Sea Cliff Healthcare Center

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of eight sampled residents (Resident 4) was revised to reflect the resident's current care needs and interventions. * The facility failed to ensure Resident 4's plan of care for swallowing problem was reviewed and revised to address Resident 4's difficulty in swallowing the medication and coughing with sips of water. This failure posed the risk of not providing appropriate, consistent, and individualized care to

the resident.Findings: Review of the facility's P&P titled Change of Condition revised 5/2019 showed to document the resident change of condition and response in eInteract Change of Condition and in the nursing progress notes, and update resident care plan, as indicated. Closed medical record review for Resident 4 was initiated on [DATE REDACTED]. Resident 4 was admitted to the facility on [DATE REDACTED], and expired on [DATE REDACTED]. Review of Resident 4's H&P examination dated [DATE REDACTED], showed Resident 4 had capacity to understand and make decisions. Review of Resident 4's admission MDS assessment dated [DATE REDACTED], showed Resident 4's BIMS score was three, indicating severe cognitive impairment. Review of Resident 4's eInteract Change in Condition Evaluation dated [DATE REDACTED] at 1030 hours, showed the resident was observed to have coughed after the first sip of water when the whole medication tablet was administered. The medications were then crushed. Review of Resident 4's plan of care failed to show the care plan problem addressing the resident's swallowing problem was reviewed and revised to reflect the resident's change in

the condition on [DATE REDACTED], when the resident had difficulty swallowing the medication and coughing with the sips of water. On [DATE REDACTED] at 1430 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified the above findings and stated Resident 4's care plan should have been revised. Cross reference to F-F684.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 4's meal intakes on the resident's Documentation Survey Report v2 - Intervention/ Task - Amount Eaten. On [DATE REDACTED] at 1430 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified Resident 4's closed medical record failed to show documented evidence

the resident was monitored and provided with care and safety measures after the resident had a change in condition in the morning of [DATE REDACTED]. The DON stated the resident was scheduled to be seen by ST the following day. The DON stated she expected the licensed nurses and ST to reassess Resident 4's change of condition. b. Review of the facility's P&P titled Physician Orders revised 5/2007 showed the drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to assure that refills are on hand. Review of Resident 4's Order Summary Report dated [DATE REDACTED], showed a physician's order dated [DATE REDACTED], to administer warfarin sodium 3 mg one tablet by mouth in the evening. Review of Resident 4's MAR for [DATE REDACTED] showed the warfarin sodium 3 mg tablet by mouth in the evening was initialed by LVN 4 with the chart code 7, indicating other/ see nurses notes. Review of Resident 4's nursing progress notes dated [DATE REDACTED] at 1800 hours, showed the licensed nurse would follow up with pharmacy for warfarin medication. On [DATE REDACTED] at 1030 hours, a telephone interview was conducted with LVN 4. LVN 4 verified she was not able to administer the warfarin sodium 3 mg medication on [DATE REDACTED] at 1700 hours, as ordered because the medication was not available. LVN 4 stated the pharmacy was asking for the recent laboratory results, however, LVN 4 stated there was no recent laboratory results available for Resident 4. LVN 4 further stated she was going to follow up with the pharmacy and the physician, however she got busy with another resident's emergency. On [DATE REDACTED] at 1430 hours, an interview and a concurrent closed medical record review was conducted with the DON. The DON verified the warfarin sodium 3 mg medication was not administered to Resident 4 on [DATE REDACTED] at 1700 hours, as ordered by the physician. The DON stated the pharmacist was responsible to dose the warfarin sodium medication. The DON verified Resident 4's closed medical record failed to show a physician's order to obtain the prothrombin time (a blood test that measures the time it takes for blood plasma to clot) and the International Normalized Ratio (INR- a blood test to monitor the residents taking anticoagulant medications). The DON stated there should have been a physician's order for the next laboratory blood draw for the pharmacy to send the warfarin sodium tablets. On [DATE REDACTED] at 1520 hours, a follow-up interview was conducted with the DON. The DON was informed and acknowledged the findings as above.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of eight sampled residents (Resident 4) when: * LVN 4 crushed Resident 4's iron (supplement) tablet and administered it to the resident. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications. Findings: Review of the facility's P&P titled Crushing Medications (undated) showed the nursing staff will crush only medications that may be crushed. The Nursing Staff will use available references and resources to determine which medications should and should not be crushed. According to National Library of Medicine Daily Med:- Iron tablets are enteric coated (coating applied to oral medications to prevent the medications from dissolving in the highly acidic stomach environment) and should not be chewed or crushed. Iron tablets are enteric coated to help protect the stomach. Iron may cause gastrointestinal discomfort, nausea, constipation or diarrhea. Tamsulosin hydrochloride (used to treat enlarged prostate) capsules should not be crushed, chewed or opened. The capsules contain a special modified-release formulation, typically sustained-release beads, that controls how the medicine is absorbed by your body. Opening the capsule can disrupt this mechanism and potentially cause serious side effects. Retrieved from https://dailymed.nlm.nih.gov/dailymed/drugInfo.

Closed medical record review for Resident 4 was initiated on [DATE REDACTED]. Resident 4 was admitted to the facility

on [DATE REDACTED], and expired on [DATE REDACTED]. Review of Resident 4's H&P examination dated [DATE REDACTED], showed the resident had capacity to understand and make decisions. Review of Resident 4's admission MDS assessment dated [DATE REDACTED], showed Resident 4's BIMS score was three, indicating severe cognitive impairment. Review of Resident 4's eInteract Change in Condition Evaluation dated [DATE REDACTED] at 1030 hours, showed the resident was observed to have coughed after the first sip of water when the whole medication tablet was administered. The medications were then crushed. Review of Resident 4's Order Summary Report dated [DATE REDACTED], showed the following physician's orders:- dated [DATE REDACTED], to administer iron 25 mg one tablet by mouth one time a day; and- dated [DATE REDACTED], to administer tamsulosin hydrochloride 0.4 mg one capsule by mouth every 12 hours. Review of Resident 4's MAR for [DATE REDACTED] showed the iron 25 mg and tamsulosin hydrochloride 0.4 mg medications were administered to Resident 4 on [DATE REDACTED] at 0900 hours.

On [DATE REDACTED] at 1020 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 4 started coughing when she first administered the whole pill on the morning of [DATE REDACTED]. LVN 4 further stated

the resident started chocking with the water. LVN 4 stated she then crushed all the resident's medications to be able to administer them to the resident. On [DATE REDACTED] at 1520 hours, an interview was conducted with

the DON. The DON was informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet