Health inspection·November 12, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - dated 10/10/24, Nystatin Suspension 100,000 unit/ml 5 ml (total of 500,000 units) by mouth swish and swallow four times a day for mouth fungal or yeast infection for 10 days Review of Resident 2's MAR for October 2024 showed the following medications were not administered: - on 10/20/24 at 2100 hours, Senna 8.6 mg one tablet by mouth at bedtime for bowel management (hold for loose stools). - on 10/20/24 at 2100 hours, enoxaparin sodium injection solution prefilled syringe 80 mg/0. 8 ml subcutaneously every 12 hours for DVT. - on 10/20/24 at 2200 hours, acetaminophen 500 mg two tablets by mouth every eight hours for pain management, not to exceed 3 gm of APAP in 24 hours. - on 10/20/24 at 2200 hours, gabapentin 300 mg one capsule by mouth three times a day for neuropathic pain. - on 10/20/24 at 2100 hours, Nystatin Suspension 100,000 unit/ml 5 ml (total of 500,000 units) by mouth swish and swallow four times a day for mouth fungal or yeast infection for 10 days. Further review of the MAR failed to show documentation if the medications were held for any reason. Further review of Resident 2's MAR showed Resident 2 had a pain level of 6 (on a 0 to 10 pain scale with 0 = no pain and 10 = worst pain) on 10/20/24 at 2300 hours. Resident 2 was given hydromorphone hydrochloride (opioid) 2 mg one tablet by mouth for moderate pain. On 11/8/24 at 1028 hours, an interview was conducted with Resident 2. Resident 2 stated she did not receive her enoxaparin sodium injection and some other medications for pain for a couple of times. Resident 2 stated she notified a nurse and was told the medications were supposed to be given on time and the resident could not get the medication if beyond the scheduled time. Resident 2 further stated she suffered a lot of pain when she did not get her medications and had to ask for stronger pain medication. On 11/8/24 at 1224 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above medications were not initialed in the MAR. The DON verified the above medications were not administered as ordered. The DON stated the medications were expected to be administered as ordered by the physician. On 11/12/24 at 1320 hours, a telephone interview was conducted with LVN 3. LVN 3 stated she had very little time to give the medications. The medications might had been given but not documented. LVN 3 stated she could not prove the medications were given because they were not initialed in the MAR. LVN 3 further stated if the resident refused the medications, she would document of the resident's refusal and inform the RN supervisor or the desk nurse. On 11/12/24 at 1414 hours, a telephone interview with LVN 4 was conducted. LVN 4 confirmed she worked as the desk nurse on 10/20/24. LVN 4 stated when she administered medication, she would pour the medications as scheduled, give the medications to the resident, then document the medications as administered. LVN 4 stated she did not receive any report on 10/20/24, that Resident 2 refused to take (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055888 If continuation sheet Page 2 of 3 Printed: 05/15/2026 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 055888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2024 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 0684 the medication. Level of Harm - Minimal harm or potential for actual harm On 11/12/24 at 1530 hours, an interview was conducted with the DON. The DON acknowledged the above medications were not initialed in the MAR. The DON stated the medication administration should be initialed on the MAR to show the medications were administered to the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055888 If continuation sheet Page 3 of 3