Huntington Valley Healthcare Center

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

evidence to show the IV peripheral was inserted and the IVF was administered as ordered by the physician.

On 9/18/25 at 1630 hours, an observation and concurrent interview was conducted with RN 2. When asked to show documented evidence the normal saline IVF was removed from the facility's IV E-kit and administered to Resident 1 on 9/5/15, RN 2 stated she had to check the facility's medication rooms for the record. RN 2 stated the facility had two nursing stations and the protocol for removing medications from the E-kit would be to complete a form and place the copy of the completed form in the E-kit and another copy would be kept at the facility. After observations of both nursing stations were conducted with RN 2, RN 2 verified there was no documented evidence a form was completed to show the normal saline IVF was removed from the E-kit on 9/5/25 for Resident 1. On 9/18/25 at 1712 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. On 9/19/25 at 1219 hours, a telephone interview was conducted with the IV Department Supervisor at Pharmacy A stated there was no documented evidence a form was completed by the facility staff to show the normal saline IVF was removed from the facility's IV E-kit for Resident 1 on 9/5/25. The IV Department Supervisor at Pharmacy A stated the process when the facility staff removed an IV medication from the IV E-kit would be to complete the form. A copy of the complete form would be kept in the E-kit and another copy would stay in the facility.

Event ID:

Facility ID:

If continuation sheet

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

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Valley Healthcare Center

8382 Newman Avenue Huntington Beach, CA 92647

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage of the medications for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2 had no medication stored at the bedside.

This failure had the potential for Resident 2 to administer the medication inaccurately.Findings: Review of

the facility's P&P titled Self-Administration of Medications revised 2/2021 showed any medications found at

the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. On [DATE REDACTED] at 0941 hours, an observation was made in Resident 2's room.

One tube of diclofenac sodium 1% topical gel (medication that treats arthritis/osteoarthritis) was observed

on the top drawer of Resident 2's bedside drawer with a fill date of [DATE REDACTED], and had expired on 11/2023.

Resident 2 was observed to be in the room. Medical record review for Resident 2 was initiated on [DATE REDACTED].

Resident 2 was admitted to the facility on [DATE REDACTED]. Review of Resident 2's H&P examination dated [DATE REDACTED], showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Nursing Self-Administration of Mediation Observation dated [DATE REDACTED], showed Resident 2 did not want to self-administer medications. Review of Resident 2's Order Summary Report dated [DATE REDACTED], showed no physician's order for the diclofenac sodium 1% topical gel (pain medication). Further review of Resident 2's medical record failed to show documentation Resident 2 could store the diclofenac medication at the bedside. On [DATE REDACTED] at 0945 hours, an observation, interview, and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 reviewed Resident 2's medical record and verified there was no physician's order or care plan allowing the resident to store the medications at the bedside. RN 1 verified Resident 2's Self-Administration of Medication assessment dated [DATE REDACTED], showed

the resident did not want to self-administer the medications. RN 1 stated the resident's family member may have brought in the medication and the facility would contact the family. RN 1 further stated the medication needed a physician's order prior to administering the medication and should not be left unattended at the resident's bedside because the facility staff would not be able to assess for proper administration of the medication by the resident. On [DATE REDACTED] at 1029 hours, an interview with Resident 2 was conducted with RN 1 and CNA 4 present. Resident 1 requested CNA 4 to translate in Vietnamese. Resident 2 stated the diclofenac medication was provided by her family. When Resident 2 was asked when the diclofenac medication was brought in by her family, Resident 2 stated she did not recall. On [DATE REDACTED] at 1135 hours, an

interview was conducted with the DON. The DON stated the medications could be left at the resident's bedside if there was a physician's order, care plan, and an evaluation to self-administration the medications.

The DON stated the other residents or facility staff could use the medication not intended for their use, if

the medication was left unattended at the resident's bedside. On [DATE REDACTED] at 1712 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged

the above findings.

Event ID:

Facility ID:

If continuation sheet

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

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Valley Healthcare Center

8382 Newman Avenue Huntington Beach, CA 92647

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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

laboratory orders, the facility needed to also call the laboratory company to inform them of the stat laboratory order. When asked if the laboratory received a stat order for Resident 1, the Hospital Lab Assistant stated they did not and stated the last blood work was completed on 8/22/25. On 9/18/25 at 1515 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified he received the physician's orders for Resident 1's stat CBC and CMP on 9/5/25 at 1315 hours. LVN 4 verified

the laboratory portal did not show the stat laboratory results for Resident 1. When asked if he saw the laboratory technician arrive after the stat laboratory was ordered, LVN 4 stated he did not see the laboratory technician prior to the end of his shift on 9/5/25. On 9/18/25 at 1712 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged

the above findings.

Event ID:

Facility ID:

If continuation sheet

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

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Valley Healthcare Center

8382 Newman Avenue Huntington Beach, CA 92647

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 0842 Level of Harm - Potential for minimal harm Residents Affected - Some

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of six sampled residents (Resident 1) was complete. * The facility failed to ensure Resident 1's TAR for August 2025 was complete regarding the monitoring of the resident's urine characteristics. This failure had

the potential to result in inadequate care due to an incomplete medical record for Resident 1. Findings:

Review of the facility's P&P titled Catheter Care, Urinary revised 5/2024 showed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The P&P further showed information should be recorded in the resident's medical record including character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. Medical

record review for Resident 1 was initiated on 9/3/25. Resident 1 was admitted to the facility on [DATE REDACTED].

Review of Resident 1's Order Summary Report showed a physician's order dated 8/13/25, for Resident 1's Foley catheter size16 Fr 10 ml and to change as needed. Review of Resident 1's TAR for August 2025 showed a physician's order dated 8/14/25, for the indwelling urinary catheter and to monitor for change in

the urine character. However, the TAR was blank on 8/15/25 for the evening shift and 8/22/25 for the night shift. On 9/18/25 at 1400 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated when the TAR was left blank, it meant it was not documented. LVN 3 stated the monitoring for the change in the urine character should have been documented if it was completed. On 9/18/25 at 1532 hours, an interview and concurrent medical record

review was conducted with LVN 5. LVN 5 verified the above findings. LVN 5 stated the licensed nurse might have monitored for the resident's urine characteristics for the evening shift on 8/15/25, and on the night shift

on 8/22/25, but might have forgotten to document on the resident's TAR. LVN 5 stated it should have been documented if it the monitoring was done as ordered. On 9/18/25 at 1712 hours, an interview was conducted with the Administrator and DON. The DON stated she expected the licensed nurses to follow the physician's orders. The Administrator and DON were informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet