HUNTINGTON BEACH, CA - Sea Cliff Healthcare Center received multiple federal violations during a February 2025 inspection, with regulators documenting widespread failures in medical record keeping, hospice care coordination, and infection control practices affecting dozens of residents.
Systematic Medical Record Documentation Failures
Federal inspectors found that Sea Cliff Healthcare failed to maintain complete and accurate medical records for 12 of 33 residents reviewed during the inspection. The violations encompassed critical documentation gaps across multiple areas of resident care.
The most concerning findings involved incomplete POLST (Physician Orders for Life-Sustaining Treatment) forms for several residents. These forms serve as crucial communication tools between healthcare providers and emergency responders, documenting a resident's wishes for end-of-life care. For Resident 47, inspectors discovered the POLST incorrectly indicated the presence of an advance directive and healthcare agent when neither existed in the medical record.
Similarly, POLSTs for Residents 146 and 158 lacked required physician signatures, while Resident 87's form failed to document which facility staff members witnessed verbal consent from the responsible party. These omissions create significant risks during medical emergencies when clear documentation of care preferences becomes essential.
Missing medication and treatment documentation presented additional safety concerns. Licensed nurses failed to complete required documentation on Medication Administration Records (MARs) and Treatment Administration Records (TARs) for multiple residents. For Resident 32, missing entries included pain monitoring, vitamin administration, and anticoagulation monitoring - critical oversight functions that help prevent medication errors and adverse events.
The documentation gaps extended to wound care protocols. Resident 16, who had a Kennedy terminal ulcer, missed required monitoring of a low air loss mattress designed to prevent pressure injuries. Resident 65 lacked documentation for prescribed skin treatments including moisturizing lotion and anti-inflammatory cream applications.
Hospice Care Coordination Breakdowns
The inspection revealed significant failures in hospice service coordination for residents under end-of-life care. Two residents admitted under hospice care experienced documented lapses in required aide visits, potentially compromising their comfort and care quality.
Resident 16, admitted to hospice care with heart failure in January 2025, was scheduled to receive hospice aide visits twice weekly. However, inspection of visit logs revealed multiple weeks where the required visits did not occur. During the week of February 9-15, 2025, a scheduled visit on February 11 had no documentation confirming it took place.
Resident 93 faced similar documentation gaps. Admitted to hospice care in December 2024 with cerebral atherosclerosis, the resident's hospice visit schedule showed numerous weeks without documented aide visits from December through February 2025.
Hospice care coordination requires precise communication between facility staff and outside providers. When visits are not completed or properly documented, residents may not receive the specialized comfort care and symptom management that hospice services are designed to provide. The missing documentation also prevents facility staff from knowing whether care plans need adjustment.
Infection Control Protocol Violations
Sea Cliff Healthcare's infection prevention program showed multiple serious deficiencies that could facilitate disease transmission throughout the facility. The violations ranged from environmental cleanliness failures to improper use of personal protective equipment.
Environmental contamination risks were evident in the facility's laundry and clean linen areas. Inspectors documented standing water on floors beneath clean linen folding tables, deteriorated surfaces with adhesive residue creating uncleanable conditions, and storage cabinets with visible mold indicators. The clean linen folding table had an uncleanable surface due to adhesive residue, while the surrounding area showed water damage from roof leaks.
Most concerning was the discovery of residents' belongings stored in water-damaged wooden cabinets showing black and brown discoloration indicative of mold growth. Clean linens were being processed in this contaminated environment, creating potential exposure pathways for residents.
Personal protective equipment failures occurred during medication administration for residents on Enhanced Barrier Precautions (EBP). These precautions are implemented for residents with indwelling medical devices like feeding tubes to prevent transmission of multidrug-resistant organisms.
During observed medication administrations, two licensed nurses failed to wear required gowns when caring for residents with feeding tubes who were on EBP protocols. The nurses also failed to properly sanitize blood pressure cuffs and stethoscopes before and after use, potentially creating cross-contamination opportunities between residents.
Hand hygiene violations were documented during multiple medication passes. One nurse failed to sanitize hands between glove changes when leaving and re-entering a resident's room. Another nurse did not perform required hand hygiene before administering nasal spray medications, violating basic infection prevention protocols.
A particularly concerning incident involved a feeding tube being dropped on the floor during medication administration. The nurse reattached the contaminated tube to the resident's gastric port without disinfection or replacement, creating direct infection risk.
Infection Surveillance and Antibiotic Stewardship Deficiencies
The facility's infection tracking and antibiotic monitoring programs showed significant accuracy problems. Proper infection surveillance helps facilities identify outbreaks early and ensures appropriate antibiotic use.
Inspectors found that Resident 144's documented eye infection meeting clinical criteria was not included on the facility's monthly infection surveillance log, preventing proper monitoring and reporting to quality assurance committees.
Conversely, two residents (127 and 159) were incorrectly listed as having infections meeting McGeer's criteria when their medical records did not support those determinations. This misclassification affects antibiotic stewardship efforts designed to prevent unnecessary antibiotic use and resistance development.
The facility's antibiotic stewardship program failed to identify these inappropriate antibiotic prescriptions or notify physicians for review, potentially exposing residents to unnecessary medication risks and contributing to antibiotic resistance.
Food Safety Equipment Maintenance Issues
The facility's ice machine, used to provide ice for resident food and beverages, was not properly cleaned and sanitized according to manufacturer specifications. The maintenance aide responsible for monthly cleaning could not demonstrate proper knowledge of required cleaning procedures or chemical concentrations.
Proper ice machine maintenance prevents bacterial growth that can contaminate food and beverages served to residents. The facility's maintenance staff lacked adequate training on manufacturer cleaning protocols, creating potential foodborne illness risks for the 157 residents who consume food prepared in the facility's kitchen.
Regulatory Response and Implications
These violations occurred during a routine federal inspection conducted by the Centers for Medicare & Medicaid Services. The findings represent systemic failures across multiple departments including nursing, infection control, maintenance, and hospice coordination.
Medical record accuracy forms the foundation of safe resident care. When documentation is incomplete or inaccurate, care providers cannot make informed decisions about treatments, medications, and emergency interventions. The widespread documentation failures at Sea Cliff Healthcare create ongoing risks for all residents.
Infection control protocols exist to protect vulnerable nursing home populations from preventable diseases. The combination of environmental contamination, improper protective equipment use, and inadequate hand hygiene creates conditions where infections can spread rapidly through the facility.
Hospice care represents a specialized service for residents in their final stages of life. When hospice visits are missed or improperly documented, residents may not receive appropriate comfort care and symptom management during their most vulnerable time.
The facility is required to submit a plan of correction addressing each violation and demonstrating how similar problems will be prevented in the future. Compliance will be verified through follow-up inspections to ensure resident safety improvements are implemented and sustained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sea Cliff Healthcare Center from 2025-02-14 including all violations, facility responses, and corrective action plans.
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