Laguna Hills, CA

Palm Terrace Healthcare & Rehabilitation Center

4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

24962 Calle Aragon, Laguna Hills, CA

(949) 587-9000

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1987-04-09

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.34

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.57

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.43

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

4.34

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.91

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

3.73

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.15

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.30

CMS adjusted RN staffing hours

Adjusted total hours

3.86

CMS adjusted total nurse staffing hours

Case-mix index

1.54

Higher values indicate more complex resident acuity

RN turnover

73%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,512

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

20.10

Composite VBP score used to determine payment impact.

Payment multiplier

0.9823

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.10% · Performance 23.57% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 9.82% · Performance 9.81% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

5.65

Baseline 42.31% · Performance 40.59% · Measure score 5.65 · Achievement 5.65 · Improvement 0.48

Adjusted total nurse staffing

2.39

Baseline 3.6 hours · Performance 3.76 hours · Measure score 2.39 · Achievement 2.39 · Improvement 0.23

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.39%	10.72% 1.7 pts worse	No Different than the National Rate · Eligible stays 374 · Observed rate 11.5% · Lower 95% interval 9.41%
Discharge to community	59.46%	50.57% 8.9 pts better	Better than the National Rate · Eligible stays 373 · Observed rate 54.69% · Lower 95% interval 54%
Medicare spending per beneficiary	1.25	1.02 0.2 pts worse
Drug regimen review with follow-up	89.18%	95.27% 6.1 pts worse	Numerator 272 · Denominator 305
Falls with major injury	0.33%	0.77% 0.4 pts better	Numerator 1 · Denominator 305
Discharge self-care score	37.84%	53.69% 15.8 pts worse	Numerator 28 · Denominator 74
Discharge mobility score	35.14%	50.94% 15.8 pts worse	Numerator 26 · Denominator 74
Pressure ulcers or injuries, new or worsened	2.95%	2.29% 0.7 pts worse	Numerator 9 · Denominator 305 · Adjusted rate 2.8%
Healthcare-associated infections requiring hospitalization	9.81%	7.12% 2.7 pts worse	No Different than the National Rate · Eligible stays 234 · Observed rate 10.26% · Lower 95% interval 6.64%
Staff COVID-19 vaccination coverage	11.68%	8.2% 3.5 pts better	Numerator 23 · Denominator 197
Staff flu vaccination coverage	65.76%	42% 23.8 pts better	Numerator 194 · Denominator 295
Discharge function score	39.19%	56.45% 17.3 pts worse	Numerator 29 · Denominator 74
Transfer of health information to provider	96.7%	95.95% 0.8 pts better	Numerator 205 · Denominator 212
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 67 · Denominator 67
Resident COVID-19 vaccinations up to date	35.33%	25.2% 10.1 pts better	Numerator 53 · Denominator 150

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.1	2.3 0.2 pts better	1.9 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.5 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.7	1.6 0.9 pts better	1.8 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	98.5% 1 pts better	93.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.9% · 4Q avg 99.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	98.2% 1.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.8%	1.6% 2.2 pts worse	3.3% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.2% · Q3 2.2% · Q4 2.1% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.0%	6.8% 3.8 pts better	11.4% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.4% · Q3 4.9% · Q4 0.0% · 4Q avg 3.0%
Percentage of long-stay residents who lose too much weight	0.6%	4.1% 3.5 pts better	5.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.1%	13.7% 6.4 pts worse	19.6% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 25.0% · Q3 20.5% · Q4 15.6% · 4Q avg 20.1%
Percentage of long-stay residents who received an antipsychotic medication	3.7%	14.2% 10.5 pts better	16.7% 13 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.5% · Q3 5.9% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.4% 0.4 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	7.3%	11.0% 3.7 pts better	16.3% 9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 7.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.4%	10.7% 3.3 pts better	14.9% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.6% · Q3 13.5% · Q4 7.7% · 4Q avg 7.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	1.0% 1 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	1.2% 0.6 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.3%	10.9% 0.6 pts better	19.8% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 7.0% · Q3 11.9% · Q4 19.1% · 4Q avg 10.3%
Percentage of long-stay residents with pressure ulcers	2.9%	4.7% 1.8 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.5% · Q3 3.1% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.9%	94.0% 5.9 pts better	81.7% 18.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.7% · 4Q avg 99.9%
Percentage of short-stay residents who had an outpatient emergency department visit	12.7%	11.2% 1.5 pts worse	12.0% 0.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.7% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.2%	1.5% 1.3 pts better	1.6% 1.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	99.7%	93.2% 6.5 pts better	79.7% 20 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 99.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.5%	23.2% 5.3 pts worse	23.9% 4.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 29.3% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-03 · Fire 2025-02-03

10 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2022-05-24 · Fire 2022-05-24

14 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 3 Health 2019-11-01 · Fire 2019-11-01

30 health deficiencies

Top issue: Quality of Life and Care (14 deficiencies)

12 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-03

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2025-02-07

E · Potential for more than minimal harm 2025-02-03

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-02-08

D · Potential for more than minimal harm 2022-05-24

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2022-06-14

D · Potential for more than minimal harm 2022-05-24

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2022-06-14

D · Potential for more than minimal harm 2022-05-24

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-06-14

D · Potential for more than minimal harm 2022-05-24

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-06-14

D · Potential for more than minimal harm 2022-05-24

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2022-06-14

D · Potential for more than minimal harm 2022-05-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-06-14

F · Potential for more than minimal harm 2019-11-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-12-30

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-13

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-08-27

D · Potential for more than minimal harm 2025-02-03

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-02-21

D · Potential for more than minimal harm 2025-02-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-02-21

D · Potential for more than minimal harm 2025-02-03

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-02-21

D · Potential for more than minimal harm 2025-02-03

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-02-21

D · Potential for more than minimal harm 2025-02-03

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-02-21

B · Minimal harm 2025-02-03

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-02-21

B · Minimal harm 2025-02-03

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-02-21

B · Minimal harm 2025-02-03

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-02-21

B · Minimal harm 2025-02-03

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-02-21

D · Potential for more than minimal harm 2024-10-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-11-09

D · Potential for more than minimal harm 2024-09-03

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-09-18

D · Potential for more than minimal harm 2024-09-03

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-09-18

D · Potential for more than minimal harm 2023-11-30

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-12-30

D · Potential for more than minimal harm 2023-11-30

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-12-30

B · Minimal harm 2023-09-08

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-09-22

D · Potential for more than minimal harm 2023-06-23

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-07-22

D · Potential for more than minimal harm 2023-05-04

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-06-02

D · Potential for more than minimal harm 2023-04-27

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-06-02

D · Potential for more than minimal harm 2023-04-27

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-06-02

D · Potential for more than minimal harm 2023-04-27

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-06-02

D · Potential for more than minimal harm 2023-03-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-04-15

D · Potential for more than minimal harm 2023-03-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-04-15

D · Potential for more than minimal harm 2023-03-15

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-04-15

D · Potential for more than minimal harm 2023-03-15

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-04-15

D · Potential for more than minimal harm 2023-03-15

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-04-15

D · Potential for more than minimal harm 2023-03-15

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2023-04-15

F · Potential for more than minimal harm 2022-05-24

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-05-24

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F761 · Pharmacy Service Deficiencies

Health

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-24

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-06-24

E · Potential for more than minimal harm 2019-11-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F761 · Pharmacy Service Deficiencies

Health

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2019-12-01

D · Potential for more than minimal harm 2019-11-01

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2019-12-01

Penalties and ownership