Palm Terrace Healthcare & Rehabilitation Center
Palm Terrace Healthcare & Rehabilitation Center in LAGUNA HILLS, CA — inspection on February 26, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 1's H&P examination dated 1/9/26, showed Resident 1 had no capacity to understand and make decisions.
Review of Resident 1's Progress Notes showed the following:- dated 2/8/26 at 2149 hours. Resident 1 was very agitated, began yelling and cussing at staff, the sheriff was called and two officers from the sheriff's office responded. Resident 1 was transferred to the hospital at 1800 hours via EMS ambulance. - dated 2/8/25 at 2303 hours, LVN 1 documented a head to toe assessment for Resident 1 under the skilled evaluation. On 2/24/26 at 1128 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 2. LVN 2 verified the progress notes dated 2/8/26 at 2149 hours and 2303 hours were charted after the resident discharged the facility at 1800 hours. LVN 2 stated if it was me, I won't chart for this resident, I can't assess this resident, he is gone, transferred to the hospital. On 2/24/26 at 1525 hours, an interview was conducted with the MDS Coordinator.
The MDS Coordinator acknowledged the progress note dated 2/8/26 at 2303 hours should not have been documented after the resident left the facility at 1800 hours.
The MDS Coordinator stated the staff who documented the note should not have documented that. On 2/25/25 at 0951 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was not assigned to Resident 1 and was just helping the nurses document. LVN 1 further stated she saw Resident 1 at the start of her evening shift and was not aware Resident 1 was transferred to the hospital. LVN 1 stated they should have checked with the nurses and CNAs then wrote the notes.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE