Pacific Haven Subacute And Healthcare Center

F 0726 Level of Harm - Actual harm Residents Affected - Few

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

water and carbohydrates) 5 % 250 ml IV at 125 ml/hr and to be given over two hours one time for mucormycosis. Review of Pharmacy 1's Proof of Prescription Delivery (undated) showed on [DATE REDACTED] at 2052 hours, seven vials of amphotericin B 50 mg were received by RN 3. Review of the facility's log of pharmacy deliveries for [DATE REDACTED] showed on [DATE REDACTED] at 2052 hours, the amphotericin B 50 mg Vial and dextrose 5 %-water IV solution (solution for the amphotericin medication to be mixed in) was delivered to RN 3. Review of Resident 1's IV MAR for [DATE REDACTED] showed the amphotericin B liposomal (AmBisome) 350 mg in dextrose 5% 250 ml IV was administered to Resident 1 on [DATE REDACTED] at 0038 hours, by RN 3. On [DATE REDACTED] at 1450 hours,

an interview and concurrent closed medical record review was conducted with RN 3. When RN 3 was shown Resident 1's physician's order for the amphotericin B liposome (AmBisome) on the IV MAR, RN 3 verified he administered the amphotericin B that was delivered by Pharmacy 1 and not the amphotericin B liposomal (AmBisome) that was ordered by the physician. RN 3 verified this was the first time he had ever given the amphotericin B medication and did not realize there was a difference between the two medications. RN 3 stated the verbiage on the packaging of the amphotericin B he received from Pharmacy 1 did not match the verbiage on the resident's physician's order written on the IV MAR. RN 3 stated the labeling on the outside of the amphotericin B packaging delivered by Pharmacy 1 showed in red font: Amphotericin B should not be given at dosages greater than 1.5mg/kg. Resident 1's weight was 69.5 kg.

RN 3 stated he did not double check and compare the dosage warnings on the amphotericin B packaging against the resident's physician's order on the IV MAR. RN 3 stated he did not research the medication prior to administering it to Resident 1 but stated he should have double checked. RN 3 also stated he had never been trained on how to administer amphotericin B products, or how to reconstitute and prepare IV medications. On [DATE REDACTED] at 0926 hours, an interview was conducted with DON. The DON stated she expected the licensed nurses to look up a medication they have not administered before. On [DATE REDACTED] at 1602 hours, an interview was conducted with RN 2. RN 2 stated a pharmacy consultant had observed her

during her first medication administration, but the facility had not observed her or signed her off when she had to reconstitute the IV medications. On [DATE REDACTED] at 1653 hours, an interview was conducted with the Administrator and Clinical Consultant. When the Administrator and Clinical Consultant were asked regarding RN 3 and the other RNs not trained and signed off for the reconstitution of IV medications, the Clinical Consultant verified the RN staff should have been trained and signed off for competency prior to reconstituting IV medications. The Clinical Consultant stated the facility would conduct training regarding

the reconstitution of IV medications for the RNs in the facility. Cross reference F-F755.

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

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

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pacific Haven Subacute and Healthcare Center

12072 Trask Ave.

Garden Grove, CA 92843

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Actual harm Residents Affected - Few

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

on the outside of the amphotericin B packaging delivered by Pharmacy 1 showed in red font: Amphotericin B should not be given at dosages greater than 1.5mg/kg. Resident 1's weight was 69.5 kg. RN 3 stated he did not double check and compare the dosage warnings on the amphotericin B packaging against the resident's physician's order on the IV MAR. RN 3 stated he did not research the medication prior to administering it to Resident 1 but stated he should have double checked. On [DATE REDACTED] at 1249 hours a follow-up telephone interview was conducted with Pharmacy 1's Chief Compliance Officer. Pharmacy 1's Chief Compliance Officer stated the final concentration of the amphotericin B solution was 1.4 mg/ml, when RN 3 reconstituted the medication in the 250 ml D5W bag, which exceeded the manufacturers' recommended concentration of 1 mg/10 ml or 0.1 mg/ml. Pharmacy 1's Chief Compliance Officer also stated the amphotericin B medication should have been mixed in 3500 ml of fluid and infused over 4-6 hours instead of two hours. On [DATE REDACTED] at 1435 hours, a follow-up telephone interview was conducted with Pharmacy 1's Chief Compliance Officer. Pharmacy 1's Chief Compliance Officer stated any side effects from the amphotericin B medication would have been exacerbated at higher dosages. Pharmacy 1's Chief Compliance Officer stated both the amphotericin B medication and amphotericin B liposomal medications were high alert medications, which had a risk of causing serious harm and required a high alert label placed on the medication packaging by the pharmacy. Additionally, Pharmacy 1's Chief Compliance Officer stated the high alert labels were used to warn care providers about the medications with similar sounding names. Pharmacy 1's Chief Compliance Officer verified the high alert medication label was not placed on

the bag containing the amphotericin B medication delivered to the facility. On [DATE REDACTED] at 1531 hours, an

interview and concurrent closed medical record review was conducted with the DON. The DON was informed of the above findings. The DON stated the licensed nurses were expected to verify the medication name, concentration, and formula, against the physician's orders and the prescription drug label. The DON stated the licensed nurses were expected to follow the six rights of medication administration: the right patient, right medication, right dose, right time, right route, and right to refuse. The DON verified the right medication, and the right dose were not followed when RN 3 administered the amphotericin B to Resident 1, instead of the amphotericin B liposomal (AmBisome) as ordered.

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