Pacific Haven Subacute And Healthcare Center
PACIFIC HAVEN SUBACUTE AND HEALTHCARE CENTER in GARDEN GROVE, CA — inspection on November 4, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Pharmacy 1's Proof of Prescription Delivery (undated) showed on [DATE] 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] showed on [DATE] 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] showed the amphotericin B liposomal (AmBisome) 350 mg in dextrose 5% 250 ml IV was administered to Resident 1 on [DATE] at 0038 hours, by RN 3. On [DATE] 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] 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] 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] 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Pacific Haven Subacute and Healthcare Center
12072 Trask Ave.
Garden Grove, CA 92843
SUMMARY STATEMENT OF DEFICIENCIES
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] 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] 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] 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.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.