care plan problem developed to address the resident's refusal to take medications, as confirmed by the Director of Nursing during an interview.
Failure to Ensure Staff Wore Identification Badges
Penalty
Summary
The facility failed to comply with State law by not ensuring that two Certified Nursing Assistants (CNAs) were wearing their name badges while on duty. This was observed during a survey when CNA 2 and CNA 6 were both found wearing visitor sticker badges instead of their employee name badges. CNA 2 acknowledged the importance of wearing the badge for resident identification, and CNA 6 similarly confirmed the necessity for residents to recognize staff. The Director of Nursing (DON) admitted that the facility had run out of temporary sticker name badges and emphasized the importance of staff wearing identification badges for resident and visitor recognition.
Deficiencies in Medication Administration and Timely Medical Response
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in medication administration and timely medical response. Resident 2 did not receive Marinol, a medication to stimulate appetite, as ordered from February 2 to February 7, 2024. The physician was not notified of this lapse, and there was no follow-up with the pharmacy regarding the medication's delayed delivery. The facility's policy on medication administration requires medications to be administered within one hour before or after the prescribed time, which was not adhered to in this case. Resident 5 experienced symptoms indicative of a stroke, including numbness and a feeling of having a stroke, but the physician was not notified until over six hours later. The facility's policy on change of condition reporting mandates that all changes in a resident's condition be communicated to the physician promptly. Despite the resident's complaints and the serious nature of stroke symptoms, there was a significant delay in notifying the physician and transferring the resident to an acute care hospital. Interviews with facility staff, including the ADON and LVN, confirmed the lack of timely communication and assessment in both cases. The ADON acknowledged the delay in following up with the pharmacy for Resident 2's medication, and the DON confirmed that the RN or physician should have been notified immediately when Resident 5 reported stroke-like symptoms. These failures in communication and adherence to facility policies had the potential to negatively impact the residents' health and well-being.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide the necessary care and services to a resident as ordered by the physician. Specifically, the facility did not order and administer the resident's aspirin and atorvastatin according to the discharge medication orders from the hospital. The resident was admitted with diagnoses of CVA, pneumonia, and potential stroke, and the discharge instructions included new orders for aspirin and atorvastatin. However, these medications were not included in the resident's Order Summary Report or MARs for April and May 2024, indicating that the medications were not administered as prescribed. Interviews with LVN 3 and the DON confirmed that the new medication orders were not followed. LVN 3 verified that the aspirin and atorvastatin were necessary for the resident's condition and should have been administered. The DON stated that the admitting nurse was responsible for reconciling the medication orders from the hospital discharge list but failed to do so. There was no documentation to show that the facility's physician was notified of the new medications, and the DON acknowledged the oversight in the medication reconciliation process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Huntington Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beachside Nursing Center | 0 mi | — | 17 | 0 |
| Huntington Valley Healthcare Center | 1.3 mi | — | 8 | 0 |
| Fountain Valley Post Acute | 4 mi | — | 32 | 0 |
| Mesa Verde Post Acute Care Center | 4.7 mi | — | 24 | 0 |
| Stanley Healthcare Center | 5.1 mi | — | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.