Anaheim Terrace: Medication Errors Hit 16% Rate - CA
The medication failures at Anaheim Terrace Care Center pushed the facility's error rate to 16.12 percent during a federal inspection in June — more than triple the 5 percent federal limit that triggers regulatory violations.
LVN 3 prepared morning medications for Resident 8 on June 11, gathering an antibiotic, blood thinner injection, vitamin supplement and laxative powder. But the nurse told inspectors she couldn't locate five other prescribed drugs: three blood pressure medications, a constipation treatment, and a magnesium supplement.
At 9:34 a.m., LVN 3 administered only the four available medications and left Resident 8 without the missing prescriptions.
The patient's medical records showed a recent diagnosis of heart failure and weakness in both arms. The missed medications included amlodipine, hydralazine and lisinopril — all prescribed to control the resident's essential hypertension.
When inspectors questioned LVN 3 about the unavailable drugs, the nurse said she "did not know why the above medications due to be administered at 0900 hours, were not available."
Hours later, the Director of Nursing revealed the missing medications were stored in a "bed hold medications bin inside the medication room." The DON explained that LVN 3 "did not know because she worked part-time."
The facility's policy required medications to be "administered in a safe and timely manner as prescribed" and within one hour of their scheduled time. But Resident 8 never received the blood pressure medications that morning.
Emergency drug supplies also sat depleted for days without replacement. During inspection of medication rooms on June 12, inspectors found an emergency kit with two yellow seals indicating it had been opened. The log showed Percocet had been removed on June 8 at 3:47 p.m., but the pain medication was never replaced.
LVN 4 acknowledged the medication "should have been replaced within 24 hours" according to facility policy.
The pharmaceutical breakdowns extended to controlled substance tracking. Inspectors found multiple gaps in the controlled medication count sheets that nurses must sign at each shift change. Missing signatures appeared on April 3, May 8, May 31, and June 6 — creating potential openings for drug diversion.
LVN 4 verified the process required two licensed nurses to conduct physical inventory of all controlled medications and document counts on reconciliation sheets. "Any discrepancy in controlled substance medication count is reported to the Director of Nursing immediately," according to facility policy.
But the documentation gaps meant supervisors couldn't verify whether controlled drugs were properly accounted for during those shifts.
Another medication crisis involved conflicting narcotic orders for Resident 25, who had been prescribed multiple powerful opioids simultaneously. The resident's chart contained a physician's order from April 15, 2020, stating "no other narcotics and/or muscle relaxants while resident on methadone."
Despite this restriction, Resident 25 continued receiving additional narcotics alongside daily methadone doses. Orders included Dilaudid every eight hours for severe pain, Percocet every four hours for moderate pain, and tizanidine three times daily as a muscle relaxant.
Medical records showed Resident 25 received all four medications throughout May and June 2024. The resident told inspectors he took "methadone, Dilaudid, Percocet, and Tylenol for pain" and had "chronic pain throughout his body."
The facility's care plan acknowledged the dangerous combination, noting that "Dilaudid, methadone, and Percocet use exposed users to the risk of opioid addiction, abuse and misuse, which could lead to overdose and death."
LVN 2 reviewed the conflicting orders with inspectors and admitted "the physician's order should have been clarified with the physician." The Director of Nursing later acknowledged that "the nurse should have clarified the orders with the physician."
But for months, staff administered the contradictory medications without questioning the obvious conflict between the "no other narcotics" order and the multiple narcotic prescriptions.
The medication administration observation revealed systemic problems with drug management. Resident 8's case demonstrated how communication failures between part-time and full-time staff could leave patients without essential medications.
The facility's policy stated that "medications are administered in accordance with the prescriber orders" and "medication administration times are determined by the resident's need and benefit, and not for the staff's convenience."
Yet the 16.12 percent error rate suggested widespread departures from these standards.
Federal regulations require nursing homes to maintain medication error rates below 5 percent to ensure resident safety. The Anaheim facility's rate exceeded this threshold by more than 300 percent.
For Resident 8, the consequences extended beyond a single missed dose. Heart failure patients require consistent blood pressure control to prevent complications. The three undelivered antihypertensive medications — amlodipine, hydralazine and lisinopril — work together to manage cardiovascular stress.
The inspection findings revealed a facility where basic pharmaceutical safeguards had broken down. Emergency drug kits sat empty, controlled substance logs contained gaps, and contradictory narcotic orders went unchallenged for years.
Most troubling was the discovery that Resident 8's medications were available all along, stored in a designated bin that the part-time nurse didn't know existed. The failure represented not just a medication error, but a fundamental breakdown in staff training and communication systems.
The Director of Nursing and Administrator acknowledged all findings during the June 13 inspection. But for residents like Resident 8, the acknowledgment came after critical medications had already been missed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Anaheim Terrace Care Center from 2024-06-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
ANAHEIM TERRACE CARE CENTER in ANAHEIM, CA was cited for violations during a health inspection on June 13, 2024.
LVN 3 prepared morning medications for Resident 8 on June 11, gathering an antibiotic, blood thinner injection, vitamin supplement and laxative powder.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.