Sea Cliff Healthcare Center

F-F641, example #2.

b. On 2/14/25 at 1012 hours, an interview was conducted with the RD. When the RD was asked about the job duties of the RD and DSS, the RD stated the DSS was responsible to complete all quarterly nutritional assessment for the residents. The RD further stated she was not involved in completing the quarterly nutritional assessments and did not check the accuracy of the quarterly nutritional assessments completed by the DSS.

On 2/14/25 at 1116 hours, an interview and concurrent medical record review was conducted with the RD.

The quarterly nutritional assessment for Resident 87 dated 1/14/25, showed the assessment was completed by the DSS and reviewed with the RD. The quarterly nutritional assessment showed Resident 87 weighed 130.8 lbs on 1/1/25. The section titled Weight History showed on 1/1/25, Resident 87 weighed 131 lbs; and

on 7/3/24, Resident 87 weighed 114 lbs. The section titled Assessed Needs showed the resident's weight was stable and to continue with the current diet as ordered. The RD verified the quarterly nutritional assessment completed by the DSS dated 1/14/25, showed Resident 87's weight was stable. The RD verified Resident 87's weight was not stable but rather she had experienced a significant weight gain of 17 lbs, 13%

in the past six months. The RD further verified the quarterly nutritional assessment dated [DATE REDACTED], completed by the DSS was not accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39683

Residents Affected - Few Based on interview, medical record review and the facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for 12 of 33 final sampled residents (Residents 16, 25, 32, 37, 46, 47, 56, 57, 65, 87, 146, and 158).

* Resident 47's POLST incorrectly showed the resident had the advanced directive and health care agent (person listed in the advanced directive who can legally make health-care decisions for the resident).

* Resident 87's POLST failed to show the names of facility staff who reviewed and confirmed the form with

the resident's responsible party.

* Resident 57's post fall eInteract Change in Condition Evaluation V4.2 showed the incorrect time for the physician and resident notification.

* Resident 158's POLST failed to show the physician's signature.

* Resident 146's POLST failed to show the physician's signature.

* The facility failed to ensure Resident 65's TARs regarding the treatment for xerosis and pruritus were completed.

* The facility failed to ensure Resident 16's LAL monitoring of the setting and functionality was done on 2/9/25, for the NOC shift.

* The facility failed to ensure accurate documentation of the meal consumption for Resident 25.

* The licensed nurses failed to ensure the documentation on the MARs were complete for Residents 32, 37, 46, and 56. In addition, the licensed nurses failed to ensure the documentation on the TAR for Residents 37 was complete.

These failures resulted in inaccurate medical records, which had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.

Findings:

Review of the facility's P&P titled Advanced Directives revised 11/2019 showed once an advanced directive is received by the facility, it will be confirmed in the resident's medical record. The facility uses a POLST form to communicate medical interventions, procedures, and end-of-life decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 Review of the facility's P&P titled Charting and Documentation revised 2/2022 showed it is the policy of the facility to ensure that the resident record is concise and reflective of resident status. Resident record will be Level of Harm - Minimal harm or completed on all residents on a schedule basis and will be reflective of current care provided to the resident. potential for actual harm The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. Is also necessary to include data needed for identification and Residents Affected - Few communication with family and friends. Rules for Charting section showed the following:

1. Notes are to be written on all long term residents by day, evening, and night shifts; frequency is determined by the individual nursing service.

2. Daily notes are required as the necessary arises.

3. New admissions must have nurse's notes on all three shifts for the first seventy-two hour.

4. Changes of condition will be documented in resident chart for at least 72 hours.

5. The admitting nurse must write a complete physical and mental nursing assessment.

6. Continuous nurse's notes are required on all residents as the necessary arises.

Review of the facility's P&P titled Physician Documentation revised 11/2024 showed the following:

- Progress notes must be written, signed, and dated with each visit. They may be either paper, or electronic (at least every 30 days for the first 90 days after admission, and at least done once every 60 days thereafter).

- Each physician visit should include an evaluation of the resident's condition, treatment, and a review of, and

a decision about, the continued appropriateness of the resident's condition and current medical regime.

Review of the facility's P&P titled Specific Medication Administration Procedures: Documentation revised 1/28/25, showed the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications. Current medication, except topicals used treatments, are listed on the resident's MAR. Topical medications used in treatments are; listed on the Treatment Administration record. The resident's MAR is initialed by the person administering the medication in the space provided under the date, and on the line for that specific medication dose administration.

1. Medical record review for Resident 47 was initiated on 2/11/25. Resident 47 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 47's DPOA dated 4/26/24, showed, This document does not authorize anyone to make medical and other health-care decisions for the resident. There was no advanced directive located in the resident's medical record to show a health care agent had been selected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 Review of Resident 47's POLST dated 11/28/24, showed the resident had an advanced directive dated 4/26/24, which was reviewed and listed the resident's health care agent's information. Level of Harm - Minimal harm or potential for actual harm Review of Resident 47's Social Services Assessment/Evaluation - V 2 dated 12/30/24, showed the resident had a DPOA but had no advanced directive formulated. Residents Affected - Few

On 2/13/25 at 1126 hours, an interview and concurrent medical record review was conducted with the Social Services Staff. The Social Services Staff stated Resident 47's provided a DPOA, but not an advanced directive. The Social Services Staff showed a scanned copy of Resident 47's POLST from the resident's medical record dated 8/2/24, which showed the resident had no advanced directive. The Social Services Staff was unsure if there was an updated POLST in the resident's paper medical record.

On 2/13/25 at 1136 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 reviewed Resident 47's POLST dated 11/28/24, located in the resident's paper medical record. LVN 5 stated the POLST showed the resident had an advance directive and listed a health care agent. LVN 5 stated if the resident was to be transferred out of the facility in an emergency, the POLST would be sent with

the resident to show the selected treatment and health care agent.

On 2/13/25 at 1143 hours, an interview and concurrent medical record review was conducted with the SSD.

The SSD verified Resident 47's most recent POLST dated 11/28/24, incorrectly showed the resident had the advanced directive and health care agent.

2. Medical record review for Resident 87 was initiated on 2/11/25. Resident 87 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 87's POLST dated 8/12/24, showed the resident had a legally recognized decision maker. In the section for the legally recognized decision maker, a box with signature (required), showed, verbal consent was obtained at 1906 hours. The form did not show the facility staff who had reviewed and confirmed the POLST information with the responsible party and witnessed the review and confirmation of

the POLST.

On 2/13/25 at 1044 hours, an interview and concurrent medical record review was conducted with the DON.

The DON stated when the facility staff were getting verbal or telephone consent for a signature, the process was to have two facility staff present, one facility staff to obtain the consent and the other facility staff to witness the consent was obtained. The DON stated for Resident 87's POLST, two facility staff names should have been listed on the POLST, to show the staff member who obtained the telephone consent and the other staff member who witnessed the consent was obtained.

3. Medical record review for Resident 57 was initiated on 2/11/25. Resident 57 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 57's eInteract Change in Condition Evaluation V4.2 dated 11/28/24 at 2343 hours, showed the resident had a fall. The evaluation showed the resident's physician was notified of the fall on 11/28/24 at 2228 hours, and the resident was notified at 2230 hours.

Review of Resident 57's post fall Neurological Assessment Flowsheet dated 11/28/24, showed the first neurological assessment was completed at 2330 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 Review of Resident 57's Post-Event IDT Review dated 12/2/24, showed the IDT met to discuss a fall incident that the resident had on 11/28/24 at 2330 hours. Level of Harm - Minimal harm or potential for actual harm On 2/13/25 at 1608 hours, an interview and concurrent medical record review was conducted with the DON.

The DON reviewed Resident 57's medical record and was asked what time the resident had a fall on Residents Affected - Few 11/28/24. The DON stated the medical record showed the fall occurred at 2330 hours. The DON verified the time of the physician and resident notifications were incorrectly documented as it was one hour before the resident's actual fall.

51539

4. Medical record review for Resident 146 was initiated on 2/11/25. Resident 146 was admitted to the facility

on [DATE REDACTED].

Review of the Resident 146's POLST dated 12/4/24, under Section D, failed to show the physician's signature.

5. Medical record review for Resident 158 was initiated on 2/12/25. Resident 158 was admitted to the facility

on [DATE REDACTED].

Review of the Resident 158's POLST dated 1/6/25, under Section D, failed to show the physician's signature.

On 2/14/25 at 1053 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified the POLST for Residents 146 and 158 were not signed by the residents' physician and stated the residents' POLST should have been signed during the physician's follow-up visit.

50967

6. Medical record review for Resident 65 was initiated on 2/12/25. Resident 65 was admitted to the facility on [DATE REDACTED].

Review of Resident 65's H&P examination dated 4/27/24, showed Resident 65 had the capacity to understand and make decisions.

Review of Resident 65's Order Summary Report dated 2/13/25, showed the following physician's orders:

- dated 11/5/24, to apply Eucerin external lotion (moisturizer) to the body topically every shift for xerosis; and

- dated 11/5/24, to apply triamcinolone acetonide (used to treat skin itching, redness, swelling, dryness, crusting, and scaling) cream 0.1% to the arms topically every shift for pruritus.

Review of Resident 65's TAR for February 2025 showed missing documentation for the Eucerin external lotion and triamcinolone acetonide cream application to the resident's skin on 2/9/25, for the NOC shift (1900-0700 hours).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 On 2/12/25 at 1340 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated complete documentation was important because it showed Level of Harm - Minimal harm or care provided to the residents. potential for actual harm

On 2/14/25 at 1447 hours, an interview was conducted with the DON. The DON stated complete Residents Affected - Few documentation was important to show proof of the services provided to the residents. The DON stated if the treatment or care was not documented, it was not done. The DON further stated the daily audits were done by the Medical Record Director, and the Unit Managers and RNs did random weekly checks of the residents' MARs and TARs. The DON was informed and acknowledged the above findings.

7. Review of the facility's P&P titled Skin and Wound Monitoring and Management (undated) showed the following:

- Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc;

- Licensed nurse to document presence of pressure reducing devices on TAR as ordered; and

- Monitoring daily via medication administration and treatment administration record.

Medical record review for Resident 16 was initiated on 2/13/25. Resident 16 was admitted to the facility on [DATE REDACTED].

Review of Resident 16's H&P examination dated 10/29/24, showed Resident 16 had the capacity to understand and make decisions.

Review of Resident 16's MDS dated [DATE REDACTED], showed Resident 16 had a BIMS score of 6 indicating severe cognitive impairment.

Review of Resident 16's Order Summary Report dated 2/13/25, showed the following physician's orders:

- dated 1/30/25, for LAL mattress for wound management, to monitor the setting and functionality every shift and may adjust the settings based on the weight and/or the resident's comfort, every day and night shift; and

- dated 1/31/25, for the sacrococcyx Kennedy terminal ulcer (a painful skin sore that appears in people who are near death) wound care treatment every shift.

Review of Resident 16's TAR for February 2025 showed missing documentation on 2/9/25, for the NOC shift, to show the resident's LAL mattress was monitored for the setting and functionality as ordered by the physician.

On 2/13/24 at 0938 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings.

On 2/14/25 at 1447 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 44175

Level of Harm - Minimal harm or 8. On 2/13/25 at 1206 hours, during the dinning observation, Resident 25 was observed eating her lunch in potential for actual harm her room. The meal tray was observed with vegetable burger, rice, dessert, salad, a cup of chicken noodle soup, a cup of milk and a cup of water. Resident 25 was observed eating couple bites of the vegetable Residents Affected - Few burger, some of the chicken noodle soup, and salad. Resident 25 was observed not touching the rice and milk.

On 2/13/25 at 1304 hours, an observation and concurrent interview was conducted with the CNA 3. CNA 3 was observed asking Resident 25 if she was done with her meal, Resident 25 stated yes. CNA 3 was then observed taking out the meal tray for Resident 25. CNA 3 verified Resident 25 ate around 25% of her meal tray.

Medical record review for the Resident 25 was initiated on 2/11/25. Resident 25 was admitted to the facility

on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of the Resident 25's Physician Order Summary dated 1/2/25, showed a physician's order to monitor

the resident's meal percentage intake every meal.

Review of the Resident 25's Documentation Survey Report v2 dated February 2025 showed on 2/13/25 at 1251 hours, the percentage of the lunch eaten by Resident 25 was documented as 76-100%.

On 2/13/25 at 1606 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 1. RN 1 was informed of the observation of Resident 25's lunch meal intake of around 25% on 2/13/25. RN 1 verified the facility staff documented 76-100% for Resident 25's lunch meal intake on 2/13/25. RN 1 stated the facility staff should accurately document the percentage of amount eaten by the resident.

On 2/14/25 at 0930 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON. The DON verified and acknowledged the above findings.

49324

9. Medical record review for Resident 32 was initiated on 2/12/25. Resident 32 was admitted to the facility on [DATE REDACTED].

Review of Resident 32's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse:

- to monitor the pain level using the following scale; 0 = no pain, 1-3 = mild, 4-6 = moderate, and 7-10 = severe every shift.

There was no documentation for the monitoring on 12/25/24, for the night shift and 1/21/25, for the morning shift.

- to administer multiple vitamins-minerals (supplement) one tablet by mouth one time a day for supplement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 There was no documentation the multiple vitamins-minerals medication was administered on 1/21/25.

Level of Harm - Minimal harm or - to provide nonpharmacological interventions for pain: 1 = Repositioning, 2 = Dim light/ quiet environment, 3 potential for actual harm = relaxation 4 = distraction, 5 = music, and 6= massage every shift.

Residents Affected - Few There was no documentation a nonpharmacological interventions were provided on 12/25/24, for the night shift.

- to administer Senna (stool softener) tablet 8.6 mg two tablets by mouth two times a day for constipation. There was no documentation the Senna medication was administered on 1/21/25, for the morning shift.

- to monitor/document/report to the MD for signs and symptoms of anticoagulant complications: blood tinged or frank blood in the urine, black tarry stools, dark or bright red blood in stools, sudden sever headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs every shift.

There was no documentation the above monitoring was performed on 1/21/25, for the morning shift.

- to administer tadalafil 5 mg one tablet by mouth one time a day for benign prostatic hypertrophy (enlarged prostate).

There was no documentation the tadalafil medication was administered on 1/21/25.

- to administer aspirin (pain medication) low dose 81 mg one chewable tablet by mouth one time a day for cerebrovascular disorder (conditions that affect the blood vessels in the brain and spinal cord) prophylaxis.

There was no documentation aspirin medication was administered on 1/21/25.

- to provide health shake 4 oz with meals for supplement.

There was no documentation the Healthshake was provided to the resident on 1/21/25, for the morning and evening shifts.

10.a. Medical record review for Resident 37 was initiated on 2/12/25. Resident 37 was admitted to the facility

on [DATE REDACTED].

Review of Resident 37's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse:

- to monitor the vital signs and record any Covid-19 signs and symptoms: F=fever, C = cough, S=new shortness of breath/difficulty of breathing, Z=chills, repeated shaking with chills, M = muscle pain, H = Headache, T = sorethroat , L = New loss of taste or smell, O = Congestion, R - runny nose, FA = fatigue, G = GI symptoms; diarrhea/Nausea, and NA = Not applicable, every night shift.

There was documentation the monitoring was performed as ordered on 12/15/24, for the night shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 - to monitor for the signs and symptoms of bleeding related to anticoagulation/antiplatelet therapy every shift. Notify the MD if any of the following signs and symptoms are present (passing blood in urine, passing blood Level of Harm - Minimal harm or when resident is having a bowel movement, sever bruising, prolonged nosebleeds (lasting longer than 10 potential for actual harm minutes), bleeding gums, vomiting blood or coughing up blood, sudden severe back pain, or difficulty of breathing or chest pain every shift; and to monitor the pain level using the following scale: 0 = no pain, 1-3 = Residents Affected - Few Mild, 4-6 = Moderate, and 7-10 = Severe, every shift.

There was no documentation for the monitoring for the above physician's orders on 12/25/24, for the night shift.

- to elevate the head of the bed to 30-45 degrees at all times on 12/25/24, for the night shift; to flush the GT tube with 50 cc of water pre and post medication administration every shift; to monitor for the signs and symptoms of pacemaker malfunction (syncope, dizziness, palpitations, slow or fast heart rate, hiccup) every shift; to observe the pacemaker site on for any signs and symptoms of infection, signs of pacemaker failure such as pulse below 60, bradycardia, syncope, palpitations, SOB, prolonged hiccups, chest pain , dizziness, weakness, swelling, discoloration, erosion of pacing wire and any pain every shift. Notify the MD if noted every shift; and to crush all crushable medications given via feeding tubes. May slow push to facilitate consumption every shift.

There were no documentation the above physician's orders were performed on 12/25/24, for the night shift.

b. Review of Resident 37's TAR for December 2024 showed the following entrries with missing documentation from the licensed nurse on 12/25/24, for the night shift:

- to monitor the left upper extremity skin discoloration for skin breakdown and increase in size, and notify the MD every shift.

- to monitor the setting and functionality of the low air loss mattress for wound management. May adjust the settings based on the weight or per the resident's comfort every shift.

11. Medical record review for Resident 46 was initiated on 2/12/25. Resident 46 was admitted to the facility

on [DATE REDACTED].

Review of Resident 46's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse on 12/25/24, for the night shift:

- to monitor the vital signs and record any Covid-19 signs and symptoms: F = fever, C = cough, S = new shortness of breath/difficulty of breathing, Z = chills, repeated shaking with chills, M = muscle pain, H = Headache, T = sorethroat , L = New loss of taste or smell, O = Congestion, R - runny nose, FA = fatigue, G = GI symptoms; diarrhea/Nausea, and NA = Not applicable every night shift.

- to provide the nonpharmacological interventions for pain: 1 = Repositioning, 2 = Dim light/ quiet environment, 3 = relaxation 4 = distraction, 5 = music, and 6= massage every shift.

- to monitor the pain level using the following scale: 0 = no pain, 1-3 = Mild, 4-6 = Moderate, and 7-10 = Sever every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0842 12. Medical record review for Resident 56 was initiated on 2/12/25. Resident 56 was admitted to the facility

on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 46's MAR for December 2024 showed the following entries with missing documentation from the licensed nurse on 12/25/24, for the night shift: Residents Affected - Few - to monitor the vital signs and record any Covid-19 signs and symptoms: F = fever, C = cough, S = new shortness of breath/difficulty of breathing, Z = chills, repeated shaking with chills, M = muscle pain, H = Headache, T = sorethroat , L = New loss of taste or smell, O = Congestion, R - runny nose, FA = fatigue, G = GI symptoms; diarrhea/Nausea, and NA = Not applicable, every night shift.

- to monitor for the signs and symptoms of bleeding related to anticoagulation/antiplatelet therapy every shift. Notify the MD if any of the following signs and symptoms are present (passing blood in urine, passing blood when resident is having a bowel movement, sever bruising, prolonged nosebleeds (lasting longer than 10 minutes), bleeding gums, vomiting blood or coughing up blood, sudden severe back pain, or difficulty of breathing or chest pain every shift.

On 2/12/25 at 0942 hours, an interview and concurrent medical record review for Residents 32, 37, 46, and 56 was conducted with LVN 3. LVN 3 verified the missing documentation on the residents' MARs and TARs should have been completed by the assigned licensed staff. LVN 3 stated the physician's orders on the MARs and TARs for the above residents were performed, but the licensed nurse had just missed to document in the MARs and TARs.

On 2/14/25 at 1531 hours, an interview was conducted with the DON. The DON verified and acknowledged

the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50967

Residents Affected - Few Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of four final sampled residents (Residents 16 and 93) reviewed for hospice services

* The facility failed to ensure Residents 16 and 93 received HA visits two times a week per the hospice provider's calendar. This failure posed the risk for delays in the communication between the hospice provider and facility, which may affect the residents' care.

Findings:

Review of the facility's P&P titled End of Life Care: Hospice and/or Palliative Care revised on 12/2023 showed the following:

- Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with Hospice will include processes for orienting staff to facility policies and procedures which may include resident's rights, documentation, and record keeping requirements; and

- However, the facility will continue to provide necessary care and services to assist the resident to achieve his or her highest practicable well-being.

1. Medical record review for Resident 16 was initiated on 2/13/25. Resident 16 was admitted to the facility on [DATE REDACTED].

Review of Resident 16's Order Summary Report dated 2/13/25, showed a physician's order dated 1/15/25, to admit the resident under Hospice A with the diagnosis of heart failure.

Review of Resident 16's Hospice Visit Sign-in Monthly Calendar showed the HA visit frequency was two times a week.

Review of Resident 16's January to February 2025 Hospice Visit Sign-in Monthly Calendar during the weeks from 1/12 to 2/8/25, showed there were no HA visits conducted two times a week. In addition, during the week of 2/9 to 2/15/25, there were two scheduled HA visits on 2/11 and 2/14/25. However, there was no documented evidence of the HA visit on 2/11/25.

Reviewed Resident 16's Hospice Visit Sign-in Sheet for January and February 2025 did not show the entries or the hospice staff's names for the biweekly scheduled for the HA visits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0849 On 2/13/25 at 0949 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated the HA visit was scheduled two times a week and the RN Case Manager was scheduled Level of Harm - Minimal harm or weekly. LVN 3 verified the above findings. LVN 3 stated the hospice staff were supposed to sign the hospice potential for actual harm monthly calendar and the visit sign in sheet. Furthermore, LVN 3 stated the facility licensed nurse assigned to the resident would call the hospice provider when the HA visits were not completed. Residents Affected - Few 2. Medical record review for Resident 93 was initiated on 2/13/25. Resident 93 was admitted to the facility on [DATE REDACTED].

Review of Resident 93's Order Summary Report dated 2/13/25, showed a physician's order dated 12/17/24, to admit the resident under Hospice B with the diagnosis of cerebral atherosclerosis.

Review of Resident 93's Vitas Personalized Visit Schedule for December 2024 and February 2025 showed

the following:

- During the weeks from 12/15 to 12/28/24, there were no HA visits conducted during these weeks.

- During the week of 12/29/24 to 1/4/25, showed there was one HA visit scheduled. However, there was no documented evidence the HA visited during this week.

- During the weeks of 1/5 to 2/8/25, showed there were two HA visits scheduled. However, there was no documented evidence of the HA visits during these weeks.

On 2/13/25 at 0949 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings.

On 2/13/25 at 1015 hours, an interview and concurrent medical record review was conducted with Hospice Case Manager. The Hospice Case Manager stated all hospice disciplines that visited the resident must sign

the calendar and the visit description log. The Hospice Case Manager stated when the hospice discipline or hospice staff did not sign in on both the calendar and visit description log, the visit was not done. The Hospice Case Manager verified the above findings.

On 2/14/25 at 1447 hours, an interview was conducted with the DON. The DON stated all hospice staff must sign on the hospice calendar or visit log to show the visits were completed. Furthermore, the DON stated the facility licensed nurses were not required to document the visits done by the HA or aide, and only documented if there were orders received from hospice doctor. The DON was informed and acknowledged

the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39683 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Some the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections.

* The laundry and clean linen rooms were not maintained to ensure a clean area, free from potential contamination.

* Resident 144 (final sampled resident)'s infection was not reported on the facility's monthly infection control log.

* Residents 127 and 159's infections (nonsampled residents) were incorrectly listed as meeting McGeer's Criteria on the facility's monthly infection control log.

* Two of four licensed nurses did not wear appropriate personal protective equipment (PPE) during the medication administrations for two of four residents (final sampled residents, Residents 111 and 152) who were on enhanced barrier precautions (EBP).

* Two of four licensed nurses did not sanitize the BP cuff and stethoscope before and after use for two of four residents (final sampled residents, Residents 111 and 152) on EBP.

* Three of four licensed nurses did not perform hand hygiene during the medication administration for three of four residents (final sampled residents, Residents 111 and 152; and nonsampled resident, Resident 68).

* One of four licensed nurses did not disinfect the feeding tube after dropping it on the floor and prior to attaching it to Resident 111's GT during the medication administration.

These failures resulted in inaccurate infection surveillance, which had the potential for spread of infection in

the facility.

Findings:

1. On 2/13/25 at 1000 hours, a laundry room inspection was conducted with the Maintenance Director. The following was observed in the clean linen room located in the basement:

- Puddles of water were observed on the floor under and around the clean linen folding table, on the floor in and around two built in storage cabinets. The Maintenance Director stated the water had leaked in from the rain.

- The clean linen folding table had adhesive residue with threads on the laminate, resulting in an uncleanable surface.

- The clean linen room window perimeter, located above the clean linen folding table, had deteriorated and cracked paint and putty, with exposed wood and dark discoloration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0880 - The wall under the above window showed signs of damage with cracks and gaps between the wall and baseboard. Level of Harm - Minimal harm or potential for actual harm - The built-in wooden cabinets located along the outside wall, was filled with discharged residents' clothing and belongings. The items were stored on a wooden pallet on the floor. The pallet was sitting in a puddle of Residents Affected - Some water, and the wood was warped and rotting with black and white staining. The base of one cabinet had black and dark brown discolorations at the base along the floor.

- The sink had blank stains and debris with white mineral-like residue.

In addition, the following was observed in the laundry room:

- The sink had blank stains and debris with white mineral-like residue.

-T he clothes dryer near the sink had metallic corrosion with brownish discoloration on the bottom frame.

The Maintenance Director verified the above findings and stated the conditions of the cabinets could cause mold formation and the white staining could be an indicator of mold.

On 2/13/25 at 1100 hours, a follow-up observation was conducted in the clean linen room. Laundry aides were observed folding clean clothes on the clean linen table, with the uncleanable surface, while a staff was wiping up the puddles of water still accumulating on the floor.

2. Review of the facility's P&P titled Infection Prevention - Surveillance of Infections and Reporting undated, showed it is the facility's policy to maintain an ongoing system of surveillance to identify possible communicable diseases or infections to ensure measures are taken to prevent any potential outbreak. An Infection Control Surveillance log will be maintained and reviewed to ensure all potential or actual infections are being identified. The Infection Control Committee will monitor these findings and report to the Quality Assurance Committee at least monthly.

On 2/14/25 at 0804 hours, an infection control and surveillance review was conducted with the IP. The IP stated the facility used the McGeer's criteria to identify true infections, and the information was listed on the monthly Infection Prevention and Control Surveillance Log to be reviewed monthly with the Quality Assurance program.

Review of Resident 144's Infection Surveillance - V 2 assessment dated [DATE REDACTED], showed the resident was prescribed an antibiotic medication for an eye infection and the resident's symptoms met the McGeer's criteria.

Review of the facility's Infection Prevention and Control Surveillance Log for November 2024 failed to show Resident 144's infection was included on the log, to be reported to and reviewed by the facility's Quality Assurance Committee. The IP verified Resident 144's infection was not included on the log and should have been.

3. On 2/14/25 at 0804 hours, an antibiotic stewardship review was conducted with the IP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0880 a. Review of the facility's Infection Prevention and Control Surveillance Log for November 2024 showed Resident 127 was prescribed an antibiotic medication on 11/11/24, for pneumonia and the resident's Level of Harm - Minimal harm or symptoms met the McGeers criteria. potential for actual harm

Review of Resident 127's Infection Surveillance - V2 dated 11/14/24, showed the criteria for pneumonia was Residents Affected - Some met. However, Resident 127's medical record failed to show the resident's symptoms met the McGeer's criteria for a true infection.

The IP verified Resident 127's symptoms did not meet the McGeers criteria, resulting in incorrect data listing

on the Infection Prevention and Control Surveillance Log for November 2024.

b. Review of the facility's Infection Prevention and Control Surveillance Log for January 2025 showed Resident 159 was prescribed an antibiotic medication on 1/4/24, for other infection related to elevated WBCs and met the McGeers criteria.

Review of Resident 159's Infection Surveillance - V2 dated 1/3/25, showed the McGeers criteria was met. However, review of Resident 159's medical record failed to show the resident symptoms met the McGeers criteria for a true infection.

The IP verified Resident 159's symptoms did not meet the McGeers criteria, resulting in incorrect data listing

on the Infection Prevention and Control Surveillance Log for January 2025.

50610

4. Review of the facility's P&P titled IPCP (infection prevention control program) Standard and Transmission-Based Precaution dated 1/28/25, showed in part, .wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogen . EBP is used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO). Indwelling medical devices include, but are not limited to central lines, PICC lines, urinary catheters, feeding tubes, and tracheostomies .

Review of the facility's P&P titled Infection Prevention-Employee Exposure dated 1/28/25, showed in parts, Protective Barriers .Gowns: Wear disposable gowns when entering room .and it is anticipated that clothing will become soiled with body fluids or when contact with soiled surfaces (such as side rails or bed linens of

an infected resident) is anticipated. Remove gown when the procedure is complete and prior to leaving the resident's room .

a. Medical record review for Resident 152 was initiated on 2/11/25.

Review of Resident 152's MAR showed the following physician's order:

- dated 11/14/24, for Enhanced Barrier Precautions: PPE Required for high resident contact care activities. Indication: implanted feeding device.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0880 On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster for EBP was observed on Resident 152's room door. LVN 8 was observed wearing a new pair of Level of Harm - Minimal harm or gloves at the medication cart and entering Resident 152's room without a gown, to assess the resident's BP. potential for actual harm After LVN 8 prepared all the medications for GT administration at the medication cart, LVN 8 stated she would need to wear a gown since Resident 152 had a GT. LVN 8 was observed wearing a new pair of gloves Residents Affected - Some and a gown during the medication administration observation.

On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 stated she did not wear a gown while checking the Resident 152's BP. LVN 8 also stated a gown and gloves were required when checking

the resident's BP and administering medications for the residents on EBP.

b. Medical record review for Resident 111 was initiated on 2/12/25.

Review of Resident 111's MAR showed the following physician's order:

- dated 9/6/24, for Enhanced Barrier Precautions: PPE Required for high resident contact care activities. Indication: implanted feeding device.

On 2/12/25 at 0814 hours, a medication administration observation via GT was conducted with LVN 4. A sign/poster for EBP was observed on Resident 111's room door. LVN 4 was observed wearing a new pair of gloves at the medication cart and entering Resident 111's room without a gown, to assess the resident's BP. While LVN 4 was measuring the resident's BP with the stethoscope and BP cuff, LVN 4's arms and clothing were observed touching the resident's linens and the resident's arm. Shortly after the BP assessment, LVN 4 returned to the mediation cart and started preparing nine medications for Resident 111. After preparing the medications, LVN 4 wore a new pair of gloves, returned to Resident 111's room again without a gown and proceeded to administer the medications through the resident's GT.

On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 stated he did not wear a gown while checking the resident's BP and administering the resident's medications. LVN 4 also stated he realized

after finishing the medication administration, he had to be gowned up. LVN 4 stated gown and gloves were required PPE when providing care to the residents on EBP, which included the BP assessment and medication administration.

On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated for the residents on EBP, the facility staff providing care such as BP measurement and medication administration, need to wear

the gown and gloves before entering the room.

5. Review of the facility's P&P titled IPCP standard and Transmission-Based Precaution dated 1/28/25, showed in part, .patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient .

Review of the facility's P&P titled Infection Prevention-Employee Exposure dated 1/28/25, showed Environmental and Equipment Protection: Dedicated use of non-critical care equipment (i.e., sphygmomanometer, stethoscope and thermometer) will be provided to MDRO resident(s), when available.

This equipment should be disinfected after each use whether dedicated to MDRO resident or shared.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0880 a. On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster of EBP was observed on Resident 152's room door. LVN 8 was observed bringing an uncleaned Level of Harm - Minimal harm or stethoscope and BP cuff to Resident 152's room, to assess the resident's BP. After the BP assessment, LVN potential for actual harm 8 brought out the stethoscope and BP cuff to the medication cart and disinfected only the earpieces of the stethoscope with the alcohol swab. LVN 8 did not sanitize the entire parts of the stethoscope and BP cuff Residents Affected - Some with the sanitizing wipe before and after use.

On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 verified she did not sanitize the BP cuff and stethoscope with the sanitizing wipe before and after use and sanitized only the earpieces of the stethoscope with the alcohol swab after use.

b. On 2/12/25 at 0814 hours, a medication administration observation via GT was conducted with LVN 4. A sign/poster of EBP was observed on Resident 111's room door. LVN 4 was observed sanitizing only the earpieces of the stethoscope without sanitizing the entire parts of the stethoscope and BP cuff. Then, LVN 4 was observed bringing the stethoscope and BP cuff to Resident 111's room, to assess the resident's BP.

After the BP assessment, LVN 4 brought out the stethoscope and BP cuff to the medication cart and sanitized only the earpieces of the stethoscope with the alcohol swab. LVN 4 did not sanitize the entire parts of the stethoscope and BP cuff with the sanitizing wipe before and after use.

On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 verified he did not sanitize the BP cuff and stethoscope before and after use. LVN 4 stated he should have cleaned the entire parts of stethoscope and BP cuff using the sanitizing wipe.

On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the BP cuff and stethoscopes should be disinfected before and after use, sanitizing the whole stethoscope from the ear parts to the diaphragm, and it should be disinfected with bleach not with the alcohol swab.

6. Review of the facility's P&P titled Infection Prevention-Hand Hygiene dated 1/28/25, showed in part, Use

an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: before donning sterile glove .after removing glove .

a. On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster of EBP was observed on Resident 152's room door. After LVN 8 brought in all the prepared medications into Resident 152's room and placed it on the resident's bedside table, LVN 8 was observed walking out of the resident's room to the medication cart to get a cup of water for the GT administration. LVN 8 discarded the gloves she was wearing and prepared a cup of water. Before reentering to the resident's room, she wore a new pair of gloves without sanitizing her hands with the alcohol gel. After LVN 8 returned to the resident's room with a cup of water, she proceeded to administer the medications via GT.

On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 stated she did not remember whether she sanitized her hands with the alcohol gel in between changing the gloves when she walked out of

the resident's room to get a cup of water.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0880 b. Review of the facility's P&P titled Administration Process dated 1/28/25, showed hands are to be washed with soap and water before and after administering injections, eye drops, eardrops, nasal sprays. Level of Harm - Minimal harm or potential for actual harm On 2/11/25 at 0903 hours, a medication administration observation was conducted with LVN 6. LVN 6 was observed preparing 10 medications, including eight tablets, one nasal spray and an insulin for injection for Residents Affected - Some Resident 68. After administering the tablets to Resident 68, LVN 6 trashed the empty cups, washed her hands in the resident's restroom with soap and water. Then, LVN 6 was observed wearing a new pair of gloves to assess the resident's glucose level using a lancet, glucometer and a test strip. After LVN 6 assessed the resident's glucose level, LVN 6 was observed changing the gloves without performing hand hygiene. After LVN 6 wore a new pair of gloves, she proceeded to administer the nasal spray to Resident 68's nostrils.

On 2/11/25 at 1137 hours, an interview was conducted with LNV 6. LVN 6 stated she thought she cleaned her hands in between changing the gloves. However, two surveyors independently observed LVN 6 not performing hand hygiene in between changing the gloves before administering the last medication to the resident, which was the nasal spray.

c. On 2/12/25 at 0814 hours, a medication administration observation via GT was conducted with LVN 4. A sign/poster of EBP was observed on Resident 111's room door. After LVN 4 administered the third medication to Resident 111's GT, LVN 4 walked out of the resident's room to get more water for the remaining gloves. Then, LVN 4 returned to the resident's room with a cup of water wearing the same gloves. LVN 4 was not observed changing the gloves. After LVN 4 re-entered the resident's room, LVN 4 resumed administering the rest of the medications via the resident's GT.

On 2/12/25 at 1110 hours, an interview was conducted with LVN 4. LVN 4 stated he did not change the gloves when he walked out of the room to get more water. LVN 4 verified he came back to Resident 111's room with the same gloves on. LVN 4 stated hand hygiene was required before entering and after leaving

the resident's room. LVN 4 verified he should have removed the gloves to prepare the cup of water, then donned a new pair of gloves before re-entering the resident's room.

On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the facility staff must perform hand hygiene in between changing the gloves using alcohol gel or washing hands with soap and water.

7. Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions dated 1/28/25, showed standard precautions are infection prevention practices that apply to the care of all the residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard precaution includes use of PPE based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens), hand hygiene, environmental cleaning and disinfection and reprocessing of reusable medical equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0880 On 2/11/25 at 0815 hours, a medication administration observation via GT was conducted with LVN 8. A sign/poster of EBP was observed on Resident 152's room door. Prior to administering the medications to Level of Harm - Minimal harm or Resident 152, LVN 8 was observed disconnecting the feeding tube from the resident's GT and placing the potential for actual harm feeding tube over the IV pole to hang it. After LVN 8 hung the GT tubing over the IV pole, the tubing was dropped on the floor. LVN 8 then grabbed the tubing from the floor and hung it again over the IV pole without Residents Affected - Some disinfecting the tubing or replacing the tubing. Then, LVN 8 proceeded to administer the medications through

the resident's GT. After finishing the medication administration, LVN 8 was observed grabbing the GT tubing from the IV pole and reattaching the tubing back to the resident's GT, without disinfecting the tubing or replacing the tubing.

On 2/11/25 at 1228 hours, an interview was conducted with LVN 8. LVN 8 verified the feeding tube was dropped on the floor, but she did not disinfect the tubing. LVN 8 stated she hung the tubing over the IV pole again and started administering the medications to Resident 152. LVN 8 also stated she did not disinfect the tubing before reattaching it to the resident's GT.

On 2/13/25 at 0856 hours, an interview was conducted with the DON. The DON stated the licensed nurse should have securely placed the tube in the holder attached to the feeding pump, instead of hanging the tubing over the IV pole. The DON also stated the licensed nurse should have disinfected the feeding tube

after it dropped on the floor and before reattaching it to the resident's GT.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 39683 potential for actual harm Based on interview, medical record review, facility document review, and facility P&P review the facility failed Residents Affected - Few to implement an antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use when two nonsampled residents (Residents 127 and 159) were being treated for conditions which did not meet the McGeer's criteria. This failure had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use.

Findings:

Review of the facility's P&P titled Infection Prevention and Control Program revised 9/2017 showed improving the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotics resistance is a national priority, and disease caused by resistant bacteria are increasing in long term care facilities and contributing to higher rates of morbidity and mortality. The facility will promote appropriate antibiotic use while optimizing the treatment of infections, while reducing possible adverse events associated to antibiotic use.

On 2/14/25 at 0804 hours, an antibiotic stewardship review and concurrent interview was conducted with the IP. The IP stated the facility used the McGeers criteria to identify true infections. The IP stated for suspected infections that did not meet the McGeer's criteria and were treated with antibiotics, the process was to notify

the physician to evaluate the antibiotic usage.

a. Review of the facility's Infection Prevention and Control Surveillance Log for November 2024, showed Resident 127 was prescribed an antibiotic medication on 11/11/24, for pneumonia and met the McGeer's criteria.

Review of Resident 127's Infection Surveillance - V2 dated 11/14/24, showed the criteria for pneumonia was met. However, review of Resident 127's medical record failed to show the resident's symptoms met criteria for a true infection.

The IP verified Resident 127's medical record failed to show the resident's symptoms met the McGeer's criteria. In addition, the resident's physician was not notified regarding the resident's antibiotic medication not meeting the McGeer's criteria and to re-evaluate the need for the use of the antibiotic medication.

b. Review of the facility's Infection Prevention and Control Surveillance Log for January 2025, showed Resident 159 was prescribed an antibiotic medication on 1/4/24, for other infection related to elevated WBCs and met the McGeer's criteria.

Review of Resident 159's Infection Surveillance - V2 dated 1/3/25, showed the McGeer's criteria was met. However, review of Resident 159's medical record failed to show the resident's symptoms met the McGeer's criteria for a true infection.

The IP stated the facility did not have a McGeer's criteria tool for the other infections. The IP verified the resident's symptoms did to meet the McGeer's criteria, and the resident's physician was not notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 51423 potential for actual harm Based on observation, interview, facility document review, and facility P&P review, the facility failed to Residents Affected - Few maintain the essential equipment in the safe operating conditions.

* The facility's ice machine was not cleaned and sanitized as per the manufacturer's instructions. This failure had the potential for the essential equipment not functioning in the way it was intended and in turn cause contamination of the food, leading to illnesses for the residents.

Findings:

Review of the facility's Matrix showed 157 of 166 residents consumed food prepared in the kitchen.

Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch.

Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the internal components are to be cleaned monthly per manufacturer's recommendations.

Review of the facility's ice machine manufacturer guidelines titled Cleaning and Sanitizing Procedure Instructions (undated) showed the following:

- Only use [Manitowac] approved ice machine cleaner and sanitizer for this application.

- Step 1: Ice must not be on the evaporator during the clean/sanitize cycle. Press the manual harvest button

in the service menu and allow the ice to harvest. Once all of the ice falls from the evaporator, turn the machine off by pushing the power button.

- Step 2: Remove all ice from the bin/dispenser.

- Step 3: Press the clean button, follow the prompts, and select Turn off when complete. The unit does not start dumping until you select Off or Ice mode. Water will flow through the dump valve and down the drain. When water trough has refilled (approximately 1 minute) and the display indicates: Add the proper amount of ice machine cleaner. (See chart #1 for proper amount). Chart #1 showed five ounces of cleaner was to be added to the water trough.

- Step 4: Wait until the clean cycle is complete (approximately 24 minutes).

- Step 5: Remove parts for cleaning.

- Step 6: Mix a solution of the cleaner and warm water. Depending on the degree of mineral buildup. A large quantity of solution may be required. Use the table to mix enough solution to thoroughly clean all parts. Chart showed: use one gallon of water with 16 oz of cleaner solution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 41 555249 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555249 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

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 0908 - Step 7: Use half of cleaner mixture to clean all components. Soak parts for five minutes, 20 minutes for heavily scaled parts. The cleaner solution will foam when it contacts lime scale and mineral deposits. Once Level of Harm - Minimal harm or the foaming stops, use a soft-bristle nylon brush, sponge or cloth to thoroughly clean the following ice potential for actual harm machine areas: side walls, base (area above the trough), evaporator plastic parts (top, bottom, and sides), bin or dispenser. Rinse all the components with clean water Residents Affected - Few - Step 8: While components are soaking, use half of the cleaner/water solution to clean all food zone surfaces of the ice machine and bin (or dispenser). Use nylon brush or cloth to thoroughly clean the following ice machine areas: side walls, base, evaporator plastic parts, bin, or dispenser. Rinse thoroughly with clean water.

- Step 9: Mix a solution of sanitizer and lukewarm water. Three gallon (12 liters) of water and two ounces of sanitizer.

- Step 10: Use half of the sanitizer/water solution to sanitize all removed components. Use a spray bottle to liberally apply the solution to all surfaces of the removed parts or soak the removed parts in the sanitizer/lukewarm solution. Do not rinse parts after sanitizing.

- Step 11: Use half of the sanitizer/water solution to sanitize all food zone surfaces of the ice machine and bin. Use a spray bottle to liberally apply the solution: side walls, base, evaporator plastic parts, bin or dispenser. Rinse all areas thoroughly with clean water.

- Step 12: Replace all removed components.

- Step 13: Wait 20 minutes.

- Step 14: Reapply power to the ice machine. Press the clean button and select make ice when complete.

- Step 15: When ice trough was refilled, and the display indicates: add the proper amount of ice machine sanitizer to the water trough by pouring between the water curtain and evaporator. (See chart #1 for proper amount.) Showed to use 3 oz of sanitizer.

On 2/11/25 at 0924 hours, an observation and concurrent interview was conducted with the Maintenance Director and MA for the ice machine located in the kitchen. The MA stated he cleaned the ice machine once

a month. The MA was asked to explain the process he used to clean the ice machine. The MA stated he mixed five ounces of the ice machine cleaner/descaler with a pitcher of water. The mixture was poured into

the machine and the clean cycle was started. The MA was asked how much water he mixed with the ice machine cleaner/descaler. The MA stated he filled the pitcher to the top with water. The MA verified he did not know how much water the pitcher held. The MA stated once the ice machine cleaner/descaler mixture ran through the machine, he removed the internal parts and soaked the parts in bleach in a large container.

The MA then stated he put five ounces of ice machine sanitizer in the sink with water. The MA was not able to state how much water he mixed with the sanitizer in the sink. The MA stated he soaked the ice machine parts in the sanitizer/water mixture. The ice machine instructions located on the inside panel of the ice machine were reviewed with the Maintenance Director and MA. The Maintenance Director stated the MA was confused with the ice machine chemicals and the instructions were in English, which was difficult for the MA to understand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 41 555249