The October inspection at Sea Cliff Healthcare Center found that Resident 4 missed their prescribed warfarin dose on a specific evening because staff failed to coordinate the basic medical monitoring required for the dangerous medication.
Warfarin is a powerful anticoagulant that prevents blood clots but can cause severe bleeding if not carefully monitored through regular blood tests. The facility's own policy requires medications be reordered at least three days before running out.
LVN 4 was scheduled to give Resident 4 warfarin sodium 3 mg at 5 p.m. as ordered by the physician. When she went to administer the medication, it wasn't available.
The pharmacy was asking for recent laboratory results before dispensing the refill. There were none.
LVN 4 told inspectors she planned to follow up with both the pharmacy and the physician about the missing lab work. Instead, she got busy with another resident's emergency and never made the calls.
She marked the medication record with a code indicating "other/see nurses notes" and wrote that she would follow up with the pharmacy for the warfarin medication. The follow-up never happened.
The Director of Nursing confirmed to inspectors that Resident 4 did not receive their prescribed warfarin that evening. She said the pharmacist was responsible for dosing the warfarin medication, but acknowledged the facility's medical record showed no physician's order for the required blood tests.
Those tests - prothrombin time and International Normalized Ratio (INR) - measure how long blood takes to clot and are essential for monitoring residents taking anticoagulants. Without current results, the pharmacy couldn't safely determine the correct warfarin dose.
The Director of Nursing admitted there should have been a physician's order for the next laboratory blood draw before the pharmacy would send warfarin tablets.
The inspection also revealed broader problems with Resident 4's care monitoring. The Director of Nursing acknowledged that the resident's medical record failed to show documented evidence of monitoring and safety measures after the resident had a change in condition one morning.
The resident was scheduled to see speech therapy the following day. The Director of Nursing said she expected licensed nurses and speech therapy staff to reassess the resident's changed condition, but the record showed no evidence this happened.
During the inspection, the Director of Nursing reviewed the facility's medication policy, which clearly states that drugs and biologicals requiring refills must be reordered from the pharmacy at least three days before the last dose to ensure refills are available.
The policy existed. The coordination failed.
Federal inspectors found the facility violated regulations requiring proper medication administration and physician services. The violation was classified as causing minimal harm or potential for actual harm to few residents.
When inspectors presented their findings to the Director of Nursing in a follow-up interview, she acknowledged the deficiencies.
The case illustrates how multiple system failures can cascade into missed medications. The facility lacked current lab orders. The pharmacy couldn't dispense medication without test results. The nurse responsible for coordinating the refill got distracted and forgot to follow up.
For Resident 4, the result was a missed dose of medication designed to prevent potentially life-threatening blood clots. The inspection record doesn't indicate whether the resident suffered any medical consequences from the missed warfarin dose.
The facility's failure extended beyond the single missed medication. Inspectors found that when Resident 4 experienced a change in condition, staff failed to document proper monitoring and safety measures in response.
Sea Cliff Healthcare Center operates at 18811 Florida Street in Huntington Beach. The complaint-based inspection was completed on October 22, 2025.
The facility must submit a plan of correction to address the medication administration and monitoring deficiencies identified during the federal inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sea Cliff Healthcare Center from 2025-10-22 including all violations, facility responses, and corrective action plans.