Palm Terrace Healthcare & Rehabilitation Center
24962 Calle Aragon, Laguna Hills, CA 92637 · Orange County · 99 certified beds · avg 92 residents/day · certified since Apr 9, 1987
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$50,950
Fines, last 3 years
3.84
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 9, 2026 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 10, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 9, 2026 · F-0726 · triggered by a complaint
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 10, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (50)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 26, 2026 | B · Minimal risk, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Feb 9, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 9, 2026 | ▲ G · Actual harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Feb 9, 2026 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Feb 9, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 9, 2026 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Feb 9, 2026 | B · Minimal risk, repeated | The facility did not dispose of garbage and refuse properly. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 3, 2025 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Feb 3, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 3, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Feb 3, 2025 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 3, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 3, 2025 | B · Minimal risk, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 3, 2025 | B · Minimal risk, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 3, 2025 | B · Minimal risk, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 3, 2025 | B · Minimal risk, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Sep 3, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 3, 2024 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 8, 2023 | B · Minimal risk, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 24, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 24, 2022 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 24, 2022 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 24, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (9 → 22).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 11 | 0 | F |
| 2023 | 3 | 0 | D |
| 2024 | 3 | 0 | D |
| 2025 | 10 | 0 | D |
| 2026 | 23 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $50,950.
| Date | Type | Amount / length |
|---|---|---|
| Feb 9, 2026 | Fine | $25,475 |
| Feb 9, 2026 | Fine | $25,475 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.84 | 4.31 | 3.95 | bottom 30% in California; top 46% in the U.S. |
| Registered Nurse hours | 0.39 | 0.61 | 0.69 | bottom 30% in California; bottom 21% in the U.S. |
| Weekend total nurse staffing | 3.27 | 3.90 | 3.50 | bottom 15% in California; bottom 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.51 | 0.48 | bottom 19% in California; bottom 19% in the U.S. |
| Total nursing staff turnover (%) | 52.5 | 36.7 | 45.8 | bottom 10% in California; bottom 31% in the U.S. |
| RN turnover (%) | 50.0 | 38.1 | 42.9 | bottom 29% in California; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.34, RN 0.44, weekend 3.69. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| The Ensign Group INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/30/2006 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 01/30/2006 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2004 |
| Eskandari, Hamid | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/01/2021 |
| Eskandari, Hamid | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2021 |
| Eskandari, Hamid | Individual | ADP of the SNF | NOT APPLICABLE | 02/01/2021 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Lindsey, Bryce | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/02/2019 |
| Lindsey, Bryce | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/02/2019 |
| Lindsey, Bryce | Individual | ADP of the SNF | NOT APPLICABLE | 04/02/2019 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 10/14/2025 |
| Welltower Victory II Landlord LP | Organization | ADP of the SNF | NOT APPLICABLE | 08/31/2016 |
| Willits, Adam | Individual | Corporate Director | NOT APPLICABLE | 07/30/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you explain health changes and treatment options to residents and their families?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Villa Valencia Healthcare Center | 0.5 mi | Laguna Hills, CA | ★★★★☆ | 4/5 | |
| Laguna Hills Health and Rehabilitation Center | 0.6 mi | Laguna Hills, CA | ★☆☆☆☆ | 1/5 | |
| Freedom Village Healthcare Center | 1.7 mi | Lake Forest, CA | ★★★★★ | 3/5 | |
| Trabuco Hills Post Acute | 3.6 mi | Lake Forest, CA | ★★☆☆☆ | 1/5 | |
| Orchards Skilled Nursing | 3.9 mi | Rancho Mission Viejo, CA | ★★★★★ | 4/5 | |
| San Juan Hills Healthcare Center | 7.5 mi | San Juan Capistrano, CA | ★★★★☆ | 3/5 | |
| Regents Point - Windcrest | 7.8 mi | Irvine, CA | ★★★★☆ | 3/5 | |
| Capistrano Beach Care Center | 11.0 mi | Dana Point, CA | ★☆☆☆☆ | 2/5 | |
| Foothill Regional Medical Center D/P SNF | 11.4 mi | Tustin, CA | ★★★★☆ | 4/5 | |
| Newport Subacute Healthcare Center | 11.7 mi | Costa Mesa, CA | ★☆☆☆☆ | 1/5 | |
| Victoria Healthcare and Rehabilitation Center | 12.1 mi | Costa Mesa, CA | ★★★★★ | 5/5 | |
| Plaza Healthcare Center | 12.4 mi | Santa Ana, CA | ★☆☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 555257.