F 0842
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and medical record review, the facility failed to ensure the medical records were accurately
documented for two of two sampled residents (Residents 1 and 2).
* When Resident 1 experienced a fall in the facility, LVN 2 inaccurately documented in the medical record
that Resident 1 had no falls, thus placing her as a low risk for falls.
* Resident 2's plan of care erroneously showed she experienced an actual fall in the facility.
These failures had the potential the residents to not receive appropriate interventions to prevent falls.
Findings:
1. On 9/8/23 at 1224 hours, an interview and concurrent medical record review was conducted with LVN 4.
LVN 4 was asked about Resident 1. LVN 4 stated Resident 1 was in her normal assignment for the 0700 to
1500 hours shift. LVN 4 reviewed the medical record and stated Resident 1 experienced a fall on 8/26/23.
LVN 4 reviewed the Fall Risk Evaluation dated 8/26/23, and stated it showed Resident 1 was at a low risk
for falls. Under Section B: history of falls, review of the document showed no falls in the past 3 months. LVN
4 was unable to explain why Resident 1 was noted as having no falls.
Medical record review for Resident 1 was initiated on 9/8/23. Resident 1 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of the Fall Risk Evaluation dated 8/10/23, showed Resident 1 was at a high risk for falls.
Review of the Fall Risk Evaluation dated 8/26/23, showed Resident 1 was at a low risk for falls, and showed
Resident 1 did not experience any falls in the prior 3 months.
On 9/8/23 at 1343 hours, a telephone interview was conducted with CNA 1. CNA 1 was asked about
Resident 1. CNA 1 stated on 8/26/23 during the 1430 to 2230 hours shift, she entered Resident 1's room
and found Resident 1 sitting on the floor next to the bed. CNA 1 stated Resident 1 stated she was trying to
get to the bathroom when she fell. CNA 1 stated she asked for assistance of other staff to assist Resident 1
back to bed.
On 9/8/23 at 1540 hours, a telephone interview and concurrent medical record review was conducted with
LVN 2. LVN 2 was asked about Resident 1. LVN 2 stated she was working when Resident 1 reported
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555257
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555257
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Terrace Healthcare & Rehabilitation Center
24962 Calle Aragon
Laguna Hills, CA 92637
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Potential for
minimal harm
Residents Affected - Some
she experienced a fall. LVN 2 stated she assessed the resident, notified the physician, and completed a Fall
Risk Assessment. When asked why falls within prior 3 months were marked as none on the Fall Risk
assessment dated [DATE], LVN 2 stated she misunderstood, and stated the form should have included
Resident's 1 fall on 8/26/23.
2. On 9/8/23 at 1158 hours, an observation and concurrent interview was conducted with Resident 2 at the
bedside. Resident 2 was observed in bed with bilateral floor mats. Resident 2 was asked if she experienced
a fall in the facility. Resident 2 stated no, she did not.
Medical record review for Resident 2 was initiated on 9/8/23. Resident 2 was admitted to the facility on
[DATE].
Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact.
Review of Resident 2's plan of care showed a care plan problem dated 9/8/23, addressing the resident's
actual fall with poor balance and unsteady gait. The interventions included to perform the neuro-checks as
ordered and assign the room close to the nurses' station.
On 9/12/23 at 1407 hours, a telephone interview and concurrent medical record review was conducted with
the DON. The DON was asked if Resident 2 experienced an actual fall. The DON reviewed the medical
record and stated Resident 2 did not experience a fall within the facility. The DON was asked to review the
plan of care. The DON verified Resident 2 had a care plan problem addressing an actual fall and stated it
must have been a mistake.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555257
If continuation sheet
Page 2 of 2
