Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palm Terrace Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an accurate medical record when progress notes were entered for a resident after the resident had already been transferred to the hospital. Policy required concise and accurate clinical documentation, yet an LVN documented a head-to-toe skilled assessment and another note describing agitation, law enforcement involvement, and transfer, all time-stamped after the resident’s departure. Staff interviews confirmed that the notes were written post-discharge, that the LVN documenting was not assigned to the resident and was unaware of the transfer, and that verification with other nurses and CNAs was not done before charting.
Surveyors found that multiple nurses lacked essential competencies in several critical areas. In one case, an LVN caring for a resident with severe respiratory disease and dementia did not call 911 despite marked desaturation, hypothermia, and hypertension, citing the resident’s DNR status, and did not document a reassessment after suctioning or after a bronchodilator treatment. An RN later found the resident hypotensive, hypoxic, and disoriented and arranged transfer. Separately, an LVN and an RN were unable to correctly demonstrate glucometer calibration and were using test strips and control solutions without regard to 90‑day post‑opening expiration, even though their competency records indicated proficiency. Another resident reported being repeatedly given the wrong medication, and an RN confirmed that an LVN had administered calcium with vitamin D instead of ordered calcium alone. In addition, an LVN administering GT medications did not flush the tube before, between, or after medications and failed to use appropriate PPE for a resident on EBP, despite documented sign‑off on GT and infection control skills.
Surveyors found that the facility did not revise pain care plans to include physician-ordered non-pharmacological interventions for three residents experiencing acute or chronic pain related to conditions such as fractures, UTI, stroke, seizures, recent surgery, pressure injuries, and impaired mobility. Although facility policy required person-centered care plans that reflect both pharmacological and non-pharmacological pain interventions, the reviewed care plans only addressed administration of pain medications and omitted ordered measures such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage. During interviews and record reviews, an LVN and the DON confirmed that the residents’ current pain plans of care should have included these non-pharmacological interventions but did not.
The facility failed to follow its pain management policy by not implementing and documenting ordered non-pharmacological pain interventions before administering PRN and scheduled analgesics for three residents. One resident with cognitive impairment received multiple doses of tramadol and acetaminophen without any recorded use of repositioning, relaxation, or other ordered non-drug measures beforehand. Another resident, who reported intermittent abdominal and low back pain and could express needs, received repeated doses of acetaminophen and hydrocodone-acetaminophen with no documentation that non-pharmacological strategies were attempted first. A third resident with fluctuating capacity received frequent Percocet doses for severe pain, again without evidence that ordered non-pharmacological interventions were provided prior to medication administration. An LVN confirmed that such interventions were not used before giving pain medications to two of the residents, and the DON acknowledged the absence of documentation for all three.
Surveyors found multiple failures in medication management, including an LVN administering several crushed meds via GT to a resident without the ordered 50 ml pre- and post-flushes or flushes between meds, and a controlled oxycodone dose for another resident not being recorded on the narcotic log despite administration documented on the MAR. A resident who is independent in decision-making reported repeatedly receiving wrong meds, and an RN confirmed that calcium with vitamin D was given instead of ordered calcium alone. In addition, two residents did not receive ordered topical pain treatments (voltaren gel and a lidoderm patch) because the meds were not available when due, despite policies requiring timely refills.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Staff did not consistently follow the required process of pouring, passing, and immediately signing the EMAR for medication administration. The DON confirmed that advance documentation in the EHR is not acceptable and acknowledged that missed medications could have significant health impacts for a resident. The Administrator and DON were made aware of these findings.
Two residents experienced medication administration errors due to improper documentation and labeling of IV medications. One resident received Vancomycin without the medication bag being dated or signed, while another had a PIV line that was not dated or labeled, hindering compliance with physician orders. These issues were confirmed by RN 1 and acknowledged by the facility's administration.
The facility failed to provide necessary respiratory care by not adhering to physician orders for oxygen administration and not properly labeling oxygen and nebulizer tubing for several residents. A resident received oxygen at a higher rate than prescribed, and multiple residents had undated or incorrectly dated tubing, contrary to facility policy.
A facility failed to ensure a resident was free from significant medication errors when an LVN did not initially check the resident's pulse rate before administering hydralazine, as required by the physician's order. The LVN later checked the pulse rate, which was within the safe range, and administered the medication. The oversight was acknowledged by the LVN and reported to the facility's administration.
The facility did not adhere to pureed food recipes and menu specifications for eight residents on pureed diets. Cold milk and vegetable broth were used instead of warm milk for pureed potatoes, and the incorrect scoop size was used for serving pureed wheat rolls. These discrepancies were confirmed by dietary staff and acknowledged by facility leadership.
The facility failed to ensure food safety and sanitation in the kitchen, with issues such as poorly maintained utensils, unlabeled food items, and lack of hair restraints among staff. These deficiencies were confirmed by the CDM and other staff, posing a risk of foodborne illnesses to residents.
The facility failed to develop baseline care plans for two residents regarding oxygen administration, potentially leading to unmet care needs. One resident received oxygen at a higher rate than ordered, while another's care plan lacked documentation of oxygen use. These issues were confirmed through observations and staff interviews.
The facility failed to properly account for controlled medications, as evidenced by missing signatures on the Narcotic Count Sheet for Medication Cart B. This posed a risk for narcotic diversion, as confirmed by interviews with an LVN and the Interim DON, who acknowledged the missing signatures and the associated risks.
The facility failed to ensure proper medication storage, with open wound care supplies found in a medication cart and orally administered medications stored with externally used medications. An LVN and the Interim DON acknowledged these deficiencies, which were observed during inspections of Medication Cart A and Medication Room A.
The facility failed to maintain accurate medical records for two residents. One resident's records showed vital signs and urinary output documented after discharge, while another resident's records inaccurately documented blood pressure readings from a restricted arm. These errors were confirmed by facility staff and had the potential to impact care.
A resident received the wrong medication when an LVN failed to properly identify the resident before administering levothyroxine 25 mcg, contrary to the facility's policy requiring two identifiers. The resident, who did not have hypothyroidism, informed the LVN of the mistake, but the medication was administered regardless. The DON confirmed the error and policy breach.
The facility failed to administer medications on time for two residents, as required by their P&P. Medications scheduled for 0800 hours were given late due to staffing issues, with one nurse covering for an absent colleague and another attending to a resident with a change in condition. The DON acknowledged that medication administration should not be interrupted, indicating a lapse in task delegation.
The facility failed to serve meals at the desired temperatures, as observed during a test tray inspection and resident interviews. Two residents reported dissatisfaction with the temperature of their meals, noting that the food was often cold. A test tray inspection confirmed that the egg omelet, bacon, and oatmeal were served at temperatures below the desired level, and a taste test verified that these items were cold.
Inaccurate Post-Discharge Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate medical record for one of eight sampled residents. Facility policy on Nursing Clinical Documentation requires that the clinical record be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition. The resident in question had an H&P indicating no capacity to understand and make decisions. The resident was admitted to the facility and later discharged to the hospital via EMS at 1800 hours on 2/8/26 after becoming very agitated, yelling, and cussing at staff, which led to the sheriff being called and two officers responding. Progress notes for this resident were documented after the resident had already left the facility. One note, timed at 2149 hours on 2/8/26, described the resident’s agitation, involvement of law enforcement, and transfer to the hospital at 1800 hours. Another note, timed at 2303 hours on 2/8/26, documented a head-to-toe assessment under a skilled evaluation by an LVN. During interviews, an LVN verified that these notes were entered after the resident’s discharge and stated that she would not chart on a resident who was no longer in the facility. The MDS Coordinator acknowledged that the 2303 hours progress note should not have been documented after the resident left. The LVN who entered the 2303 hours note stated she was not assigned to the resident, was only helping with documentation, had seen the resident at the start of her shift, and was unaware of the transfer, adding that staff should have checked with nurses and CNAs before writing the notes.
Widespread Nursing Competency Failures in Emergency Response, Glucometer Use, Med Pass, and GT Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses possessed and demonstrated the competencies required to provide safe and effective care, as evidenced by multiple incidents involving five nurses. For one resident with aspiration pneumonia, respiratory failure, COPD, CHF, chronic atelectasis, and dementia, the care plan required monitoring for respiratory distress and reporting changes to the physician. On the night in question, this resident’s vital signs changed significantly: blood pressure rose to 174/102, respiratory rate increased to 22, oxygen saturation dropped to 83–85% on 2 L O2 via nasal cannula, and temperature fell to 95°F. LVN 8 documented thick white phlegm in the resident’s mouth, performed oral suctioning with 200 ml of phlegm obtained, notified the physician and DON, and left messages for emergency contacts, but did not call 911. LVN 8 stated they believed that because the resident was DNR, 911 should not be contacted and that they were waiting for direction from the MD, RN, and family, despite acknowledging the resident was in distress and still breathing with a heartbeat. Further review of the same resident’s record showed that earlier vital signs that night were within normal limits, and that after the change in condition and suctioning, there was no documented reassessment of vital signs. The MAR showed the resident received levothyroxine and ipratropium bromide inhalation, but there was no documentation of vital sign reassessment after the inhalation treatment. Later that morning, RN 1 assessed the resident and found blood pressure 78/58, respiratory rate 12, oxygen saturation 73%, and disorientation with inability to follow commands. Oxygen was escalated to a non-rebreather at 15 L/min and another nurse was instructed to call 911, and the resident was transferred to the hospital. The DON later stated that LVN 8 focused primarily on breathing and failed to address the abnormal vital signs, and that LVN 8 had not attended the facility’s in-service on LVN scope for respiratory devices. Additional deficiencies in competency were identified in glucometer calibration, medication administration, and GT medication technique. When asked to calibrate a glucometer, LVN 2 stated she had only been shown once, believed NOC shift nurses did it, and was unsure when calibration was needed, stating she would ask an RN supervisor. The glucometer quality control record showed mismatched lot numbers and missing open dates on strips, and control solutions labeled with open dates, while RN 1 performed a control test without entering control mode and stated she relied on box expiration dates rather than the 90-day post-opening limit. Both LVN 2 and RN 1 had competency documents indicating they met glucometer calibration skills. Another resident reported that an LVN repeatedly gave her the wrong medications; on one occasion, RN 2 verified that the resident had been given calcium with vitamin D instead of the ordered calcium alone, and RN 2 told the LVN to follow the physician’s order. In a separate observation, LVN 5 administered medications via GT without flushing the tube with 50 ml water before and after, did not flush between medications, and did not wear appropriate PPE for a resident on EBP, despite documentation that GT and infection control competencies had been signed off. These findings collectively showed that multiple nurses lacked the specific competencies and standard-of-practice skills required for safe care.
Failure to Incorporate Ordered Non-Pharmacological Pain Interventions Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to include ordered non-pharmacological pain interventions for three residents. Facility policies on Pain Recognition and Management and Comprehensive Person-Centered Care Planning require that pain management be consistent with professional standards, include both pharmacological and non-pharmacological interventions, and that the interdisciplinary care plan be reviewed and revised after each assessment. For Resident 4, who had a left femoral fracture, a physician’s order dated 11/26/25 specified non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage as needed. However, the pain care plan initiated on 11/28/25 only included administering medication as ordered and did not incorporate these non-pharmacological interventions. During interviews and concurrent record reviews, LVN 7 and the DON acknowledged that the current plan of care for pain should have reflected these interventions. For Resident 19, who had acute/chronic pain related to UTI, stroke, and seizures, a physician’s order dated 1/21/26 also included the same set of non-pharmacological pain interventions. The care plan for acute/chronic pain initiated on the same date listed interventions such as administering medication as ordered but did not include the ordered non-pharmacological measures. Similarly, Resident 27, who reported on-and-off abdominal and lower back pain and had acute pain related to recent surgery, pressure injuries, medical condition, and impaired mobility, had a physician’s order dated 12/17/25 for the same non-pharmacological pain interventions. The pain care plan initiated on 12/18/25 again only reflected medication administration and omitted the non-pharmacological interventions. LVN 7 and the DON confirmed during interviews and record reviews that the residents’ current pain care plans should have included these non-pharmacological interventions, but they were not incorporated.
Failure to Implement and Document Non-Pharmacological Pain Interventions Prior to Analgesic Use
Penalty
Summary
The deficiency involves the facility’s failure to provide and document non-pharmacological pain interventions prior to administering PRN and scheduled pain medications for three residents. Facility policy titled “Pain Recognition and Management” (revised 4/2025) required staff to manage or prevent pain consistent with the comprehensive assessment and care plan, including both pharmacological and non-pharmacological interventions based on resident needs, preferences, and goals. For each of the three residents, physician orders included specific non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage to be used as needed. For one resident with moderate cognitive impairment, physician orders included scheduled and PRN tramadol for pain, as well as PRN acetaminophen for mild and moderate pain, along with ordered non-pharmacological interventions. Medication administration records for November, December, and January showed multiple administrations of tramadol and acetaminophen; however, the medical record contained no documented evidence that any of the ordered non-pharmacological interventions were provided prior to giving these pain medications. The DON later verified these findings during record review. For a second resident who could make her own medical needs known and reported intermittent abdominal and lower back pain, physician orders included PRN acetaminophen for mild and moderate pain, PRN hydrocodone-acetaminophen for severe pain, and the same set of non-pharmacological interventions. MARs for December, January, and February showed repeated administrations of acetaminophen and hydrocodone-acetaminophen, but the medical record lacked documentation that non-pharmacological interventions were implemented before medication administration. A third resident, with fluctuating capacity but able to make needs known, had multiple sequential PRN Percocet orders for severe pain and corresponding non-pharmacological pain orders. MARs for January and February documented frequent Percocet administration, yet there was no documented evidence that non-pharmacological interventions were provided prior to these doses. LVN 7 stated that non-pharmacological interventions should be used before pain medications and confirmed that such interventions were not provided before administering pain medications to two of the residents, and the DON acknowledged the lack of documentation for all three residents.
Multiple Failures in Medication Administration, Documentation, and Availability
Penalty
Summary
The deficiency involves multiple failures in pharmaceutical services, including improper administration of medications via gastrostomy tube (GT), incomplete controlled substance documentation, wrong medication administration, and lack of medication availability. For one resident with GT orders, a nurse crushed several medications (apixaban, Florastor, sennosides, and docusate sodium), mixed each with a small amount of water, and administered them sequentially through the GT without flushing between medications. The nurse also flushed the GT with only 10 ml of water before starting and did not flush with the ordered 50 ml of water before and after medication administration, contrary to the physician’s order specifying 50 ml pre- and post-medication flushes. The nurse later verified she had not followed the ordered flush volumes or flushed between medications, and the DON confirmed awareness of these findings. Another deficiency was identified in the handling and documentation of a controlled medication for a different resident. When the oxycodone 10 mg bubble pack was counted with a nurse, there were 25 tablets remaining, while the Narcotic and Hypnotic Record indicated 26 tablets should be left. The record showed one tablet removed at a specific time, and the MAR showed the resident received oxycodone twice that day at two documented times. The nurse confirmed that the nurse who removed and administered one of the oxycodone doses did not document the removal on the Narcotic and Hypnotic Record, and the DON verified these findings. Additional deficiencies included wrong-medication administration and failure to ensure availability of ordered pain medications. One resident, documented as capable and independent in decision-making, reported that a nurse repeatedly gave her the wrong medications; on one occasion she brought a pill to an RN, who identified it as calcium with vitamin D, while the resident’s order was for calcium only. The RN stated she informed the nurse involved that she must follow the physician’s order and not substitute what was available. In separate observations, two residents with orders for routine topical pain medications (voltaren gel for one resident’s right shoulder three times daily, and a daily lidoderm patch for another resident’s right shoulder) did not receive these medications because they were not available at the time of administration. Nurses stated the medications were out and that refills were being or had just been ordered, despite facility policy and DON expectations that routine medications be reordered several days before the supply is exhausted.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident 1 no longer resides at facility as of 08/11/25. On 08/13/25, 08/14/25, and 08/15/25, all licensed nurses were in-serviced by DON on medication rights of administration and provided with a copy of the medication administration P&P which states correct administration and documentation -- pour, pass, sign. Licensed nurses were also educated on the one-hour medication pass parameter time. 2. Resident 2 no longer resides at facility as of 08/26/25. On 08/13/25, Resident 2 was assessed by DON for adverse reactions related to missed medication. Resident denied any adverse reactions. MD was notified of missed medications by DON immediately, and no new orders were given. On 08/13/25, DON provided 1:1 training to LVN 1 regarding the rights of medication administration. LVN 1 was provided with facility's P&P on medication administration. DON also provided LVN 1 with 1:1 in-service on proper procedure for medication clarification, documentation, and monitoring. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/14/25, 08/15/25, 08/18/25, 08/20/25, and 08/22/25, DON, DSD, and RN conducted a medication observation for 20 residents to validate pour, pass, sign, timely medication administration, and correct documentation. All 20 residents received their medication on time, and licensed nurses followed pour, pass, sign procedures and accurately documented administration. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 08/13/25, 08/14/25, and 08/15/25, DON provided in-services to all licensed nurses regarding rights of medication administration and facility's P&P on medication administration, specifically "pour, pass, sign." Additionally, DON and/or designee will provide in-services monthly for 4 months and as needed to ensure compliance and competency with P&P. Starting 08/14/25, DON and/or designee will perform a random medication observation of 4 residents per week for 12 weeks and as needed to ensure timely medication administration and accurate documentation. Any deficient findings will be reported to the DON and/or designee for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON and/or designee will report to the QA&A Committee monthly for review and recommendations for 3 months until substantial compliance is achieved. Completion Date: 08/27/25
Failure to Ensure Immediate and Accurate Medication Documentation
Penalty
Summary
Staff were required to follow the administration process of pouring, passing, and immediately signing the EMAR for safe and accurate documentation of medication administration. When questioned about the acceptability of advance documentation in the EHR for care and services, including medication administration, the DON confirmed that such practice was not acceptable. The DON also acknowledged that any missed medication could significantly impact a resident's health, depending on the medication's indication. During an interview, both the Administrator and DON were informed of and acknowledged these findings.
IV Medication Administration Errors
Penalty
Summary
The facility failed to ensure the proper administration and documentation of IV medications for two residents, leading to medication errors. Resident 38 was observed receiving an IV antibiotic, Vancomycin, without the medication bag being dated, timed, or signed by the administering nurse. This lack of documentation was confirmed by RN 1 during an observation and interview. The resident's medical records indicated a physician's order for Vancomycin to be administered every 12 hours for an abdominal abscess, but the absence of proper labeling posed a risk for medication errors. Similarly, Resident 587 had a PIV line that was not dated or labeled, as observed during a room visit. The physician's order required the PIV site to be changed every 72 hours or as needed, but the lack of labeling made it difficult to track the duration of the PIV line. RN 1 confirmed the oversight, acknowledging that the PIV sites should be dated and labeled to comply with the physician's orders. Both the Administrator and Interim DON were informed of these findings and acknowledged the deficiencies.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide necessary respiratory care for several residents, as evidenced by multiple deficiencies in the administration and management of oxygen therapy. For Resident 686, the facility did not adhere to the physician's order for oxygen administration, providing oxygen at a higher rate than prescribed. Observations revealed that the resident was receiving oxygen at 5 liters per minute instead of the ordered 3 liters per minute. This discrepancy was not documented, and there was no evidence that the physician was notified of the change or the resident's subsequent difficulty in breathing and decreased oxygen saturation. Additionally, the facility did not ensure proper labeling and dating of oxygen tubing for Residents 28 and 438. Resident 28's nasal cannula tubing was dated incorrectly, and Resident 438's tubing was undated, contrary to the facility's policy that requires tubing to be changed weekly and dated. These lapses in protocol were confirmed through interviews with staff, who acknowledged the oversight in labeling the tubing. Furthermore, Resident 436's nebulizer tubing was also found to be undated, which is a deviation from the facility's policy. The lack of proper documentation and adherence to procedures for respiratory equipment management could potentially impact the residents' medical conditions. These findings highlight the facility's failure to maintain consistent and accurate respiratory care practices for its residents.
Failure to Follow Medication Administration Protocol
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a medication administration observation. The facility's policy requires that medications be administered as prescribed by the attending physician, including checking specific parameters before administration. On the specified date, a Licensed Vocational Nurse (LVN) prepared hydralazine for a resident, which is used to treat high blood pressure. The medication's instructions required the nurse to hold the medication if the resident's systolic blood pressure (SBP) was less than 110 mmHg or if the pulse rate was less than 60 beats per minute. Although the LVN checked the resident's blood pressure, they did not initially check the pulse rate before preparing to administer the medication. Upon being reminded of the requirement, the LVN checked the resident's pulse rate, which was 69 beats per minute, and then administered the medication. The resident's medical records confirmed the physician's order to hold the medication under the specified conditions. The LVN acknowledged the oversight during an interview, and the facility's Administrator and Interim Director of Nursing were informed of the findings. This oversight in following the medication administration protocol had the potential to negatively impact the resident's health outcomes.
Failure to Follow Pureed Food Recipes and Menu
Penalty
Summary
The facility failed to ensure that the pureed food recipes and menu were followed for eight residents receiving pureed diets. Specifically, the pureed recipe for potatoes was not adhered to, as cold milk and vegetable broth were used instead of warm milk, contrary to the facility's documented recipe. This deviation was confirmed during an observation and interview with a dietary staff member, who acknowledged the discrepancy in the preparation of pureed red potatoes. Additionally, the facility did not follow the prescribed serving size for pureed wheat rolls. The menu specified the use of Scoop #16, equivalent to 1/4 cup, but instead, Scoop #12, equivalent to 1/3 cup, was used. This was observed during a tray line observation and confirmed by the Dietary Supervisor Assistant. The facility's Administrator, DON, and CDM acknowledged these findings, indicating a failure to adhere to the established dietary guidelines and menu specifications.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. Several deficiencies were noted, including the poor condition of food preparation utensils and equipment. A large pot was heavily marred with black discoloration, and cutting boards were observed with significant wear and discoloration. A can opener had brown discoloration, and other kitchen tools such as a measuring cup, spatula strainer, and ice cream scoopers were found with residues and chipped handles. These conditions were verified by the Certified Dietary Manager (CDM) and other kitchen staff, who acknowledged the risk of food contamination. Additionally, the facility did not adhere to its policy on labeling and dating food items. Unlabeled and undated food items were found in the freezer and refrigerator, including containers of solid food substances and various beverages. The CDM confirmed these findings and admitted to not knowing why certain food items were not stored properly. Furthermore, the kitchen staff failed to wear appropriate hair restraints, as observed with the Dietary Supervisor Assistant, which was acknowledged as a requirement by the Dietary Resource. These failures had the potential to cause foodborne illnesses to the residents consuming food prepared in the kitchen.
Failure to Develop Baseline Care Plans for Oxygen Administration
Penalty
Summary
The facility failed to develop baseline care plans to address the administration of oxygen for two residents, which had the potential for their care needs not being met. Resident 686, who was admitted with a history of acute respiratory failure secondary to congestive heart failure, had a physician's order for oxygen administration at 3 liters per minute via nasal cannula. However, during an observation, it was noted that the resident was receiving oxygen at 4 liters per minute, and there was no baseline care plan in place to address this discrepancy. This was confirmed by both an LVN and an RN during interviews and medical record reviews. Similarly, Resident 438 had a physician's order for continuous oxygen at 3 liters per minute via nasal cannula, but the resident's plan of care did not document the administration of supplemental oxygen. An observation confirmed that the resident was receiving oxygen as ordered, but the lack of documentation in the care plan was verified by the IP during an interview and medical record review. These oversights in care planning could potentially lead to unmet care needs for the residents involved.
Failure to Properly Account for Controlled Medications
Penalty
Summary
The facility failed to ensure the proper accounting and safeguarding of controlled medications, specifically narcotics, which posed a risk for loss or diversion. The deficiency was identified through a review of the facility's policies and procedures, which require a physical inventory of all controlled medications to be conducted by two licensed nurses at each shift change. This inventory is to be documented on an audit record or accountability record. However, the Narcotic Count Sheet for Medication Cart B showed multiple instances of missing signatures from incoming and outgoing licensed nurses on specific dates, indicating that the required inventory checks were not properly documented. Interviews with facility staff, including an LVN and the Interim DON, confirmed the missing signatures on the Narcotic Count Sheet. The LVN explained that the purpose of the Narcotic Count Sheet log is to ensure that narcotic medication counts are reconciled and accounted for at the end of each shift. The Interim DON acknowledged the missing signatures and stated that failing to account for controlled medications poses a risk for narcotic diversion. This lack of proper documentation and accountability for controlled substances represents a significant deficiency in the facility's pharmaceutical services.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper medication storage, as observed during an inspection of Medication Cart A. Open packages of wound care supplies, including Skin Closure Strips and calcium alginate dressing, were found in the medication cart. These items were not stored in a manner that maintained their sterility, as they were open and partially used. The Licensed Vocational Nurse (LVN) acknowledged these findings and confirmed that all wound care supplies should be single-use to ensure sterility. Additionally, the facility did not adhere to its policy of storing orally administered medications separately from externally used medications. During an inspection of Medication Room A, it was observed that Latanoprost eye drops and nitroglycerin tablets were stored together in the same tray inside the refrigerator. Furthermore, various over-the-counter and house supply medications, including earwax softener drops, nasal spray, calamine lotion, artificial tears, nicotine patches, and pain reliever patches, were stored side by side without separation. The Interim Director of Nursing (DON) acknowledged these findings and confirmed that internal and external medications should be stored separately.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their care. For Resident 85, the medical records inaccurately documented vital signs and urinary output after the resident had been discharged and transferred to an acute hospital. This discrepancy was confirmed during an interview with the Interim Director of Nursing (DON), who acknowledged that such documentation should not have occurred once the resident was no longer at the facility. For Resident 44, the facility did not accurately document the blood pressure access site in the resident's medical record. Despite a care plan and physician's order specifying that no blood pressure readings should be taken from the left arm due to an AV shunt, the records showed multiple instances where blood pressure was measured from the left arm. This was verified by the MDS Coordinator and acknowledged by the Administrator and Interim DON. These documentation errors had the potential to impact the residents' care needs due to the inaccuracies in their medical information.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A licensed nurse, identified as LVN 6, did not properly check and identify the resident before administering medication. The facility's policy and procedure for medication administration, dated January 2019, required the use of at least two identifiers to confirm resident identity before medication administration. However, LVN 6 administered levothyroxine 25 mcg to a resident who did not have a history of hypothyroidism, without verifying the resident's identity using the required methods. The incident occurred in the early morning when LVN 6 administered the medication to the resident, who was able to make self-understood and understand others, as indicated by a BIMS summary score of 14. The resident informed LVN 6 that she did not take medications in the early morning, but LVN 6 proceeded to administer the medication and later returned to acknowledge the error. The Director of Nursing confirmed the medication error and verified that the facility's policy was not followed, resulting in the resident receiving the wrong medication.
Delayed Medication Administration for Two Residents
Penalty
Summary
The facility failed to provide necessary pharmacy services to two residents, resulting in medications not being administered within the prescribed time. The facility's policy and procedure (P&P) for medication administration requires medications to be given within 60 minutes of the scheduled time, except for those ordered before or after meals. However, observations and interviews revealed that medications scheduled for 0800 hours were administered late to both residents. For Resident 1, an interview and observation on 9/3/24 showed that medications due at 0800 hours were administered late because the nurse assigned to administer them did not show up. LVN 2, who was observed administering the medications, confirmed the delay and stated that he had to cover for the absent nurse, resulting in late administration for other residents as well. Similarly, LVN 3 confirmed that she finished administering the 0800 hours medications at 0954 hours, indicating a consistent delay in medication administration. Resident 2's medical records showed multiple medications scheduled for 0800 hours, including atenolol-chlorthalidone, fish oil, gabapentin, and Prozac. On 9/3/24, LVN 4 administered these medications late due to attending to a resident with a change in condition. The Director of Nursing (DON) stated that medication administration should not be interrupted and expected other staff to handle residents with changes in condition, highlighting a failure in staffing and task delegation that led to the deficiency.
Deficiency in Meal Temperature
Penalty
Summary
The facility failed to ensure that meals were served at the desired temperatures, which could potentially lead to decreased oral intake and undesirable weight loss for residents. During interviews, two residents expressed dissatisfaction with the temperature of their meals. One resident stated that the hot food items on their meal tray were not hot enough and expressed a preference for warm food. Another resident mentioned that the food could be improved and noted that it was often cold. A test tray inspection was conducted to assess the temperature of the food being served. The inspection revealed that the egg omelet, bacon, and oatmeal were served at temperatures significantly below the desired level, with readings of 105.6, 86.1, and 108.6 degrees Fahrenheit, respectively. Additionally, the milk was found to be at 51.2 degrees Fahrenheit. A taste test confirmed that the egg omelet, oatmeal, and bacon were cold, and the Dietary Services Supervisor (DSS) verified the temperature drop, acknowledging that the food items were indeed cold.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Laguna Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Valencia Healthcare Center | 0.5 mi | — | 7 | 0 |
| Laguna Hills Health And Rehabilitation Center | 0.6 mi | — | 9 | 0 |
| Freedom Village Healthcare Center | 1.7 mi | — | 19 | 0 |
| Trabuco Hills Post Acute | 3.6 mi | — | 53 | 0 |
| Orchards Skilled Nursing | 3.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.