Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sea Cliff Healthcare Center during CMS and state inspections, most recent first.
A facility failed to ensure psychotropic meds were properly monitored for several residents. One resident received both risperidone strengths at the same time instead of the intended dose, and multiple residents had nonpharmacological interventions documented together rather than separately for each antipsychotic, antidepressant, antianxiety, or mood-stabilizing med. One resident also had no documented evidence that nonpharmacological interventions were attempted before divalproex was given.
Improper storage and labeling of respiratory equipment were found for several residents. A resident ordered continuous O2 had the concentrator turned off, then turned on by a CNA, and the setting was found higher than ordered; the resident’s nebulizer mask was left out of its set-up bag. Other residents had unlabeled or undated nasal cannulas, a nebulizer mask left on a cabinet, and a Yankauer suction tip left on a nightstand with visible fluid in the tubing. Staff, including an RN, LVNs, and the DON, verified the findings.
A facility failed to follow ordered BP parameters for midodrine and clonidine for several residents, with staff administering doses when SBP was outside the physician’s hold instructions and, in one case, without documenting BP checks at the time of dosing. The facility also failed to monitor a resident on insulin therapy with follow-up Hgb A1c testing, and the DON and licensed staff acknowledged the findings.
Medication storage and bedside handling deficiencies were identified in several areas. Expired items were found in medication carts, Medication Room A had repeated temperature readings above the recommended range for sodium chloride injection, and external-use products were stored with internal-use items in the central supply cabinet. A tube of hydrophilic wound dressing ointment was left at a resident’s bedside without an order, and three packets of zinc oxide paste were found on another resident’s bedside cabinet despite the resident’s orders listing barrier cream but not that product.
Kitchen sanitation, dating, and produce washing failures: The facility failed to keep food-contact equipment and utensils in sanitary condition, with a discolored can opener, heavily marred and melted cutting boards, and scoopers with dried food particles observed by the DSS. The facility also had food items past their use by or best by dates in storage and preparation areas, and an LPN/Dietary Aide stated cantaloupes were washed under cold water without using a brush to scrub the tough rinds. The DON, RD, DSS, and Administrator acknowledged the findings.
Staff failed to follow infection control practices in several areas, including laundry handling, medication prep, device care, and resident room storage. A laundry worker folded clean linen against her uniform while the laundry area had gray dust on pipes near the dryers. An LVN did not disinfect an insulin pen cap before giving insulin, and an RN did not disinfect a vial stopper before preparing cefazolin. Staff also failed to perform hand hygiene after touching a resident’s nasal cannula and oxygen concentrator, did not use EBP and proper PPE for residents with midline IV catheters, and left unlabeled basins, a hairbrush, and water bottles in resident areas.
The facility failed to follow its own care planning policy by not implementing required monitoring for bedrail entrapment for two residents whose care plans called for safety checks every shift, with no documentation in the medical record that such monitoring occurred and an LVN confirming it was not done. The facility also did not develop a care plan for a resident with intergluteal/perianal MASD despite an active treatment order, as confirmed by an RN. In addition, another resident’s care plan inaccurately documented the location of a midline catheter as being in the right upper arm when it was actually in the left upper arm, a discrepancy verified by nursing staff and acknowledged by the DON.
Incomplete informed consent for psychotropic medications: The facility did not fully document or obtain proper consent before using psychotropic meds for three residents. One resident's risperidone consent did not match the exact dose given, another resident's consents for alprazolam, quetiapine, and mirtazapine were left incomplete, and a third resident who could not make decisions did not have the Public Patient Representative involved when consent was obtained for fluoxetine and olanzapine. The DON and SSD acknowledged the documentation and consent issues.
Two residents were found with meds stored at the bedside without proper self-administration assessment. One resident with severe cognitive impairment had OTC bismuth subsalicylate in a nightstand drawer with no MD order or self-administration assessment, and another resident had calcium carbonate tablets left on the bedside table by an LVN despite being cognitively intact and having a scheduled order.
Failure to Maintain Resident Dignity and Privacy: Two residents were observed with privacy and dignity concerns. One resident with severe cognitive impairment had exposed thighs during care and was fed while the CNA stood at the bedside, with the CNA acknowledging privacy was not provided and that she should have been sitting to maintain eye contact and dignity. Another cognitively intact resident was seen from the hallway wearing a diaper with thighs exposed, the privacy curtain open, and no sheet or blanket on the bed while calling for help and asking to be covered.
A resident’s care plan was not revised to reflect significant weight loss or a physician-ordered heel offloading intervention. The resident had a BIMS score of 14, lost 10.74% of body weight in one month, and the record did not show timely care plan updates or documentation of a January weight/refusal to weigh. The resident also had a history of heel pressure injury, but the care plan was not updated to include elevating the heels on a pillow when in bed, as ordered by the MD.
Failure to follow wound care and pressure relief orders for two residents. An RN cleansed a sacrococcyx pressure injury with the wrong cleanser instead of NS as ordered, and another resident’s heels were not offloaded on a pillow as ordered; the care plan also did not reflect the heel-offloading intervention.
Failure to Document Monthly Weights and Update Nutrition Care Plan: A cognitively intact resident had a significant weight loss documented in the record, but the care plan was not revised to reflect the loss. The monthly weight record also lacked documentation of a later weight or a refusal to be weighed, and the LVN, RD, RNA, and DON all verified the missing documentation.
IV access care was not properly maintained and monitored for three residents with PICC or midline catheters. One resident's midline dressing was changed outside the ordered interval, another resident lacked required arm circumference and catheter-length documentation after the initial assessment, and a third resident had IV monitoring orders written for a peripheral IV instead of the actual midline catheter. RN and DON interviews confirmed the record discrepancies and missing documentation.
A resident with ESRD on dialysis had repeated missing documentation for ordered fluid restriction and bladder continence monitoring. Medical record review showed multiple shifts across several months where total fluid intake and total output were not charted. A CNA confirmed the missing entries, and an LVN acknowledged the facility failed to consistently monitor the resident’s intake and output, noting it was important for a dialysis resident.
Medication administration competency failures were identified when an LPN gave a resident medications left at the bedside by another nurse, including levothyroxine, Protonix, and morphine, even though the resident’s MAR showed those meds had already been administered earlier that morning. In a separate event, another LPN administered Lantus insulin to a resident using a pen that was beyond the manufacturer’s 28-day discard guidance. The DON acknowledged both findings.
Medication administration errors occurred when an LPN left three meds at a resident’s bedside and another LPN later administered those meds, even though the resident was approved for self-administration and the meds had been dispensed by the night nurse. In a separate event, an LPN administered Lantus insulin from a pen that was past the manufacturer’s 28-day discard timeframe. The DON was informed of the findings.
A pharmacist consultant failed to identify and report an irregularity during monthly med regimen review for a resident with DM on long-term insulin. The resident’s chart showed no Hgb A1C follow-up for over a year, and the monthly MRRs did not include a recommendation for A1C monitoring, despite the pharmacist stating A1C should typically be checked every 3 to 6 months.
Two residents experienced medication administration errors. One resident received Risperdal 1.5 mg BID even though the physician order and provider intent were for a lower dose, and staff documentation showed conflicting order entries. Another resident received clonidine HCl multiple times despite a hold parameter requiring the medication only when systolic BP was above 160 mmHg; MAR entries showed doses given when BP readings were below that threshold. Interviews with the NP, PA, LVN, and DON confirmed the discrepancies.
PASRR screening was not accurately completed for one resident. The PASRR Level I form marked no for serious mental illness, but the resident’s record showed a diagnosis of unspecified psychosis on admission. The MDS Coordinator stated the PASRR should have been updated to reflect the psychosis diagnosis, and the DON acknowledged the findings.
A resident who had difficulty swallowing medication was not properly assessed or monitored after the incident, and the care plan was not updated to reflect the change in condition. Additionally, warfarin sodium was not administered as ordered due to missing laboratory results and lack of follow-up, and meal intake documentation was incomplete.
A resident with severe cognitive impairment was given crushed iron and tamsulosin medications by an LVN after experiencing difficulty swallowing whole pills. Facility policy and national guidelines indicate these medications should not be crushed, but the LVN proceeded to do so without consulting appropriate references. The DON was made aware of the incident.
A resident with severe cognitive impairment developed new swallowing difficulties, including coughing when taking medication and sips of water. Although the medication was subsequently crushed, the care plan was not reviewed or updated to reflect these changes, contrary to facility policy. The DON confirmed the care plan should have been revised.
A resident was found self-administering multiple medications at bedside without a required assessment, physician's order, or care plan documentation. Staff confirmed that the resident was not authorized to have medications unattended and that facility policy requiring IDT assessment and documentation was not followed.
A facility failed to maintain an effective infection control program, with issues in laundry room cleanliness, inaccurate infection reporting, and improper use of PPE. Staff did not consistently sanitize equipment or perform hand hygiene, and a feeding tube was not disinfected after falling on the floor. These deficiencies were confirmed by staff and the DON.
The facility failed to follow its protocols for enteral feeding and medication administration for three residents. Nurses administered medications via GT by pushing instead of using gravity, and did not check tube placement and residuals as required. These actions were confirmed by the DON and had the potential to cause complications.
A resident requiring continuous oxygen therapy did not receive it as ordered, as the nasal cannula was found hanging on a feeding tube stand instead of being in place. A nurse confirmed the oversight, and the DON acknowledged the findings. The resident was dependent on staff for daily activities and had a physician's order for continuous oxygen to maintain saturation levels above 90%.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses for 157 residents. Observations included improperly thawed chicken without a pull date, a dirty frying pan, improper storage of dry bulk food, wet meal preparation equipment, lack of backflow prevention in floor drains, and unsanitary storage of cleaning equipment.
A facility failed to ensure accurate completion and review of nutritional assessments for a resident, leading to an oversight of significant weight gain. The RD did not participate in or verify the MDS Nutritional Status assessment, which was incorrectly coded by the DSS, resulting in inaccurate documentation of the resident's nutritional status.
The facility failed to ensure two residents under hospice care received scheduled hospice aide visits as required. Despite physician orders for biweekly visits, documentation showed missed visits for both residents. Interviews confirmed the absence of required signatures from hospice staff, indicating visits were not completed. The DON acknowledged the need for hospice staff to sign visit logs, but facility nurses were not documenting visits unless orders were received from the hospice doctor.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident was treated for pneumonia without meeting McGeer's criteria, and the physician was not notified for reevaluation. Another resident was treated for an infection related to elevated WBCs, but symptoms did not meet the criteria, and the physician was not informed.
The facility failed to properly clean and sanitize its ice machine according to the manufacturer's instructions, posing a risk of contamination. The Maintenance Assistant was confused about the cleaning process, using incorrect amounts of cleaner and sanitizer, and the instructions were difficult for him to understand. This failure could potentially lead to food contamination and health issues for residents.
The facility failed to meet pharmaceutical service needs by leaving medications unattended, not replacing an opened CII E-kit within 72 hours, improperly disposing of a refused Percocet tablet, and discarding medication wastes inappropriately. These actions were against the facility's policies, potentially leading to medication misuse and unavailability of emergency medications.
A facility was found to have a 20% medication error rate during an observation, involving two residents. Errors included not measuring heart rate before administering blood pressure medications, incorrect aspirin dosage, and improper form of multivitamins. Additionally, the facility failed to follow enteral tube medication administration procedures, not flushing the GT with the required water amount. Interviews confirmed these practices did not align with physician orders and facility policies.
The facility failed to properly label and store medications, including megestrol acetate without a shake well label, Katerzia stored at room temperature instead of refrigerated, and an opened Levemir insulin vial without an open date. Additionally, expired Tempa-DOT thermometers were found in Medication Room A. These deficiencies were acknowledged by the staff and the DON.
The facility failed to maintain accurate medical records for several residents, including errors in POLST forms, incomplete documentation of treatments and medications, and inaccuracies in meal consumption records. Staff interviews confirmed these lapses, which were acknowledged by the DON.
The facility failed to accurately code the MDS for two residents regarding significant weight changes. One resident experienced a weight loss of over 5% in a month, while another had a 14% weight gain, yet these changes were not reflected in their MDS assessments. The errors were confirmed by the MDS Coordinator, with the dietary department responsible for the assessments.
A resident experienced an unwitnessed fall, and the facility failed to conduct timely neurological assessments as per their policy. The assessments were supposed to occur every hour after the initial evaluations, but one scheduled assessment was missed, leading to a delay in care. The DON confirmed the oversight during a review.
Two residents in an LTC facility were involved in a physical altercation, where one resident scratched the other's face, prompting a defensive bite. Both residents sustained injuries, and the facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse. Medical records indicated cognitive impairments in both residents, and staff observations confirmed the altercation.
A facility failed to create a care plan for a resident who repeatedly refused medications, despite having a policy that mandates comprehensive, person-centered care plans. The resident's medical records documented instances of medication refusal, but no care plan was developed to address this issue, as confirmed by the DON.
The facility did not comply with State law as two CNAs were observed without their name badges, wearing visitor stickers instead. Both CNAs acknowledged the importance of wearing badges for resident identification. The DON confirmed the facility had run out of temporary badges and stressed the importance of staff identification for residents and visitors.
The facility failed to provide necessary care for two residents, leading to deficiencies in medication administration and timely medical response. A resident did not receive Marinol as ordered, and the physician was not notified of the lapse. Another resident experienced stroke symptoms, but the physician was not notified until over six hours later. Interviews with staff confirmed the lack of timely communication and assessment, potentially impacting the residents' health.
A facility failed to order and administer a resident's aspirin and atorvastatin according to hospital discharge orders. The resident, admitted with CVA, pneumonia, and potential stroke, did not receive the prescribed medications. Interviews with staff confirmed the oversight, and the DON acknowledged the failure in the medication reconciliation process.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure four sampled residents were free from unnecessary psychotropic medication use and failed to properly monitor nonpharmacological interventions associated with those medications. The deficiency involved residents receiving antipsychotic, antidepressant, antianxiety, and mood-stabilizing medications, with documentation showing that interventions were either grouped together for multiple medications or not documented as attempted before medication administration. The facility’s policy stated psychotropic medications were to be used only after nonpharmacological interventions had been attempted and failed, and that treatment plans were to be reviewed to re-evaluate psychotropic use. For one resident, the record showed orders for quetiapine and risperidone for different behaviors, but the nonpharmacological interventions documented on the MAR were grouped together and did not specify which interventions were attempted for each medication. A nurse confirmed that separate documentation should have been present because the medications addressed different behaviors. For another resident, the record showed an increase intended from risperidone 0.5 mg twice daily to 1 mg twice daily, but the resident was administered both strengths together, resulting in 1.5 mg twice daily. The pharmacist later questioned whether both orders should remain active, and the physician documented that the intent was to continue 1 mg twice daily, not 1.5 mg twice daily. The same resident also had orders for citalopram and mirtazapine, along with an order for nonpharmacological interventions every shift for antidepressant and antipsychotic use, but the interventions were documented together rather than separately for each medication. Another resident had divalproex sodium ordered for mood swings related to bipolar disorder, with care plan interventions including redirection and reassurance, but the record did not show documented evidence that nonpharmacological interventions were attempted before administration. A fourth resident had orders for alprazolam, quetiapine, and mirtazapine, with nonpharmacological interventions listed for all three medications every shift, but the interventions were documented together and not separated by medication or behavior. The DON and other staff reviewed and verified these findings during interviews.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents who had physician orders for oxygen therapy or suction equipment. Resident 24 was ordered continuous oxygen at 2 LPM via nasal cannula and ipratropium-albuterol via mask every six hours, but during observation the oxygen concentrator was turned off while the nasal cannula remained connected, and when the concentrator was turned on it was found to be delivering 2.5 LPM. The nebulizer mask for this resident was also observed on the nightstand and not stored in a set-up bag when not in use. CNA 1 stated she turned the oxygen concentrator on for the resident after the resident asked her to do so, and LVN 1 verified the oxygen setting and the improper storage of the nebulizer mask. Resident 161 was observed receiving oxygen at 2 LPM via nasal cannula, and an unlabeled nasal cannula tubing connected to a portable oxygen tank was hanging on the wheelchair. RN 1 verified the tubing was unlabeled and stated it was used when the resident went to therapy, adding that the therapist might have taken the set-up bag and not replaced it. Resident 113 had oral suction ordered at bedside as needed, but the Yankauer suction was observed on the nightstand and not stored in a set-up bag, with brownish fluid visible in the suction tubing. RN 1 verified the suction tubing condition and the improper storage. Additional respiratory equipment issues were identified for other residents. Resident 95 had a nebulizer mask observed on top of the cabinet that was undated and not stored in a set-up bag, and LVN 3 verified this condition. Resident 99 was observed on oxygen via nasal cannula, but the cannula was not labeled with a date, and LVN 3 stated it should have been dated so staff would know when to change it. Resident 132 was also on oxygen via nasal cannula, and the bag hanging at the oxygen concentrator was dated 12/28/25 while the nasal cannula itself had no date; LVN 8 verified this and stated the cannula should have been labeled with the date. The DON was informed and acknowledged the findings for the residents reviewed.
Medication orders not followed and diabetes monitoring not completed
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary medications by not following physician orders for blood pressure parameters and by not monitoring a resident’s diabetic control as expected. The report identified four sampled residents with medication-related deficiencies involving midodrine, clonidine, and insulin therapy. Facility policy required staff to observe the rights of medication administration and to record required information on the appropriate documentation record. Resident 1 had diagnoses and orders related to hypotension and was prescribed midodrine 5 mg twice daily, with instructions to hold the medication if systolic blood pressure (SBP) was greater than 120 mmHg. The medical record showed multiple administrations of midodrine without corresponding blood pressure monitoring at the time of administration on several dates, and the resident also received the medication when the SBP was above the ordered parameter on two occasions. Resident 2 was prescribed midodrine 5 mg every six hours for hypotension, with instructions to hold it if SBP was greater than 130 mmHg, yet the MAR showed the medication was administered when the SBP was 132 mmHg, 132 mmHg, 135 mmHg, and 132 mmHg on separate occasions. Resident 3 had no capacity to understand and make decisions and was prescribed clonidine 0.1 mg every eight hours for elevated blood pressure, with instructions to give it only if SBP was greater than 160 mmHg. The MAR showed clonidine was administered repeatedly when SBP readings were below that threshold, including multiple administrations with SBP values in the 100s and 120s. Resident 6 had Type 2 diabetes mellitus and was prescribed insulin glargine daily and insulin lispro on a sliding scale, but the record did not show follow-up Hemoglobin A1c monitoring after the last documented result, and the Medication Regimen Review did not include a pharmacist recommendation to monitor Hemoglobin A1c. The DON and licensed staff were interviewed and acknowledged the findings.
Medication Storage and Bedside Medication Handling Deficiencies
Penalty
Summary
The facility failed to provide proper medication storage and labeling for multiple medication areas and resident bedside items. In Medication Cart A, an open box of diphenhydramine with an expiration date of 2/2025 was found during inspection. In Medication Cart B, a sealed pair of sterile gloves and an opened box of multi-function sterile red caps were found with expiration dates, and both items were removed after being identified. The facility’s policy stated that drugs must be labeled and stored according to manufacturers’ specifications and that expired drugs must not be kept in stock. In Medication Room A, temperature logs showed repeated readings above the manufacturer-recommended storage temperature of 77 degrees Fahrenheit for sodium chloride injection. The logs for 12/2025 and 1/2026 documented multiple temperatures of 78 degrees Fahrenheit, one reading of 80 degrees Fahrenheit, and one reading of 84 degrees Fahrenheit. RN 1 reviewed the logs and the manufacturer’s instructions and verified the findings. The DON was informed of the temperature concerns. In the Central Supply Room, external-use medications were stored side by side with internal-use items, including saline enema, fish oil, ear wax removal drops, and saline nasal spray. In addition, a tube of hydrophilic wound dressing ointment was found at the bedside of Resident 150, who stated she did not remember using it and had no physician’s order for it. Three packets of Protect zinc oxide paste were also found on top of Resident 95’s bedside cabinet; Resident 95 stated staff applied it to her buttocks, while the record showed orders for barrier cream but not for Protect zinc oxide paste. RN staff and the DON verified these observations.
Kitchen sanitation, dating, and produce washing failures
Penalty
Summary
The facility failed to ensure food preparation utensils and equipment were maintained in sanitary and cleanable working condition. During a kitchen observation with the DSS, one can opener had brown discoloration, two green cutting boards, one brown cutting board, one red cutting board, and one blue cutting board were heavily marred and melted, and two scoopers had dried white and brown food particles on them. The DSS verified these findings and stated the items should be replaced to ensure particles would not go into the food. The facility’s sanitation policy stated equipment and utensils were to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas. The facility also failed to ensure food items were discarded by the required date and that fruits with tough rinds were washed appropriately. In the walk-in refrigerator, a bag of used tofu dated 12/20/25 was observed, and in the preparation refrigerator, a pitcher of nectar water with a use by date of 1/5/26 was found; the DSS verified both items should be discarded. In dry storage, a bag of hamburger buns with a best by date of 12/23 was observed. In addition, six cups of cantaloupe were observed in the preparation refrigerator, and a Dietary Aide stated she washed cantaloupes under cold water but did not use a brush to scrub the tough rinds. The Administrator, DON, RD, and DSS acknowledged the findings.
Infection control practices not maintained during linen handling, medication administration, device care, and resident room storage
Penalty
Summary
The facility failed to maintain infection control practices in multiple areas of care and the environment. During observation in the laundry room, Laundry Staff 1 was seen folding clean linen toward her body and touching her uniform twice. The Maintenance Supervisor observed the same action and acknowledged that the linen had been folded against the staff member’s clothing. The laundry area was also observed with grayish dust particles on pipes near the dryers, and when the pipes were touched, dust flew into the air. The Maintenance Supervisor acknowledged the pipes were not clean and could possibly contaminate clean linen and residents’ clothing. In medication administration, LVN 4 prepared and administered insulin to a resident without cleaning the rubber cap of the insulin pen injector first. RN 3 also prepared and administered cefazolin to another resident without cleaning the rubber stopper of the vial before medication preparation. Both nurses verified the observations. The facility’s policy and CDC guidance reviewed in the report stated that vial diaphragms should be disinfected before administration. The facility also failed to follow infection prevention practices for residents with devices and in resident rooms. A resident with a nasal cannula and oxygen concentrator was observed being touched by LVN 8, who then left the room and went directly to the med cart and laptop without performing hand hygiene. Two residents with midline IV catheters were not placed on Enhanced Barrier Precautions as documented in the report, and one RN disconnected an IV without wearing a gown. In addition, unlabeled personal items and containers were observed in shared bathrooms and resident areas, including a gray basin and hairbrush in one room and five unlabeled basins in another room, as well as five small bottles of water on the floor near a resident’s cabinet. The DON, IP, and staff interviewed in the report acknowledged these findings.
Failure to Develop and Implement Accurate, Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans consistent with its own policy and residents’ assessed needs. The facility policy required the IDT to develop comprehensive care plans with measurable objectives and timeframes, and to implement baseline care plans within 48 hours of admission. For one resident with moderately impaired cognition who used bilateral half side rails, the care plan identified a risk for entrapment and required monitoring of the resident’s safety for entrapment every shift. However, review of the medical record showed no documented evidence that this monitoring occurred, and an LVN confirmed that the intervention to monitor for entrapment every shift had not been implemented or documented in the MAR or progress notes. A second resident, cognitively intact and using a bariatric bed with built-in bilateral half side rails, also had a care plan identifying risk for entrapment/bodily injury and requiring monitoring of safety for entrapment every shift. Medical record review similarly failed to show documentation that this monitoring was performed. During interview and concurrent record review, the same LVN verified that the resident’s care plan intervention to monitor for entrapment every shift was not implemented as ordered. In both cases, the care plan interventions related to bedrail entrapment risk were not carried out or documented as required. The facility also failed to develop appropriate care plans for two additional residents’ identified conditions. One resident had a physician’s order to cleanse intergluteal cleft extending to perianal MASD with soap and water, pat dry, and apply barrier cream each day shift, but the medical record contained no care plan addressing this MASD; an RN confirmed the absence of such a care plan. Another resident had a documented midline IV access in the left upper arm, but the care plan referenced IV medication and a midline catheter in the right upper arm instead. An RN verified that the midline was actually in the left upper arm and that the care plan inaccurately identified the right upper arm. The DON was informed of and acknowledged these findings for the involved residents.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to fully inform residents or their responsible parties and obtain completed informed consent before using psychotropic medications for three sampled residents. The facility's policy stated that physician orders for psychotherapeutic drugs should not be initiated until informed consent is obtained, and that residents unable to provide consent without a health care decision-maker require a diligent search for a representative and, if none is available within 72 hours, contact with the Office of the Long Term Care Patient Representative. For Resident 2, the record showed orders for risperidone, but the consent form dated 10/30/25 documented consent for a daily dosage of 1 mg twice daily only. The MAR showed the resident received both 0.5 mg and 1 mg doses during the review period, and the consent form did not include the exact daily dosage for the medication as administered. The DON acknowledged the finding during interview. For Resident 14, the resident was documented as unable to make her own decisions. Orders were present for fluoxetine and olanzapine, and consent forms dated 12/18/25 showed the facility's IDT obtained consent. During interview, the SSD stated the Public Patient Representative was not involved or informed regarding the psychotropic medication consents and that the IDT should not have signed the forms without a representative present. For Resident 4, orders were present for alprazolam, quetiapine, and mirtazapine, but the consent forms dated 12/18/25 did not have the boxes checked to show whether the representative consented or declined. RN 2 stated two licensed nurses obtained the consents by telephone, but the documentation did not show whether the representative consented or declined, and the DON verified the findings.
Unassessed Bedside Medication Storage
Penalty
Summary
The facility failed to ensure two sampled residents were assessed to self-administer medications. During the initial tour, Resident 23, who had severe cognitive impairment per the MDS, was found with a Stomach Relief bismuth subsalicylate product stored in the left nightstand drawer. The medication was present without a physician’s order, and the record did not show any self-administration assessment for the resident. LVN 3 verified the medication was in the drawer and stated the family member should have informed the nurse when bringing it in; the LVN also stated the medication would need an order even if it was over the counter. Resident 162 was observed with two calcium carbonate tablets in a medication cup on the bedside table. The resident’s record showed an order for calcium carbonate chewable 500 mg, two tablets by mouth two times a day, and the MDS quarterly assessment showed a BIMS score of 13, indicating cognitive intactness. Resident 162 stated the nurse left the medication at the bedside and that she usually takes it after lunch. LVN 4 confirmed the tablets were calcium carbonate, stated he had given the medication at about 0945 hours, and said he should not have left it at the bedside for safety reasons. The DON was informed and acknowledged the findings.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure two sampled residents were treated with dignity. Resident 2 was admitted on 7/25/24 and had an H&P dated 7/3/25 showing the resident was able to make decisions, while the MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment. During an observation in the resident’s room, the door was open and CNA 6 pulled up the top sheet to check heel protectors, exposing the resident’s thighs. CNA 6 later acknowledged that privacy was not provided and that the room was open and visible to other residents, visitors, and staff outside the room. Resident 2 was also observed eating in bed while CNA 6 stood and fed the resident. CNA 6 acknowledged standing while feeding the resident and stated there was no chair available, adding that she should have been sitting to maintain eye contact and dignity. Resident 30 was admitted on 5/31/25 and had a BIMS score of 14, indicating cognitive intactness. During an observation from the hallway, Resident 30 was seen wearing a diaper with the thighs exposed, the privacy curtain open, and no top sheet or blanket on the bed; the resident was calling for help and asking to be covered. CNA 5 acknowledged the resident was exposed and did not have any sheets or blanket to cover the resident.
Care Plan Not Updated for Weight Loss and Heel Offloading
Penalty
Summary
The facility failed to ensure Resident 30’s care plan was revised to address the resident’s weight loss and pressure injury prevention needs. Resident 30 was admitted on 5/31/25 and had a BIMS score of 14, indicating cognitive intactness. The facility’s Nutrition Care Management policy stated that care and services should include monitoring and evaluating the resident’s response to interventions, with the care plan updated and revised as appropriate. Resident 30’s monthly weights showed 130.4 lbs. on 11/9/25 and 116.4 lbs. on 12/4/25, reflecting a 10.74% weight loss in one month. The care plan for nutrition, dated 11/19/25, included monthly weight monitoring, but the record did not show that the care plan was revised to address the actual weight loss. The monthly weight report also did not show documentation of the resident’s weight for January 2026 or whether the resident refused to be weighed. The facility also failed to revise Resident 30’s care plan to include a physician-ordered intervention for heel pressure relief. The physician ordered heels to be elevated on a pillow when the resident was in bed to offload pressure on 11/9/25. Resident 30’s care plans included a risk for skin breakdown care plan dated 5/31/25 and a resolved pressure injury to the right heel care plan dated 11/9/25, but neither was revised to include the heel-elevation intervention. The facility’s Skin Management System policy stated that a plan of care would be initiated for areas of actual skin breakdown and reviewed and revised as needed. Interviews with LVN 6 and the RD confirmed the care plan was not updated to reflect the resident’s weight loss, refusal to be weighed, or the heel-offloading order, and the DON acknowledged the findings.
Failure to Follow Wound Care and Heel Offloading Orders
Penalty
Summary
The facility failed to ensure necessary care and services were provided to prevent a new pressure injury and to promote healing of an existing pressure ulcer for two residents. For one resident, the medical record showed a physician’s order to cleanse a sacrococcyx pressure injury extending to the right and left buttocks with normal saline, apply Santyl ointment, and cover with a dry dressing every day shift. During wound care observation, RN 4 cleansed the wound with Skintegrity wound cleanser instead of normal saline, and later stated she had read the order incorrectly and should have used normal saline. For another resident, the physician ordered heels to be elevated on a pillow when in bed to offload pressure. The resident’s care plans did not include this intervention, and during observations the resident’s heels were not offloaded: one heel was touching the mattress and the other heel was resting on the resident’s lower leg. RN 4 acknowledged the heels were not offloaded and later observed that both heels were touching the pillow rather than being offloaded.
Failure to Document Monthly Weights and Update Nutrition Care Plan
Penalty
Summary
Resident 30 was admitted to the facility on 5/31/25 and had a BIMS score of 14, indicating the resident was cognitively intact. The facility’s Nutrition Care Management policy stated that monthly weights were to be completed unless discontinued by physician order, and resident refusals were to be documented and incorporated into the plan of care. Resident 30’s care plan for a nutrition problem or potential nutritional problem, dated 11/19/25, included monthly weight monitoring. The resident’s weight record showed 130.4 lbs. on 11/9/25 and 116.4 lbs. on 12/4/25, reflecting a 10.74% weight loss in one month. The medical record did not show that the care plan was revised to address the weight loss or that the resident refused to be weighed. The Monthly Weight Report also did not show documentation of a January 2026 weight or a refusal. During interviews, the LVN, RD, RNA, and DON each verified that the record lacked documentation of the January weight and refusal status, and the RD confirmed the care plan was not updated timely to reflect the weight loss and refusal to be weighed.
IV Accesses Not Properly Maintained and Monitored
Penalty
Summary
The facility failed to properly maintain and assess IV accesses for three residents with central venous access devices. The facility's policy for dressing and injection cap changes for central venous access devices stated that routine dressing changes for central, PICC, and midline catheters were to be done every seven days and as needed, and that arm circumference was to be documented before and after the procedure and compared to the admission measurement. The report identified deficiencies involving Resident 9, Resident 161, and Resident 196 during observation, interview, and medical record review. Resident 161 had a double-lumen midline catheter in the left upper arm with a dressing dated 12/29/25. The medical record showed an arm circumference of 11.5 inches documented on 12/30/25, but there was no documentation of arm circumference after the initial assessment. RN 1 verified that the dressing was changed on 1/6/26, which was eight days after the prior dressing date and not within the seven-day interval ordered by the physician. RN 1 also verified that the cap-change order in the record was written for a PICC line rather than a midline catheter. Resident 9 had physician orders to measure arm circumference every seven days during dressing changes, measure external catheter length from end to hub to insertion site, and measure arm circumference on admission. The record showed arm circumference was measured at 30 cm on 11/18/25, but there was no documentation of arm circumference or external catheter length after the initial assessment. Resident 196 was receiving IV ertapenem through a midline catheter in the left upper arm, but the physician orders for IV monitoring were written for a peripheral IV and did not identify monitoring for the resident's midline catheter. RN 2 and the DON both verified that the orders were inaccurate and did not match the resident's actual IV access.
Failure to Consistently Monitor Dialysis Resident’s Intake and Output
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for Resident 95, who had ESRD and was receiving dialysis. Review of the resident’s H&P dated 9/24/25 showed the resident had ESRD and was on dialysis, and the MDS assessment showed the resident was cognitively intact. The facility’s P&P stated the resident’s clinical record should be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition. Medical record review showed repeated missing documentation for Resident 95’s ordered 1500 ml fluid restriction and bladder continence monitoring. In November 2025, total fluid intake was not monitored on multiple shifts, and total output was not monitored on multiple shifts. In December 2025, total fluid intake and total output were again not monitored on multiple shifts. In January 2026, total fluid intake was not monitored on one shift. During interviews, a CNA verified the missing intake and output entries and stated CNAs should have charted everything they did for residents. An LVN acknowledged the facility failed to consistently monitor the resident’s intake and output and stated it was important to know the intake and output for a dialysis resident. The DON was informed and acknowledged the findings.
Medication Administration Competency Failures
Penalty
Summary
The facility failed to ensure that LVN 8 followed safe medication administration practices for Resident 102. During an observation, three tablets were found in a medication cup on the resident’s nightstand, and Resident 102 stated the medications were levothyroxine sodium, Protonix, and morphine sulfate and that the nurse may not have been able to wake her in the morning. LVN 8 verified the medications were levothyroxine sodium, Protonix, and morphine sulfate, stated they had been dispensed by the night shift licensed nurse, and then administered the medications left at the bedside to the resident. LVN 8 later stated she should not have given medications dispensed by another nurse to the resident for safety. Resident 102’s record showed orders for Protonix 40 mg in the morning, levothyroxine sodium 100 mcg every 24 hours, and morphine sulfate 15 mg three times a day, and the MAR showed these medications had already been administered earlier that morning. The facility also failed to ensure LVN 4 used appropriate medication handling practices for Resident 6. During a medication administration observation, LVN 4 prepared and administered 5 units of Lantus SoloStar insulin glargine to Resident 6. The insulin pen cap was labeled with a date opened, and the manufacturer’s guideline reviewed by surveyors stated an opened Lantus SoloStar pen should be discarded after 28 days, even if insulin remains in the pen. LVN 4 later verified the finding. Facility records showed LVN 4 and LVN 8 had completed clinical competency reviews for medication administration, and the DON was informed and acknowledged the findings.
Medication Administration Errors and Improper Bedside Medication Handling
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration. During observation and interview, Resident 102 was found lying in bed with three tablets in a medication cup on the nightstand beside the bed. The resident identified the medications as levothyroxine sodium, Protonix, and morphine sulfate and stated the nurse may not have been able to wake her in the morning. LVN 8 later verified the medications were left by the night shift licensed nurse and stated medications should not be left at the bedside for safety reasons. LVN 8 also stated she administered the medications that had been left by another nurse. Resident 102’s record showed she was approved for self-administration of medications by mouth and may keep medications at bedside, and her orders included Protonix 40 mg daily, levothyroxine sodium 100 mcg every 24 hours, and morphine sulfate 15 mg three times daily. The facility also failed to ensure proper insulin administration for Resident 6. During medication administration observation, LVN 4 prepared and administered 5 units of Lantus SoloStar insulin glargine pen injector to Resident 6. The insulin pen cap was labeled with a date opened that was beyond the manufacturer’s guideline requiring an opened Lantus SoloStar pen to be discarded after 28 days, even if insulin remained in the pen. LVN 4 verified the finding during interview, and the DON was informed of the findings.
Pharmacist Failed to Identify Missing A1C Monitoring
Penalty
Summary
The facility failed to ensure the licensed pharmacist completed monthly medication regimen reviews in accordance with its policy and identified all irregularities for one sampled resident. The facility policy stated the pharmacist consultant reviews each resident’s medication regimen at least monthly and reviews ordered drugs, resident-related information, physician progress notes, nurses’ notes, and laboratory results, with findings and recommendations reported to the Administrator, DON, responsible physician, and Medical Director where appropriate. Resident 6 had diabetes and was receiving long-term insulin therapy, including insulin glargine 5 units daily and insulin lispro on a sliding scale. The resident’s last documented Hemoglobin A1C result was 5.7% from 1/2/25, and the medical record did not show a follow-up Hemoglobin A1C test for over a year. Review of the monthly Medication Regimen Review reports for 2025 did not show a recommendation for a Hemoglobin A1C test, and the medical record did not show follow-up for that lab. During interview, the Pharmacist Consultant stated Hemoglobin A1C should be checked every three to six months and should not typically go beyond six months without monitoring.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication errors. Review of the facility’s medication administration policy showed staff were to observe the five rights of medication administration, and the physician order policy required verbal orders to be recorded immediately and to include the drug name, strength, dosage, frequency, route, and reason for use. The deficiency involved Resident 2 and Resident 3, both reviewed during the survey for unnecessary medications and medication administration accuracy. For Resident 2, the record showed physician orders for Risperdal 0.5 mg twice daily and a later order for Risperdal 1 mg twice daily for psychosis and angry outbursts. However, the MAR showed the resident was administered both the 0.5 mg and 1 mg tablets at each scheduled dose time, totaling 1.5 mg per administration, across multiple dates in October 2025 through January 2026. The record also showed a progress note indicating a plan to increase Risperdal from 0.5 mg BID to 1 mg BID, and a telephone order documenting Risperdal 1 mg BID. During interview, the NP stated he did not order the medication, and the PA stated he intended the dose to be 1 mg BID, not 1.5 mg BID. For Resident 3, the record showed an order for clonidine HCl 0.1 mg every eight hours for elevated blood pressure, with instructions to give it only if systolic BP was greater than 160 mmHg. The MAR showed clonidine was administered on numerous occasions when the resident’s systolic BP readings were below 160 mmHg, including many readings in the 100s and 120s. Resident 3’s H&P showed the resident had no capacity to understand and make decisions. During interview, the LVN verified the findings, and the DON stated licensed staff were expected to read and follow physician orders before administering medication.
PASRR Screening Not Updated for Resident With Psychosis
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not accurately completed for one of five sampled residents, Resident 12. The facility’s policy required each resident to be properly screened using the State-specified PASRR and to have a PASRR completed upon admission, with referral to appropriate state agencies based on the assessment. Resident 12 was admitted to the facility, and the PASRR Level I Screening dated 11/24/25 showed that under Section III - Serious Mental Illness, "No" was marked for whether the resident had a diagnosis of serious mental illness such as psychosis and mood disturbance. Medical record review showed Resident 12’s H&P dated 11/25/25 stated the resident had the capacity to understand and make decisions. The face sheet diagnosis information dated 1/9/26 showed a diagnosis of unspecified psychosis with an onset date of 11/24/25. During interview and concurrent record review, the MDS Coordinator stated the acute care hospital completed the PASRR, but if there were discrepancies, the facility would update and complete the PASRR upon admission. The MDS Coordinator verified Resident 12 had a diagnosis of psychosis upon admission and stated Section III of the PASRR Level I Screening should have been marked "Yes" and that the facility should have done a reassessment and submitted another PASRR with accurate information. The DON acknowledged the findings.
Failure to Monitor Change in Condition and Administer Ordered Medication
Penalty
Summary
The facility failed to provide necessary care and services for a resident who experienced difficulty swallowing medications. After the resident coughed and choked when given a whole medication tablet with water, the nurse crushed the remaining medications and informed speech therapy (ST) of the change in condition. However, there was no documented evidence that the resident was assessed or monitored following this event, nor were care and safety measures provided as required by facility policy. The resident's care plan was not reviewed or revised to address the new swallowing problem, and meal intake documentation was incomplete for the day of the incident. Additionally, the facility did not administer warfarin sodium, an anticoagulant, as ordered by the physician. The medication was unavailable because the pharmacy required recent laboratory results, which had not been obtained or ordered. The nurse responsible acknowledged that the medication was not given and that follow-up with the pharmacy and physician was not completed due to being occupied with another emergency. The resident's medical record did not contain a physician's order for the necessary blood tests (prothrombin time and INR) required for warfarin dosing. Interviews with staff confirmed these lapses in care and documentation. The Director of Nursing (DON) verified that the resident was not monitored after the change in condition and that the warfarin sodium was not administered as ordered. The DON also confirmed the absence of a care plan update and the lack of orders for required laboratory tests, as well as incomplete documentation of the resident's meal intake.
Improper Crushing and Administration of Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed and administered an iron tablet to a resident, despite facility policy stating that only medications which may be crushed should be altered in this way. The facility's policy requires nursing staff to use available references to determine which medications are safe to crush. According to the National Library of Medicine, iron tablets are enteric coated and should not be crushed, as the coating is intended to protect the stomach. The resident in question had a physician's order for iron 25 mg and tamsulosin hydrochloride 0.4 mg, both of which were administered on the day of the incident. The resident, who had severe cognitive impairment as indicated by a BIMS score of three, began coughing and choking after the LVN attempted to administer the whole pill with water. In response, the LVN crushed all of the resident's medications, including those that should not be crushed according to reference materials. The Director of Nursing (DON) was informed and acknowledged these findings during the investigation.
Failure to Revise Care Plan for Swallowing Difficulties
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised to reflect the resident's current care needs and interventions following a change in condition. Specifically, after the resident experienced difficulty swallowing medication and coughed when taking sips of water, the care plan was not updated to address these new swallowing problems. The facility's policy required documentation of changes in condition and updates to the care plan as indicated, but this was not followed in this case. Medical record review showed that the resident had severe cognitive impairment, as indicated by a BIMS score of three, and was observed to cough after attempting to swallow a whole medication tablet with water. The medication was subsequently crushed, but the care plan was not revised to reflect this intervention or the resident's new swallowing difficulties. The Director of Nursing confirmed that the care plan should have been updated to address the resident's change in condition.
Failure to Assess and Document Resident's Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed with a medication cup containing multiple medications at their bedside and proceeded to self-administer these medications without the presence of a licensed nurse. The resident's medical record did not contain an assessment, physician's order, or care plan addressing the ability to self-administer medications. The facility's policy requires that the interdisciplinary team (IDT) assess the safety of self-administration, clarify physician orders to include "may keep at bedside," and document these determinations in the care plan, none of which were completed for this resident. Interviews with facility staff, including an LVN and the DON, confirmed that the resident was not supposed to have medications unattended at the bedside and that the required assessment and documentation were missing. The medications involved included blood pressure medications, blood thinners, and supplements. The DON verified that the resident's records lacked the necessary assessment, physician's order, and care plan problem for self-administration of medications, in direct violation of facility policy and federal requirements.
Plan Of Correction
Corrective Action for those residents identified as being affected by this deficiency: Resident 3 was assessed by the DON if he wishes to self-administer medications on 7/24/2025 and resident declined. Identification of other residents having the potential to be affected by this same deficiency: All residents have the potential to be affected by the same deficiency. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. How the facility will monitor its performance to make sure that solutions are sustained: Documented findings of the audit will be forwarded to the QAPI committee monthly for at least 4 weeks beginning September 2025 for review and action planning as indicated or as the QAPI committee determines compliance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the laundry and clean linen rooms, conditions were not maintained to ensure a clean area free from potential contamination. Puddles of water were observed on the floor, adhesive residue on the clean linen folding table, and signs of damage and discoloration on the walls and cabinets, which could lead to mold formation. These conditions were verified by the Maintenance Director, who acknowledged the potential for mold and contamination. The facility's infection surveillance and reporting were also found to be inadequate. Resident 144's infection was not reported on the facility's monthly infection control log, and infections for Residents 127 and 159 were incorrectly listed as meeting McGeer's Criteria. The Infection Preventionist (IP) confirmed these discrepancies, indicating a failure in accurately identifying and reporting infections, which is crucial for preventing potential outbreaks. Additionally, there were multiple instances of staff failing to adhere to proper infection control practices. Two licensed nurses did not wear appropriate personal protective equipment (PPE) during medication administration for residents on enhanced barrier precautions (EBP). Furthermore, the same nurses did not sanitize blood pressure cuffs and stethoscopes before and after use, and hand hygiene was not consistently performed during medication administration. In one instance, a nurse did not disinfect a feeding tube after it fell on the floor before reattaching it to a resident's gastrostomy tube (GT). These lapses in infection control practices were confirmed through interviews with the involved staff and the Director of Nursing (DON).
Failure to Follow Enteral Feeding and Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding enteral feeding and medication administration for three residents. Two licensed nurses administered medications to residents via gastrostomy tubes (GT) by pushing the medications through the tube instead of allowing them to flow by gravity, as per the facility's policy. This was observed during medication pass observations for two residents, where one nurse admitted to using the incorrect method initially and then switched to the gravity method. The Director of Nursing (DON) confirmed that medications should be administered by gravity, with gentle pushing only if there is resistance. Additionally, one licensed nurse did not check the tube placement and residual volume before administering medications to a resident, which is required by the facility's policy. This oversight was acknowledged by the nurse during an interview and confirmed by the DON, who stated that checking tube placement and residual volume is necessary to ensure safe medication administration. Furthermore, another resident's enteral feeding was initiated without verifying the GT placement and checking gastric residuals, as required by the facility's policy. The nurse involved admitted to not performing these checks, and the DON confirmed the importance of these procedures to prevent complications. These failures in following established protocols had the potential to lead to complications related to GT care and management.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident who required continuous oxygen therapy. The facility's policy on oxygen administration, revised in February 2023, mandates that oxygen therapy be administered by a licensed nurse as ordered by the physician. However, during an observation on February 11, 2025, it was noted that the resident's nasal cannula tubing was not in place on the resident but was instead hanging on the feeding tube stand, despite the oxygen being set at two liters per minute. A registered nurse (RN) confirmed the observation and acknowledged that the nasal cannula should have been on the resident's nose to ensure continuous oxygen administration. The Director of Nursing (DON) also verified and acknowledged these findings during an interview and medical record review. The resident, who was dependent on staff for activities of daily living, had a physician's order for continuous oxygen to maintain oxygen saturation levels above 90%.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, posing a risk for foodborne illnesses among the 157 residents who consumed food prepared in the kitchen. During an inspection, it was observed that frozen meat was not thawed safely, as seven bags of thawed raw chicken in the walk-in refrigerator lacked a pull date, making it impossible to determine when they were placed there. Additionally, a frying pan with heavy black residue was found, indicating it was not clean or in good working condition, and should have been discarded. Further observations revealed that dry bulk food was not stored properly, with a plastic scoop left in a powdered thickener container. Meal preparation equipment was not air-dried, as evidenced by a wet blender stored with its lid on. Two floor drains lacked backflow prevention, as the drainage pipes of the juice machine and walk-in refrigerator did not have an air gap. Lastly, cleaning equipment was not stored in a sanitary manner, with a broom found on the floor in the utility closet, contrary to guidelines requiring maintenance tools to be stored off the floor to prevent pest harborage.
Failure to Accurately Complete Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the Registered Dietitian (RD) completed or reviewed the Minimum Data Set (MDS) Nutritional Status assessment and the quarterly nutritional assessment for accuracy for one of the residents, identified as Resident 87. The California Business and Professions Code 2586 requires Registered Dietitians to conduct nutritional and dietary assessments. However, the RD did not participate in completing or verifying the accuracy of the MDS Section K assessment, which was incorrectly coded by the Dietary Services Supervisor (DSS). The MDS Coordinator confirmed that the assessment was incorrectly coded, and the RD acknowledged that she was not involved in the process. Resident 87 experienced a significant weight gain of 17 pounds, or 13%, over six months, which was not accurately reflected in the assessments. The quarterly nutritional assessment completed by the DSS inaccurately indicated that the resident's weight was stable, despite the significant weight gain. The RD verified that the assessments were not accurate and that she was not involved in reviewing them, which posed a risk to the resident's nutritional needs being unmet.
Failure to Provide Scheduled Hospice Visits
Penalty
Summary
The facility failed to provide necessary hospice care services for two residents, identified as Residents 16 and 93, who were under hospice care. Resident 16, diagnosed with heart failure, was admitted under Hospice A with a physician's order for hospice aide (HA) visits twice a week. However, from January to February 2025, there were no documented HA visits conducted twice a week as required. Specifically, during the week of February 9 to February 15, 2025, there was no evidence of a scheduled HA visit on February 11, 2025. The hospice visit sign-in sheets lacked entries or signatures from hospice staff for the scheduled visits, and the facility's licensed nurse was expected to contact the hospice provider if visits were not completed. Similarly, Resident 93, diagnosed with cerebral atherosclerosis, was admitted under Hospice B with a similar requirement for HA visits. From December 2024 to February 2025, there were multiple weeks where no HA visits were documented, despite being scheduled. Interviews with the Licensed Vocational Nurse (LVN) and the Hospice Case Manager confirmed the absence of documented visits, as hospice staff were required to sign the calendar and visit description log to confirm their visits. The Director of Nursing (DON) acknowledged that hospice staff must sign the hospice calendar or visit log to confirm completed visits, but facility nurses were not required to document visits unless orders were received from the hospice doctor.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for two nonsampled residents. Resident 127 was prescribed antibiotics for pneumonia, but a review of the medical records indicated that the symptoms did not meet the McGeer's criteria for a true infection. Despite this discrepancy, the resident's physician was not notified to reassess the necessity of the antibiotic treatment. Similarly, Resident 159 was prescribed antibiotics for an infection related to elevated white blood cells, which was initially thought to meet the McGeer's criteria. However, upon further review, it was found that the symptoms did not align with the criteria for a true infection. The facility's Infection Preventionist (IP) confirmed the absence of a McGeer's criteria tool for such infections and acknowledged that the physician was not informed about the need to reevaluate the antibiotic use.
Improper Cleaning of Ice Machine
Penalty
Summary
The facility failed to maintain its essential equipment, specifically the ice machine, in safe operating conditions. The ice machine was not cleaned and sanitized according to the manufacturer's instructions, which could potentially lead to contamination of food and illnesses among residents. The facility's policy required monthly cleaning of the ice machine's internal components, but the Maintenance Assistant (MA) did not follow the correct procedure. The MA mixed five ounces of cleaner with an unspecified amount of water and ran it through the machine, then soaked the parts in bleach, which was not in accordance with the manufacturer's guidelines. During an observation and interview, the MA admitted to not knowing the exact amount of water used in the cleaning process and was confused about the instructions, which were in English and difficult for him to understand. The Maintenance Director confirmed the MA's confusion and acknowledged the discrepancy between the cleaning process used and the manufacturer's instructions. This failure to adhere to proper cleaning procedures posed a risk of the ice machine not functioning as intended, potentially leading to contamination and health issues for the residents who consumed food prepared in the kitchen.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to ensure the provision of pharmacy services met the needs of the residents in accordance with the facility's policies and procedures. During a medication administration observation, a licensed nurse left medications unattended on a resident's bedside table multiple times while retrieving supplies, which was against the facility's policy that requires medications to be secured or taken with the nurse if the line of vision cannot be maintained. This oversight had the potential for misuse of medications by residents, staff, or visitors. Additionally, the facility did not replace an opened CII E-kit within the required 72-hour timeframe, as per the facility's policy. The CII E-kit, which contained controlled medications, was opened and not replaced in a timely manner, potentially leading to the unavailability of emergency medications when needed. Furthermore, a tablet of Percocet was removed from the CII E-kit and not disposed of properly after a resident refused it, contrary to the facility's policy that requires refused or held doses to be destroyed. Moreover, a staff member improperly disposed of non-scheduled medication wastes by discarding them into a regular trash bin instead of using the designated drug disposal system. This action was observed during the preparation for medication administration, where the nurse failed to identify which medications were prepared and subsequently discarded the remaining medications into the trash. This practice was not in line with the facility's policy, which mandates the use of a drug disposal system to prevent misuse and environmental harm.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a cumulative error rate of 20% during a medication administration observation. Six medication errors were identified out of 30 opportunities involving two residents. For one resident, the errors included not measuring the heart rate before administering blood pressure medications, administering the incorrect dosage of aspirin, and providing a tablet form of multivitamins instead of the prescribed liquid form. The Licensed Vocational Nurse (LVN) involved did not adhere to the physician's orders, which required checking both systolic blood pressure and heart rate before administering certain medications. Additionally, the facility's policies and procedures for enteral tube medication administration were not followed. The LVN did not flush the resident's gastrostomy tube (GT) with the required amount of water before and after medication administration, nor between each medication, as per the physician's orders. This was observed during the administration of medications to two residents, where the LVN used less water than prescribed and did not flush the GT between medications, potentially leading to tube clogging. Interviews with the LVN and the Director of Nursing (DON) confirmed the discrepancies between the observed practices and the facility's policies. The DON acknowledged that the licensed nurses should have adhered to the physician's orders and the facility's procedures, including the specific instructions for medication administration and GT flushing. These failures in following established protocols contributed to the high medication error rate observed during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications according to the manufacturer's instructions and the facility's policies and procedures. An amber bottle of megestrol acetate oral suspension was found without the necessary label instructing nurses to shake the container well before use. This omission was acknowledged by LVN 10, who confirmed that the information was crucial for the proper preparation of the medication. The Director of Nursing (DON) also confirmed that suspension medications require adequate shaking to ensure uniform preparation. Additionally, a bottle of Katerzia oral suspension, which requires refrigerated storage, was found stored at room temperature in Medication Cart 2. LVN 10 acknowledged that the medication was improperly stored and suggested that it might have been left in the cart after use. The DON confirmed that medications should be stored according to the manufacturer's instructions and returned to the refrigerator after use. Furthermore, an opened vial of Levemir insulin was found without an open date in Medication Cart 1, making it impossible to determine its expiration. LVN 9 confirmed that insulin vials should be discarded 28 days after opening. The DON reiterated the importance of dating insulin vials upon opening. Lastly, three boxes of expired Tempa-DOT thermometers were found in Medication Room A, which the Central Supply Staff confirmed should have been removed. The DON stated that staff should check expiration dates and dispose of expired supplies.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for 12 out of 33 sampled residents. This included errors in the Physician Orders for Life-Sustaining Treatment (POLST) forms, such as missing physician signatures for two residents and incorrect documentation of advanced directives and health care agents for another resident. Additionally, there was a lack of documentation of staff review and confirmation of POLST information with a resident's responsible party. Further deficiencies were noted in the documentation of treatment administration records (TARs) and medication administration records (MARs). For instance, one resident's treatment for xerosis and pruritus was not documented as completed, and another resident's low air loss mattress monitoring was not recorded for a specific shift. There were also inaccuracies in documenting meal consumption, with one resident's intake being overestimated in the records compared to actual observations. The facility's failure to maintain accurate records extended to the documentation of vital signs, pain levels, and medication administration for several residents. This included missing entries for monitoring COVID-19 symptoms, administering medications, and providing nonpharmacological interventions for pain. Interviews with staff confirmed these documentation lapses, which were acknowledged by the Director of Nursing.
Inaccurate MDS Coding for Weight Changes
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which could impact their individualized care plans. Resident 25 experienced a significant weight loss of more than 5% in a month, as evidenced by a decrease from 153 lbs to 139.6 lbs over a period of one month. Despite this, the MDS was inaccurately coded to indicate no significant weight loss. The MDS Coordinator confirmed the error, noting that the dietary department was responsible for completing the nutrition assessment. Similarly, Resident 87's MDS was inaccurately coded regarding weight gain. The resident's weight increased from 114 lbs to 130.8 lbs, a 14% increase, yet the MDS did not reflect this change. The MDS Coordinator verified the incorrect coding, which was completed by the Dietary Services Supervisor (DSS). These inaccuracies in the MDS coding could lead to residents not receiving appropriate care plans tailored to their nutritional needs.
Failure to Conduct Timely Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the highest practicable well-being for a resident who experienced an unwitnessed fall. The facility's policy and procedure for neurological evaluations, revised on 3/28/23, required assessments every 15 minutes for one hour, then every 30 minutes for four hours, then every hour for two hours, and then every shift for 72 hours. However, after the resident's fall on 1/18/25, the required hourly neurological assessments were not completed as scheduled. Specifically, the first hourly assessment was conducted at 0155 hours on 1/19/25, but the subsequent assessment due at 0255 hours was missed, with the next assessment occurring two hours later at 0355 hours. During an interview on 2/13/25, the Director of Nursing (DON) confirmed that the neurological assessments should have been conducted according to the specified frequency on the flowsheet. The DON reviewed the resident's Neurological Assessment Flowsheet and acknowledged that the scheduled assessment for 0255 hours on 1/19/25 was not completed. This oversight in following the established protocol for post-fall neurological evaluations had the potential to delay necessary care for the resident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from physical abuse, resulting in an altercation between them. Resident 2 allegedly called Resident 1 a derogatory name and scratched her face, prompting Resident 1 to bite Resident 2's hand in self-defense. This incident was observed by staff, who found Resident 1 with Resident 2's hand in her mouth. Both residents sustained injuries, with Resident 1 having a scratch on her face and Resident 2 having a bite mark on her hand. The facility's policies and procedures on abuse prevention and resident rights were reviewed, revealing that the facility is responsible for ensuring residents are free from abuse and neglect. Despite these policies, the altercation between the residents occurred, indicating a failure in oversight and monitoring. The facility's investigation confirmed the abuse incident, with both residents admitting to their involvement in the altercation. Medical records showed that Resident 1 had moderate cognitive impairment, while Resident 2 had severe cognitive impairment. Both residents were assessed following the incident, with Resident 1 having dried scratches on her face and neck, and Resident 2 having a deep laceration on her hand. Staff interviews corroborated the residents' accounts of the incident, confirming that Resident 1 acted in self-defense after being scratched by Resident 2.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was refusing to take medications. The facility's policy requires the interdisciplinary team to create a person-centered care plan with measurable objectives and timeframes to address the medical, nursing, and psychosocial needs identified in the comprehensive assessment. Despite this policy, the medical records for the resident showed multiple instances of medication refusal, with notes indicating the resident was shouting and calling out. However, there was no care plan problem developed to address the resident's refusal to take medications, as confirmed by the Director of Nursing during an interview.
Failure to Ensure Staff Wore Identification Badges
Penalty
Summary
The facility failed to comply with State law by not ensuring that two Certified Nursing Assistants (CNAs) were wearing their name badges while on duty. This was observed during a survey when CNA 2 and CNA 6 were both found wearing visitor sticker badges instead of their employee name badges. CNA 2 acknowledged the importance of wearing the badge for resident identification, and CNA 6 similarly confirmed the necessity for residents to recognize staff. The Director of Nursing (DON) admitted that the facility had run out of temporary sticker name badges and emphasized the importance of staff wearing identification badges for resident and visitor recognition.
Deficiencies in Medication Administration and Timely Medical Response
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in medication administration and timely medical response. Resident 2 did not receive Marinol, a medication to stimulate appetite, as ordered from February 2 to February 7, 2024. The physician was not notified of this lapse, and there was no follow-up with the pharmacy regarding the medication's delayed delivery. The facility's policy on medication administration requires medications to be administered within one hour before or after the prescribed time, which was not adhered to in this case. Resident 5 experienced symptoms indicative of a stroke, including numbness and a feeling of having a stroke, but the physician was not notified until over six hours later. The facility's policy on change of condition reporting mandates that all changes in a resident's condition be communicated to the physician promptly. Despite the resident's complaints and the serious nature of stroke symptoms, there was a significant delay in notifying the physician and transferring the resident to an acute care hospital. Interviews with facility staff, including the ADON and LVN, confirmed the lack of timely communication and assessment in both cases. The ADON acknowledged the delay in following up with the pharmacy for Resident 2's medication, and the DON confirmed that the RN or physician should have been notified immediately when Resident 5 reported stroke-like symptoms. These failures in communication and adherence to facility policies had the potential to negatively impact the residents' health and well-being.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide the necessary care and services to a resident as ordered by the physician. Specifically, the facility did not order and administer the resident's aspirin and atorvastatin according to the discharge medication orders from the hospital. The resident was admitted with diagnoses of CVA, pneumonia, and potential stroke, and the discharge instructions included new orders for aspirin and atorvastatin. However, these medications were not included in the resident's Order Summary Report or MARs for April and May 2024, indicating that the medications were not administered as prescribed. Interviews with LVN 3 and the DON confirmed that the new medication orders were not followed. LVN 3 verified that the aspirin and atorvastatin were necessary for the resident's condition and should have been administered. The DON stated that the admitting nurse was responsible for reconciling the medication orders from the hospital discharge list but failed to do so. There was no documentation to show that the facility's physician was notified of the new medications, and the DON acknowledged the oversight in the medication reconciliation process.
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What surveyors actually found near you
We read the 3,280 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huntington Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beachside Nursing Center | 0 mi | ★★★★★ | 18 | 0 |
| Huntington Valley Healthcare Center | 1.3 mi | ★★★★★ | 8 | 0 |
| Fountain Valley Post Acute | 4 mi | ★★★★★ | 32 | 0 |
| Mesa Verde Post Acute Care Center | 4.7 mi | ★★★★★ | 25 | 0 |
| Stanley Healthcare Center | 5.1 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.