Health inspection·August 13, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (supplement) 600 mg medication was not available. LVN 1 stated he would not administer the calcium 600 mg medication until he clarified the order with the physician. LVN 1 was observed administering Resident 2's morning medications except the calcium 600 mg medication. Medical record review for Resident 2 was initiated on 8/13/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's BIMS score was 12 (moderate cognitive impairment). Review of Resident 2's H&P examination dated 8/10/25, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Order Summary Report dated 8/13/25, showed physician's order dated 8/5/25, for calcium 600 mg oral tablet, give one tablet by mouth one time a day for supplement. Review of Resident 2's MAR for August 2025 showed the following:- dated 8/12/25, the calcium 600 mg to be administered at 0900 hours had a documentation code 7 (other/see nurse notes). Review of the Resident 2' MAR note on 8/12/25 at 0850 hours, for the calcium medication showed need clarification from MD, and- dated 8/13/25, the calcium 600 mg to be administered at 0900 hours had a check mark to indicate it was given. Review of Resident 2's medical record failed to show the staff had clarified the calcium 600 mg medication order to the resident's physician on 8/12/25, as documented in the MAR. Additionally, review of Resident 2's MAR for August 2025 failed to show the calcium 600 mg medication was administered on 8/12/25. On 8/13/25 at 1150 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no new order for Resident 2's calcium nor a documentation to show the calcium medication was clarified with the physician on 8/12/25. RN 1 verified LVN 1 administered the calcium medication on 8/13/25 at 0900 hours. RN 1 stated LVN 1 failed to administer Resident 2's calcium 600 mg on 8/12/25, and it would be considered a medication error. RN 1 stated the licensed nurses must follow the physician's orders and when the medications were not available, the physician must be notified and to obtain an order. On 8/13/25 at 1210 hours, an observation and concurrent interview was conducted with LVN 1. When asked if he administered Resident 2's calcium medication scheduled at 0900 hours, LVN 1 showed the calcium 600 mg scheduled for 0900 hours was checked marked in the MAR to indicate administered. LVN 1 was asked to show the supply of the calcium 600 mg medication administered. LVN 1 opened the medication cart and showed a bottle of the calcium medication. However, the bottle showed calcium 600 mg with vitamin D. LVN 1 acknowledged the calcium 600 mg medication had vitamin D in it and stated it was the supply of the calcium 600 mg medication the facility currently have. LVN 1 was asked what he had administered to Resident 2 if the facility did not have the calcium 600 mg available. LVN 1 stated he did not administer Resident 2's calcium 600 mg since it was not available. LVN 1 acknowledged he had documented the calcium medication was administered even when Resident 2 did not receive the medication. In addition, LVN 1 was asked if the calcium medication was provided to Resident 2 or if he had clarified the calcium medication with the physician on 8/12/25. LVN 1 stated the calcium 600 mg medication was not administered on 8/12/25. LVN 1 further stated when he called the physician, the physician did not reply. LVN 1 acknowledged there was no documentation to show he attempted to call the physician or had endorsed to the next charge nurse to follow up. LVN 1 stated the medications not given as ordered by the physician could be detrimental to residents' health, the resident was taking the medications for a reason. On 8/13/25 1240 at hours, an interview was conducted with RN 1. RN 1 stated the licensed nurses must not document in the EMAR when the medication was not available and not administered. RN 1 stated the process for the medication administrations must be pour, pass, and sign. Furthermore, RN 1 stated it was unacceptable to document the medication was administered when the resident did not receive the medication. On 8/13/25 at 1250 hours, an interview was conducted with the DON. The DON stated the medication administration process must be pour, pass, and sign the EMAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555257 If continuation sheet Page 2 of 3 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 08/13/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete immediately for safe and accurate documentation. When asked if an advance documentation on any resident's EHR for care and services including the medication administration is acceptable, the DON stated it was not acceptable. Furthermore, the DON stated any missed medication could greatly affect the resident's health especially depending on the indication of the medication. On 8/13/25 at 1300 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 555257 If continuation sheet Page 3 of 3