Pacific Haven Subacute and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Pacific Haven Subacute and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF726Nov 4, 2025

  Based on interview, closed medical record review, facility document review, and facility P&P review, the facility failed to ensure the RNs were properly trained on the administration and preparation of IV medications, as evidenced by: * The Nursing Skills Competency Skills Checklist for the RNs did not include the reconstitution (process of adding specific amount and type of sterile liquid to a powered medication to create a usable solution for IV administration) of an IV medication. * RN 3 did not receive training on the administration of medications containing amphotericin B (powerful antifungal medication used to treat serious, potentially life-threatening fungal infections). […]

• Actual harm, isolatedF755Nov 4, 2025

  Based on observation, interview, medical record review, and facility document review, the facility failed to provide the pharmaceutical services to ensure the accurate medication dispensing and administration for one of three sampled residents (Resident 1) as evidenced by: * Pharmacy 1 dispensed 350 mg of amphotericin B (powerful antifungal medication used to treat serious, potentially life-threatening fungal infections), instead of 350 mg of amphotericin B liposome (a different formulation of amphotericin B with different dosing requirements) as ordered by Resident 1's physician. * Pharmacy 1 dispensed a 250 ml bag of D5W (intravenous solution of 5% dextrose in water), which was intended for use with the amphotericin B liposomal (AmBisome). […]

• No harm, potential for more than minimal, patternF694Jul 15, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous (IV) access for three of three final sampled residents (Residents 13, 34, and 100) reviewed for IV access care. * The facility failed to ensure the midline external catheter measurement was completed and documented upon admission in the medical records for Resident 100. In addition, the care plan failed to include the interventions of measuring the resident's arm circumference and external catheter length of the left upper arm midline catheter. * The facility failed to label Resident 13's IV site with date, time, and initials when the IV was inserted. […]

• No harm, potential for more than minimal, patternF695Jul 15, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of five final sampled residents (Residents 21, 35, and 45) and three nonsampled resident (Residents 4, 42, and 68) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Resident 21's oxygen therapy. * The facility failed to ensure Resident 4, 42, and 68's oxygen concentrators were maintained in a clean and sanitary condition. * The facility failed to ensure Resident 45's oxygen nasal canula tubing was labeled with date. * The facility failed to ensure Resident 35's oxygen tubing was changed every seven days and dated. […]

• No harm, potential for more than minimal, patternF812Jul 15, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the kitchen utensils had smooth, cleanable surfaces and were maintained in good repair. * The facility failed to ensure the cutting boards were maintained in sanitary condition and had smooth, cleanable surfaces. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to storage. * The facility failed to ensure the microwave utilized to warm up the residents' food was in a sanitary condition. […]