Sea Cliff Healthcare Center
SEA CLIFF HEALTHCARE CENTER in HUNTINGTON BEACH, CA — inspection on February 14, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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].
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.
555249
Form Approved OMB
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