Health inspection·July 25, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and the facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) was assessed to determine if it was safe for the resident to self-administer the medications. * Resident 3 was observed with a medication cup filled with multiple medications at the bedside table. Resident 3 had no assessment, physician's order, and/or care plan problem addressing the self-administration of the medications. This failure had the potential for Resident 3 to administer medications inaccurately.Findings: Review of the facility's P&P titled Self-Administration of Medications (undated) showed the following:a. Residents will be informed that they have a right to self-administer drugs upon admission;b. if a resident requests to self-administer drugs the IDT will determine if the practice is safe before the resident may exercise this right;c. the IDT will determine who is responsible for the storage of the drugs and documentation of the administration of drugs, as well as the location of Drug Administration;d. these determinations need to be included in the residence care plan; e. the physicians order for such drugs will be clarified to include may keep at bedside; andf. residents who self-administer drugs will be periodically reevaluated based on any changes in the resident's status. Medical record review for Resident 3 was initiated on 7/24/25. Resident 3 was admitted to the facility on [DATE]. On 7/24/25 at 1108 hours, a concurrent observation and interview was conducted with Resident 3. A medication cup filled with multiple medications were present at the resident's bedside. When Resident 3 was asked if the medications inside the medication cup belong to him, Resident 3 stated Yes, then proceeded to self-administer the medications without the licensed nurse present. Review of Resident 3's Order Summary Report dated 7/24/25, failed to show a physician's order to self-administer the medications. Further review of Resident 3's medical record failed to show Resident 3 was assessed for the self-administration of the medications. Review of Resident 3's plan of care failed to show a care plan problem to address Resident 3's ability to self-administer the medications. On 7/24/25 at 1114 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above findings. LVN 1 verified Resident 3 was not supposed to have the medications unattended at the bedside. LVN 1 stated the facility's process for the residents to self-administer the medications require an assessment from the physician to indicate the resident could self-administer the medications. On 7/24/25 at 1454 hours, a follow up interview was conducted with LVN 1. LVN 1 verified the medications inside the medication cup were Resident 3's scheduled at 0900 hours medications. When asked what medications were inside the medication cup, LVN 1 stated the following medications: folic acid (supplement), amlodipine (blood pressure medication), carvedilol (blood pressure medication), apixaban (blood thinner medication), aspirin (blood thinner), vitamin D (supplement), and lisinopril (blood pressure medication). On 7/25/25 at 1548 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the following medications were documented as administered to the resident on 7/24/25 at 0900 hours: amlodipine, aspirin, cyanocobalamin (vitamin b12 supplement), Residents Affected - Some Page 1 of 2 555249 555249 07/25/2025 Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648

F 0554 Level of Harm - Potential for minimal harm folic acid, Lasix (diuretic), lisinopril, thiamin (supplement), and apixaban. The DON verified Resident 3 had no assessment, physician's order, and/or a care plan problem addressing the self-administration of the medications. On 7/25/25 at 1617 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON were informed and acknowledged the above findings. Residents Affected - Some 555249 Page 2 of 2