6 Reports
Inspection Report — May 12, 2026
Annual Inspection
Date: May 12, 2026
Visit Reason
The report covers 27 inspections of Palmer Ranch Residence from August 14, 2012 to May 12, 2026, including standard and complaint visits.
Findings
Across the inspection history, 22 deficiencies were recorded, all Class 3 or lower, with no serious deficiencies. Seven legal actions with fines totaling $5,650 were taken.
Citations (22)
Emergency Management Planning — cited February 24, 2026, corrected March 17, 2026
Admissions - Continued Residency — cited July 31, 2025, corrected October 2, 2025
Resident Care - Elopement Standards — cited July 31, 2025, corrected September 16, 2025
Risk Mgmt & Qa — cited January 23, 2024, corrected February 29, 2024
Background Screening Clearinghouse — cited January 23, 2024, corrected February 29, 2024
Medication - Assistance With Self-admin — cited March 23, 2021, corrected October 13, 2021
Medication - Labeling and Orders — cited March 23, 2021, corrected October 13, 2021
Training - Staff In-service — cited March 23, 2021, corrected October 13, 2021
Training - Hiv/aids — cited March 23, 2021, corrected October 13, 2021
Training - Do Not Resuscitate Orders — cited March 23, 2021, corrected October 13, 2021
Records - Resident — cited March 23, 2021, corrected October 13, 2021
Emergency Management Planning — cited December 15, 2020, corrected March 23, 2021
Staffing Standards - Levels — cited April 5, 2018, corrected July 30, 2018
Admissions - Health Assessment — cited April 5, 2018, corrected July 2, 2018
Resident Care - Rights & Facility Procedures — cited April 5, 2018, corrected July 30, 2018
Medication - Administration — cited April 5, 2018, corrected July 30, 2018
Medication - Storage and Disposal — cited April 5, 2018, corrected July 30, 2018
Medication - Labeling and Orders — cited April 5, 2018, corrected July 30, 2018
Staffing Standards - Staff — cited April 5, 2018, corrected July 30, 2018
Resident Care - Activities of Daily Living — cited October 15, 2017, corrected December 4, 2017
Resident Care - Rights & Facility Procedures — cited October 15, 2017, corrected December 4, 2017
Staffing Standards - Levels — cited October 15, 2017, corrected December 4, 2017
Report Facts
Inspections: 27
Visits with deficiencies: 8
Clean visits: 11
Deficiencies: 22
Serious deficiencies: 0
Legal actions: 7
Total fines: 5650
Inspection Report — Jul 21, 2025
Complaint Investigation
Date: Jul 21, 2025
Visit Reason
The inspection was conducted to investigate allegations that a Licensed Practical Nurse administered unauthorized medications, including Melatonin and Benadryl, to residents without physician orders.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and observations that LPN Staff A administered Melatonin and Benadryl without orders to several residents, causing behavioral changes. The Director of Nursing verified the findings.
Findings
The investigation substantiated the allegation that LPN Staff A administered Melatonin and Benadryl to multiple residents without orders, resulting in observed behavioral changes such as increased confusion, excessive drowsiness, and aggression in some residents. The facility failed to protect residents from chemical abuse.
Citations (1)
F 0600: The facility failed to protect residents from abuse by administering unauthorized medications with sedative effects to residents, including Melatonin and Benadryl, without physician orders.
Report Facts
Melatonin pills unaccounted for: 54
Residents reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Staff A | Licensed Practical Nurse | Named in medication abuse finding for administering unauthorized Melatonin and Benadryl |
| Director of Nursing | Director of Nursing | Verified the substantiation of the abuse allegation |
Inspection Report — Mar 19, 2025
Complaint Investigation
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to complaints regarding neglect and inadequate pain management, medication administration, pharmaceutical services, and medical record maintenance at the nursing facility.
Complaint Details
The complaint investigation focused on neglect related to elopement risk and supervision failures for two residents, inadequate pain management for one resident, delays in obtaining physician-ordered medications for two residents, and incomplete medical records for two residents. The investigation included interviews, record reviews, and observations confirming these issues.
Findings
The facility failed to prevent elopement risk for confused residents, ensure timely and accurate pain management and medication administration, and maintain complete and accurate medical records for residents. Multiple deficiencies were identified related to elopement risk assessments, medication order reconciliation, and documentation.
Citations (4)
F 0600: The facility failed to prevent neglect by inadequate assessments and supervision for confused residents, resulting in elopement incidents involving two residents.
F 0697: The facility failed to provide safe and appropriate pain management based on resident goals and preferences for one resident, including failure to reconcile hospital discharge medication orders.
F 0755: The facility failed to obtain physician-ordered medications in a timely manner for two residents, resulting in delayed medication administration.
F 0842: The facility failed to maintain complete and accurate medical records for two residents, lacking admission assessments, medication verification, and communication documentation.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
BIMS score: 3
BIMS score: 11
BIMS score: 6
Tramadol tablets: 2
Pain score: 10
Inspection Report — Aug 29, 2024
Annual Inspection
Date: Aug 29, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at the nursing facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report — May 11, 2023
Routine
Date: May 11, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, dietary services, infection control, and facility operations at a nursing home.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with pacemakers, delays in scheduling specialist appointments, inadequate use of protective devices for residents, improper catheter care and justification, unsecured medication storage, delayed dental services, unqualified dietary management staff, and unsafe food handling practices.
Citations (8)
F 0656: The facility failed to develop a comprehensive care plan for a newly inserted pacemaker for Resident #204, lacking appropriate interventions and follow-up care.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences for Residents #37 and #38, including failure to schedule a neurology evaluation and improper use of protective geri-sleeves.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident #37, including failure to ensure use of a prescribed device to prevent hand contracture.
F 0690: The facility failed to ensure valid medical justification for continued use of an indwelling foley catheter for Resident #1 and failed to prevent urinary tract infections for Residents #13 and #203 by improper catheter care.
F 0761: The facility failed to ensure all drugs and biologicals were labeled or stored in locked compartments for Residents #32 and #39, with unsecured medications found at bedside.
F 0791: The facility failed to provide timely dental care services to meet the needs of Resident #38, with delays in scheduling and lack of communication.
F 0801: The facility failed to employ a qualified Dietary Manager as required by regulation, risking improper dietary management and nutritional care.
F 0812: The facility failed to store and serve food in accordance with professional standards, with uncovered, undated food items and improper food handling leading to potential cross-contamination.
Report Facts
Residents reviewed for pacemakers: 3
Residents sampled for care and services: 26
Residents reviewed with indwelling foley catheter: 5
Residents reviewed for medication storage: 2
Residents reviewed for dental services: 1
Residents in facility: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Staff F | Infection Preventionist | Verified inhaler medication was stored unsecured and agreed urinary catheter bags should not be stored on the floor. |
| Assistant Director of Nursing | ADON | Confirmed neurology appointment order and verified medication storage issues. |
| Director of Nursing | DON | Reviewed documentation and confirmed issues with care plan and catheter care. |
| Registered Dietician | RD | Contracted dietician responsible for assessments and sanitation audits; verified dietary manager unqualified. |
| Dietary Manager | Dietary Manager | Hired without required qualifications or prior food service experience. |
| Social Service Director | SSD | Reported delay in dental appointment scheduling for Resident #38. |
| Certified Nursing Assistant Staff C | CNA | Verified residents not wearing protective sleeves and catheter care observations. |
| Certified Nursing Assistant Staff N | CNA | Observed urinary catheter drainage bags on floor and medication storage practices. |
| Rehabilitation Director | Rehab Director | Confirmed lack of restorative program for Resident #37. |
Inspection Report — Sep 10, 2021
Annual Inspection
Date: Sep 10, 2021
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with healthcare regulations and facility policies at Brookdale Palmer Ranch SNF.
Findings
The facility was found deficient in multiple areas including failure to prevent pressure ulcers, lack of informed consent for bed rails, improper medication management including expired drugs and medication errors, breaches in infection control during medication administration, and failure to conduct regular maintenance inspections of bed frames and rails.
Citations (6)
F 0686: The facility failed to implement ordered preventive measures and monitoring to prevent pressure ulcers for Resident #32, resulting in a suspected deep tissue pressure injury on the left heel.
F 0700: The facility failed to review risks and benefits or obtain informed consent prior to installing bed rails for Residents #32 and #34, and did not document negotiated risk agreements or alternatives.
F 0755: The facility failed to implement a system for periodic reconciliation and proper disposal of controlled substances and expired medications, including expired Lorazepam and Proair inhaler.
F 0759: The facility failed to administer medications according to physician orders, resulting in two medication errors for Residents #190 and #191, with a 7.69% error rate.
F 0880: The facility failed to administer medications in a sanitary manner, with Licensed Practical Nurse Staff B handling medications with ungloved hands for Residents #190 and #191.
F 0909: The facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a maintenance program to identify entrapment risks.
Report Facts
Medication error rate: 7.69
Medication expiration: 90
Pressure injury size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Staff B | Licensed Practical Nurse | Named in medication error findings, expired medication handling, and infection control breach during medication administration. |
| Director of Nursing | Director of Nursing | Interviewed regarding skin integrity review forms, medication disposal procedures, and controlled substances reconciliation. |
| Unit Coordinator Licensed Practical Nurse Staff A | Licensed Practical Nurse | Responsible for ensuring weekly skin assessments were completed; interviewed about pressure wound notification. |
| Maintenance Director | Maintenance Director | Interviewed about lack of regular maintenance inspections for bed frames, mattresses, and bed rails. |
6 CMS Surveys
CMS Survey — May 11, 2023
May 11, 2023
CMS Survey — Mar 19, 2025
Mar 19, 2025
CMS Survey — Jul 21, 2025
Jul 21, 2025
CMS Survey — Sep 10, 2021
Sep 10, 2021
CMS Survey — May 11, 2023
May 11, 2023
CMS Survey — Aug 29, 2024
Aug 29, 2024
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