Health inspection·September 3, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a. On 8/29/24 at 1550 hours, an interview with Resident 1 was conducted. Resident 1 stated medications were usually received late. On 9/3/24 at 0947 hours, an observation and concurrent interview with LVN 2 was conducted. LVN 2 was observed administering the medications to Resident 1. When LVN 2 was done administering the medications, LVN 2 was asked about the medications administered to Resident 1. LVN 2 confirmed the medications given to Resident 1 were due at 0800 hours. LVN 2 stated he just started the medication administration at 0830 hours because the nurse assigned to administer the medications did not show up today. LVN 2 further stated he still needed to administer the medications scheduled for 0800 hours to other residents at this time. On 9/3/24 at 0954 hours, an observation and concurrent interview with LVN 3 was conducted. LVN 3 was observed wheeling the medication cart back towards Nurses Station A. LVN 3 confirmed she just finished passing the medications scheduled to be administered at 0800 hours. b. Medical record review for Resident 2 was initiated on 9/3/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 09/05/24, showed a physician's order to administer the following: - atenolol-chlorthalidone (a medication used to control high blood pressure) 50-25 mg one-half tablet one time a day for hypertension. Hold for systolic blood pressure (SBP) less than 110 mmHg or heart rate less than 55 beats per minute ordered on 8/23/24. - fish oil (omega-3 fatty acids, a supplement) 1000 mg one capsule by mouth one time a day ordered on 3/23/24. - gabapentin (a medication to treat and prevent seizures or treat nerve pain) 600 mg one tablet by mouth three times a day, ordered on 6/26/24. - Prozac (fluoxetine, a medication used for depression) 40 mg by mouth one time a day, ordered on 1/26/24. - Tylenol (a medication used for mild pain and fever) 325 mg two tablets by mouth every four hours as needed for moderate pain, levels 4-6 (on a 0-10 pain scale with 0 = no pain and 10 = worst pain) not to exceed three grams per day of acetaminophen from all sources ordered on 11/14/23. Review of Resident 2's MAR for September 2024 showed the following medications were to be administered at the following times: - atenolol-chlorthalidone 50-25 mg, give half tablet one time a day and to hold for systolic blood pressure (SBP) less than 110 mmHg or heart rate less than 55 beats per minute, administer at 0800 hours. - Fish oil 1000 mg give one capsule by mouth one time a day medication, administer at 0800 hours. - gabapentin 600 mg one tablet by mouth three times a day medication, administer at 0800, 1200, and 1600 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555257 If continuation sheet Page 2 of 5 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 09/03/2024 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 0755 - Prozac 40 mg by mouth one time a day medication, administer at 0800 hours. Level of Harm - Minimal harm or potential for actual harm - Tylenol 325 mg give two tablets by mouth every four hours as needed for moderate pain (4-6) not to exceed 3 grams per day of acetaminophen from all sources. Residents Affected - Few On 9/3/24 at 1006 hours, a concurrent medication administration observation and interview was conducted with LVN 4. During the medication administration observation, LVN 4 prepared and administered the following medications to Resident 2: - atenolol-chlorthalidone 50-25 mg one-half tablet - fish oil 1000 mg one capsule - gabapentin 600 mg one capsule - fluoxetine 40 mg one capsule - Tylenol 325 mg two caplets for complain of pain After the medication administration observation, LVN 4 was asked about the medications administered to Resident 2, LVN 4 confirmed she gave Resident 2 the medications that were supposed to be given at 0800 hours. LVN 4 stated one of her residents had a change of condition and needed to take care of the resident first. LVN 4 further stated she still needed to administer the medications scheduled for 0800 hours, to other residents at this time. c. On 9/3/24 at 0954 hours, an observation and concurrent interview with LVN 3 was conducted. LVN 3 was observed wheeling the medication cart back towards Nurses Station A. LVN 3 confirmed she just finished passing the medications scheduled to be administered at 0800 hours. On 9/3/24 at 1040 hours, a follow-up interview was conducted with LVN 3. LVN 3 confirmed she finished administering the medications scheduled for 0800 hours at 0954 hours. LVN 3 stated she usually finishes the 0800 hours medication administration by a little before 1000 hours most of the time because she made sure the residents swallowed the medications she gave to the residents. On 9/3/24 at 1410 hours, an interview with the DON was conducted. The DON stated the medication administration should not be interrupted. The DON expected the RN supervisor, or the desk nurse to take care of residents with change in condition and should start the medication administration when a licensed nurse scheduled to give the medications did not show up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555257 If continuation sheet Page 3 of 5 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 09/03/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure resident's meals were served at the desired temperatures. This failure had the potential for the undesirable food temperatures to result in decreased oral meal intake and undesirable weight loss for the residents. Residents Affected - Few Findings: a. Medical record review for Resident 3 was initiated on 9/3/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 8/30/24, showed Resident 3 had the capacity to make decisions. On 8/29/24 at 1505 hours, an interview was conducted with Resident 3. Resident 3 stated the hot food items on the meal tray were not hot enough. Resident 3 stated he would like to at least eat the warm food. b. Medical record review for Resident 4 was initiated on 9/3/24. Resident was admitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 was able to make to make self-understood and understand others. Resident 4's BIMS summary score showed 15 (cognitively intact). On 9/3/24 at 0908 hours, an interview with Resident 4 was conducted. Resident 4 stated the food could be improved. Resident 4 further stated, most of the time the food is already cold. On 9/3/24 at 0748 hours, a test tray was requested to be added to Station 1's meal tray cart. On 9/3/24 at 0806 hours, a meal tray cart with doors containing the test tray and meal trays for the residents was parked by Nurses' Station 1. On 9/3/24 at 0810 hours, the resident's meals trays were passed except for the test tray. The CNAs were observed to close the doors after getting resident's meal trays. The DSS brought the covered test tray in the conference room located across the Nurses' Station 1. On 9/23/24 at 0811 hours, a test tray inspection was conducted with the DSS. The temperatures of the following food items were checked and showed the following readings: - egg omelet was at 105.6 degrees Fahrenheit, - bacon was at 86.1 degrees Fahrenheit, - oatmeal was at 108.6 degrees Fahrenheit, - milk was at 51.2 degrees Fahrenheit. A taste test of the food served on the test tray was also conducted with the DSS. The egg omelet, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555257 If continuation sheet Page 4 of 5 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 09/03/2024 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 0804 oatmeal, and bacon were cold. The DSS verified the egg, oatmeal, and bacon temperature went down and were cold. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555257 If continuation sheet Page 5 of 5