F0765

Failure to Ensure Immediate and Accurate Medication Documentation

Palm Terrace Healthcare & Rehabilitation CenterLaguna Hills, California Survey Completed on 08-13-2025

Summary

Staff were required to follow the administration process of pouring, passing, and immediately signing the EMAR for safe and accurate documentation of medication administration. When questioned about the acceptability of advance documentation in the EHR for care and services, including medication administration, the DON confirmed that such practice was not acceptable. The DON also acknowledged that any missed medication could significantly impact a resident's health, depending on the medication's indication. During an interview, both the Administrator and DON were informed of and acknowledged these findings.

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
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