Pacific Haven Subacute and Healthcare Center

Inspectors wroteBased 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. * The facility failed to ensure the peripheral line was labeled for Resident 34. [...]

Inspectors wroteBased 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. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions.

Inspectors wroteBased 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. * The facility failed to maintain the hood over the stove in a clean and sanitary condition. [...]

Inspectors wroteBased on interview, medical record review, facility documents review, and facility P&P review, the facility failed to maintain an accurate medical record for five of 19 final sampled residents (Resident 3, 6, 12, 45, and 54). * The facility failed to ensure the section D of the POLST and Advance Directive Acknowledgement form was completed accurately for Resident 6. * The facility failed to ensure section D of the POLST was not left blank for Resident 45. * Resident 54's POLST failed to show if the resident had formulated an advance directive. *The facility failed to accurately document COVID-19 immunization status for Residents 3 and 12; the residents' medical records showed the residents were only tested for COVID-19. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to implement their infection control surveillance program for the months of January to June 2026. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications met the facility's criteria for infection. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent for the use of the psychotropic medications was obtained and had the complete necessary information prior to the administration of the psychotropic medications medication for two of five sampled residents (Residents 9 and 77) reviewed for unnecessary medications. * The facility failed to ensure Resident 9's informed consent was obtained prior to administering the valproate sodium (mood stabilizer medication) to Resident 9. * The facility failed to ensure the informed consent information were completed for Resident 77's use of Rexulti (antidepressant), diazepam (antianxiety), mirtazapine (antidepressant), and trazadone (antidepressant) medications. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain safe, clean, and homelike environment for one of 37 rooms (Room A). * Room A was observed with accumulation of brownish, grayish particles along the base moldings; gray stains on the floor between the sink and the toilet in the bathroom; and yellow brown discoloration above the drain stopper of the bathroom sink. This failure posed a serious risk to the residents' health and safety.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 9) reviewed for unnecessary medications was free from unnecessary psychotropic medications.* The facility failed to ensure nonpharmacological interventions were implemented prior to the use of the valproate sodium medication (anticonvulsant used to manage mood disorder) for Resident 9; and the physician order had an appropriate indication for use. These failures had the potential for poor health outcomes due to adverse effects of the medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement care plan interventions for one of 23 final sampled residents (Resident 9). * Resident 9's medical record failed to show documented evidence the facility monitored Resident 9's side effects and possible adverse reactions related to the use of valproate sodium medication. This failure had the potential risk of not providing appropriate, consistent, and individualized care to Resident 9.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent further falls and/or injuries for one of two final sampled residents (Resident 9) reviewed for falls. * The facility failed to complete an accurate post fall assessment for Resident 9. This failure posts the risk for the resident to sustain further falls and/or injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one of final sampled resident (Resident 34). * Resident 34's GT was observed to be undated and the tubing was uncovered. This failure had the potential for the resident to develop health complications, including infection.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain medication was administered to one nonsampled resident (Resident 101) as per the parameter ordered by the physician. * The facility did not administer Resident 101's pain medication as ordered by the physician. This failure had the potential to put Resident 101 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for one of two final sampled residents (Resident 5) reviewed for dialysis services. * The facility failed to ensure the emergency dialysis kit kept at bedside was complete and had a scissor clamp for Resident 5. In addition, the facility failed to ensure Resident 5's dialysis access site was consistently and accurately assessed as ordered by the physician. This failure had the potential to delay the nursing staff in identifying complications related to the resident's dialysis access site.

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to ensure Resident 85's medication was stored in a secure and locked compartment. * The facility failed to ensure oral medications were stored separately from non- orally used medications in the medication room. * The facility failed to ensure the medication bin with the medications was maintained in a sanitary manner in the medication room. These failures had the potential to negatively impact the residents' health outcomes.

Inspectors wroteBased on observation, interviews, facility document review, and facility P&P review, the facility failed to ensure the resident's food preferences were followed for one sampled resident (Resident 5). * Resident 5's lunch tray contained buns, breaded chicken, fries, lettuce, and tomato, even though her meal ticket listed tomato as one of her dislikes. This failure had the potential to result in poor meal intake and negatively impact Resident 5's psychosocial well being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately determine whether Resident 2's prescribed Zosyn (antibiotic) had met the McGeer's criteria. This failure had the potential to result in adverse reactions associated with antibiotics and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview, record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 2) reviewed for immunizations and four out of eight staff members reviewed for COVID-19 vaccinations were offered the COVID-19 vaccination. * The facility failed to ensure Resident 2 had a completed COVID-19 informed consent for the refusal of the vaccination. * The facility failed to maintain documentation if the staff members received COVID-19 vaccinations were provided education regarding the benefits and risks of COVID-19 vaccine and were offered the COVID-19 vaccine per facility P&P. These failures places the residents and staff members at risk of COVID-19.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the abuse allegations were thoroughly investigated for one of three sampled residents (Resident 6) reviewed for abuse. * The facility failed to conduct a thorough investigation into Resident 6's abuse allegation prior to allowing CNAs 5 and 6 to return to work. This failure had the potential to leave the vulnerable residents for further abuse, mistreatment, and injury.

Inspectors wroteBased 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). In addition, RN 3 did not research information about the amphotericin B liposomal or Amphotericin B medications, prior to administering the medication for the first time. [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased on observation, interview, medical record review,and facility P&P review, the facility failed to ensure one of six sampled residents reviewed for dining (Resident 1) received food prepared in a form to meet the resident's individual dietary needs. * The facility failed to ensure Resident 1 was provided with the chopped vegetables as per the physician's diet order. This failure had the potential for Resident 1 not liking the food based on the dietary modification and could affect the resident's quality of life.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired supply was removed from the medication cart, the medication was labeled, and the supplies were clean and sanitary for Medication Cart A. * The facility failed to ensure the supplies in the cart were kept in clean and sanitary manner and the expired supplies were removed from the current supplies from Medication Cart B. * The facility failed to ensure the internal medications were not mixed with external medications for Medication Cart C. In addition, the facility failed to ensure the non-controlled medication was not stored with the controlled medication inside Medication Cart C. [...]

Inspectors wrote4.a. On 4/29/25 at 1100 hours, Room A's resident closet contained a disposable brief stored on the floor, exposed, unwrapped, and touching the shoe box and splint. The resident's diaper was disorganized. Linen was placed underneath the chair leg, and the diaper was exposed and lying on the floor of the closet. On 4/29/25 at 1400 hours, an observation and concurrent interview was conducted with LVN 11. LVN 11 verified the above findings and stated the staff should have organized and cleaned the residents' closet. LVN 11 acknowledged the potential for contamination as the diaper, gown, and linen were touching the floor and chair legs. b. On 4/29/25 at 1055 hours, Room C's resident closet had a wheelchair cushion stored on the floor of the closet. The cushion was dusty and had small pieces of wood debris. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 30) was safe to self-administer a medication. * There was no assessment or care plan to address Resident 30's self-administration of medications when the resident had two bottles of Alphagan eye drops (medication used to lower high eye pressure) at the bedside and had been self-administered this medication. This failure had the potential to negatively impact the residents' well-being and administer the medications inaccurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 78) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 78's prescription for lorazepam (antianxiety medication) had documentation of the physician's clinical rationale to show when the PRN order was extended beyond 14 days. This failure had the potential to negatively impact the Resident 78's well-being from the continued use of the lorazepam medication.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 19 final sampled residents (Residents 14 and 78) and one of three residents reviewed for closed records (Resident 8). * The facility failed to develop a care plan to address Resident 78's use of padded side rails. In addition, the facility failed to develop a care plan to address Resident 78's use of IV device. * The facility failed to develop a care plan to address Resident 14's use of the sequential compression device. * The facility failed to develop a care plan for Resident 8's DM. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests for one of two final sampled residents (Resident 78) reviewed for activities. * The facility failed to provide the activities for Resident 78 which met the resident's identified interests such as watching TV. This failure had the potential for Resident 78 to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to the reported injury was addressed and reported to the resident's responsible party and the physician for one of 19 final sampled residents (Resident 6). This failure posed the risk of Resident 6's injury to worsen.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the necessary treatment and services were provided to maintain or improve their ROM functions and prevent further declining of the ROM functions for two of two final sampled residents (Residents 38 and 44) reviewed for ROM functions. * Residents 38 and 44 did not receive the restorative nursing treatment daily as ordered by the physician. This failure posed the risk for the residents to develop complications from immobility and not achieve their highest practicable level of independence.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to monitor the onset of weight loss for one of three final sampled residents (Resident 25) reviewed for nutrition. * The facility failed to ensure the RD's recommendations were followed up with the physician and addressed in the IDT Nutrition when Resident 25 had a significant weight loss of 11 lbs/11.1% in three months. This failure posed the risk of nutritional interventions not being implemented in a timely manner and potentially could cause the residents to have further weight loss.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents reviewed for enteral services received the appropriate treatment and services. Additionally, the enteral feedings were not properly stored or monitored. * The expired enteral feeding bottles were stored in the subacute storage unit. * The facility failed to ensure Residents 14 and 32's HOB were elevated at a 30 degree angle or above when the residents were receiving the enteral feeding via the GT. These failures posed the risk for complications related to the use of the enteral feeding for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of sampled residents (final sampled resident, Resident 32 and nonsample resident, Resident 63) reviewed for respiratory care received the appropriate treatment. * The facility did not ensure the nebulizer mask, tubing, and bag were changed weekly or properly labeled for Resident 63. * The facility failed to ensure Resident 32 was provided with the correct type of tracheostomy set for emergency use. Resident 32 was provided with an uncuffed tracheostomy set instead of a cuffed tracheostomy set. In addition, the facility failed to ensure the suction device was changed weekly as per the physician's order. These failures had the potential to negatively impact the respiratory health and overall well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided for two of 19 final sampled residents (Residents 32 and 72) and two nonsampled residents (Residents 26 and 296) when: * The facility failed to ensure the administration of controlled medication for Resident 296 was documented in the narcotic record. * The facility failed to ensure a record of controlled medications for Residents 26 was completed * The facility failed to ensure Resident 72's old lidocaine external patch (patch used for pain relief) was removed as ordered by the physician. * The facility failed to adhere to Resident 32's blood pressure and blood glucose parameters as prescribed by the physician for two medications: [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met. * A red bucket solution was stored next to the food items. * There was a staff portable radio stored on the beverage preparation area. * Two soft, wrinkled, and blackened bell peppers were stored inside the refrigerator. * A bag of croissants opened 4/3/25, was stored inside the refrigerator. * There was a staff water bottle stored inside walk in refrigerator. * There was an unlabeled package of mushrooms in the refrigerator. * There was an unlabeled frozen pizza and unlabeled bag of tamales. These failures posed the risk of unsanitary and possible food-borne illness.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the resident care equipment and refrigerator were maintained in the safe operation condition when: * The record of quality control for one glucometer from Medication Cart C was not accurate. * The facility staff used whiteout to correct documentation entries in the Quality Control Record for Glucometers A and B. The facility was not able to refer to the previous entries made as a result of completely erasing the original documentation requiring corrections. * The refrigerator inside Medication Room A containing medications was not kept within the acceptable temperature parameters. * The walk-in freezer inside the kitchen remained free of ice buildup. These failures had the potential to affect care and services provided to the residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain a copy of the advance healthcare directive for one of six final sampled residents (Resident 32) reviewed for advance directives. This failure had the potential for the resident's decisions regarding their healthcare and treatment options to not be honored.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to follow the menu for nine residents who were on pureed diets. * The facility failed to ensure the pureed potato recipe was followed during the pureed food preparation. This failure had the potential of not following the menu and not meeting the residents' nutritional needs which could lead to nutritional-related health complications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food prepared in the facility's kitchen was attractive in appearance and at an appetizing temperature. This failure had the potential for the residents to not eat the food served and could affect their nutritional status.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the medical record for one of three final sampled residents (Resident 8) reviewed for closed records was complete. * There was inconsistent documentation of Resident 8's monitoring for the indwelling urinary catheter care and checking of Quinton catheter (a type of central venous catheter inserted on the chest wall used for hemodialysis access when the conventional vascular access is difficult to establish) to the right upper chest wall. This failure had the potential for Resident 8's care needs to not be met as there were missing documentation in the medical record.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure staff used appropriate hand hygiene and glove use when they handled ready-to-eat food. This failure affected 59 residents who received meals from the kitchen, out of the 95 residents who currently reside in the facility.

Inspectors wroteBased on observations, interviews, and facility document and policy review, the facility failed to ensure staff properly cleaned glucometers according to a manufacturer's labeled specifications for use as a disinfectant to help prevent the spread of bloodborne pathogens during use, for 2 of 13 glucometers observed in use during medication pass.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident who had not been assessed as safe to self-administer medications did not self-administer an inhaler, failed to follow physician's orders for administration of an inhaler, and failed to follow facility policy for medication administration for 1 (Resident #299) of 4 residents observed during a medication pass.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to licensed staff only documented medications they administered during medication administration for 1 (Resident #299) of 4 residents observed for medication administration.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the supplemental oxygen was administered as ordered by the physician and by the competent staff for four of five sampled residents (Residents 1, 2, 3, and 5). * Supplemental oxygen was not administered as ordered for Residents 1, 2, and 3. * Resident 5's supplemental oxygen was administered and removed by a CNA. These failures had the potential to put the residentsat risk of respiratory complications.

Inspectors wroteBased on interview, observation, and medical record review, the facility failed to ensure the medical records were accurate and complete for four of five sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to not effectively evaluate the care and services provided and residents' health conditions.