LAGUNA HILLS, CA - Federal inspectors documented multiple medication safety violations and care delivery failures at Palm Terrace Healthcare & Rehabilitation Center during a February 2025 inspection, revealing systemic issues with intravenous therapy protocols, medication administration, and respiratory care management.
Intravenous Therapy Documentation Failures
Inspectors identified critical deficiencies in the facility's intravenous medication protocols that posed significant risks to resident safety. During a morning tour on January 29, 2025, surveyors observed a resident receiving Vancomycin, a potent antibiotic used to treat serious bacterial infections including abdominal abscesses. The IV medication bag containing one gram of Vancomycin lacked essential documentation: no date, no administration time, and no nurse signature.
When the registered nurse was questioned about the undocumented medication, she acknowledged the deficiency. This violation directly contradicted the facility's own undated Nursing Clinical policy, which explicitly requires labeling IV containers with the resident's name, medication, dose, nurse initials, time, and date.
Proper IV medication labeling serves multiple critical functions in hospital and nursing home settings. The date and time documentation allows healthcare providers to track when medications were started, ensuring they are administered for the correct duration and changed according to proper sterile protocols. The nurse signature creates accountability and enables other staff members to identify who can answer questions about the medication administration. Without this information, subsequent shifts cannot verify whether the medication has been hanging too long, potentially losing effectiveness or becoming contaminated.
The inspection revealed additional IV therapy deficiencies when surveyors observed another resident with an unlabeled and undated peripheral intravenous line dressing on the right hand. This resident was receiving Ceftriaxone, a two-gram intravenous antibiotic for urinary tract infection treatment. The physician's orders specifically required the PIV site to be changed every 72 hours and as needed for infiltration or soiling.
The registered nurse confirmed the PIV line dressing was neither dated nor labeled, acknowledging that dating and labeling ensures staff members know how long the resident has had the IV line and when it requires changing. Peripheral IV sites require regular rotation because prolonged use in one location increases risks of phlebitis (vein inflammation), infiltration (IV fluid leaking into surrounding tissue), and infection. Without proper dating, staff cannot determine when the 72-hour window expires, potentially leaving IV lines in place beyond safe parameters.
Respiratory Care Protocol Violations
The facility demonstrated significant failures in respiratory care delivery, affecting multiple residents who required supplemental oxygen therapy. Inspectors documented that nursing staff administered oxygen at rates different from physician orders, and failed to properly maintain respiratory equipment.
One resident with acute respiratory failure secondary to congestive heart failure had a physician's order for continuous oxygen at three liters per minute via nasal cannula. However, during observation on January 29, 2025, inspectors found the resident receiving oxygen at five liters per minute through an oxygen concentrator—nearly double the prescribed rate.
The following day, a licensed vocational nurse was observed with the same resident, who was now receiving oxygen at four liters per minute, still exceeding the ordered rate. When the nurse reduced the oxygen to the prescribed three liters per minute, the resident's oxygen saturation dropped to 87% (below the normal range of 95-100%), and the resident complained of difficulty breathing during inspiration.
Oxygen administration requires precise control because it functions as a medication with specific dosing requirements. For patients with certain conditions, particularly chronic obstructive pulmonary disease, excessive oxygen can suppress the respiratory drive, potentially causing dangerous carbon dioxide retention. Conversely, insufficient oxygen leads to hypoxemia, depriving tissues of necessary oxygen.
The medical record contained no documentation explaining who increased the resident's oxygen rate, when it was increased, or the clinical rationale for exceeding the physician's order. The record also lacked evidence that the physician was notified prior to the unauthorized increase. This documentation gap creates a dangerous situation where changes in respiratory support occur without proper medical oversight or communication between healthcare team members.
Additional respiratory care deficiencies involved equipment maintenance. Inspectors observed two residents with undated oxygen tubing, and another resident with undated nebulizer tubing. The facility's own policy required oxygen tubing to be changed weekly and as needed, with the change date written on the tubing. A licensed vocational nurse confirmed this requirement but could not explain why multiple residents had undated equipment.
Regular replacement of oxygen delivery equipment prevents bacterial colonization and ensures proper function. Oxygen tubing can accumulate moisture, creating environments where bacteria multiply. Nebulizer equipment requires even more stringent hygiene standards because the mist directly enters the lungs, carrying any contamination deep into the respiratory system.
Medication Administration Errors
Federal surveyors conducting a medication pass observation documented a significant medication error when a licensed vocational nurse failed to check a resident's pulse rate before administering a blood pressure medication with specific hold parameters.
The resident had a physician's order for Hydralazine 25 mg twice daily for hypertension, with clear instructions to hold the medication if systolic blood pressure measured less than 110 mmHg or pulse rate dropped below 60 beats per minute. The nurse checked the resident's blood pressure but proceeded to prepare the medication without assessing the pulse rate.
When inspectors intervened before medication administration, pointing out the missed pulse check, the nurse returned to the resident's room and obtained a pulse rate of 69 beats per minute before administering the medication. Had the pulse rate been below 60 beats per minute, administering Hydralazine could have caused dangerous bradycardia (abnormally slow heart rate), potentially leading to dizziness, syncope (fainting), or inadequate blood flow to vital organs.
Hold parameters exist because certain cardiovascular medications can produce cumulative effects on heart rate and blood pressure. Hydralazine works by relaxing blood vessels, which can lower blood pressure and sometimes affect heart rate. When a patient's pulse is already low, adding a medication that might further slow the heart creates risks of inadequate cardiac output—the heart beating too slowly to pump sufficient blood to meet the body's needs.
Medication Storage and Controlled Substance Accountability
Inspectors identified failures in pharmaceutical services that increased risks of medication errors and potential drug diversion. The facility's narcotic count sheets, used to track controlled substances, contained multiple missing signatures from incoming and outgoing licensed nurses across several shifts in January 2025.
The facility's policy required two licensed nurses to conduct a physical inventory of all controlled medications at each shift change, documenting the count on an audit record with both nurses signing. Missing signatures meant the facility could not verify that controlled medication counts were properly reconciled between shifts.
Controlled substance accountability systems serve as the primary safeguard against medication diversion—the illegal removal of medications for personal use or distribution. When nurses fail to sign count sheets, the facility loses the ability to track who last verified the medication inventory. If discrepancies later emerge, determining when and how controlled substances went missing becomes impossible. The facility's own interim director of nursing acknowledged that unaccounted controlled medications create risks for narcotic diversion.
Additional medication storage violations included improperly stored wound care supplies and failure to separate internal and external medications. Inspectors found open packages of skin closure strips that had been cut in half and an opened calcium alginate dressing with a cut portion stored in a medication cart. Single-use sterile supplies lose their sterility once packages are opened, potentially introducing infection risks when applied to residents' wounds.
Additional Issues Identified
The inspection documented numerous other deficiencies affecting resident care quality and safety. The dietary department failed to follow pureed food recipes and menus, using cold milk instead of warm milk in potato preparation and using incorrect scoop sizes when serving pureed wheat rolls. These deviations affect nutritional content and portion control for residents requiring texture-modified diets due to swallowing difficulties.
Kitchen sanitation problems included heavily marred pots and cutting boards with discoloration, measuring cups with oil residue, and utensils with chipped handles. Multiple food items in refrigerators and freezers lacked proper dating and labeling, preventing staff from determining how long items had been stored. One dietary supervisor was observed working without required hair restraints, creating contamination risks.
Medical record accuracy problems emerged when inspectors found documented vital signs and fluid intake/output entries for a resident after the resident had been transferred to an acute care hospital. Another resident receiving dialysis had blood pressure readings documented from an arm containing an arteriovenous shunt, directly contradicting physician orders and facility policy prohibiting blood pressure measurements on extremities with dialysis access sites. Taking blood pressure on an arm with a dialysis access can damage the delicate vascular connection that dialysis patients depend on for life-sustaining treatment.
The facility also failed to update care plans to reflect current treatments, including oxygen therapy that had been ordered but never added to the resident's documented care plan. Care plans serve as the primary communication tool for ensuring all staff members understand each resident's needs and current interventions.
These violations occurred at a 98-bed facility in Laguna Hills, California, during an inspection completed February 3, 2025. The deficiencies span multiple departments and care processes, indicating systemic issues with staff training, supervision, and quality assurance monitoring. Federal regulations require nursing homes to provide pharmaceutical services, respiratory care, and dietary services that meet professional standards and ensure resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Terrace Healthcare & Rehabilitation Center from 2025-02-03 including all violations, facility responses, and corrective action plans.
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