Health inspection·May 15, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 14) who was not a candidate for self-administered medication had an ointment medication at the bedside and self-administered it. Residents Affected - Few * Resident 14 had three foil packets of Calmoseptine (skin barrier cream) 3.5 gram ointment at the bedside which she self-administered to her bottom area. Resident 14's Self-Administration of Medication assessment dated [DATE], showed Resident 14 was not a candidate for self-administration of medication. Resident 14 did not have a physician's order to self-administer the Calmoseptine. This failure had the potential for poor health outcomes to Resident 14. Findings: Review of the facility's P&P titled Self-Administration of Medication dated 2/21 showed if the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medication. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do. The self-administered medications are stored in a safe and secure place which is not accessible by other residents. Any medications found at bedside that are not authorized for self-administration are turned over to the nurse on charge for return to family or responsible party. Medical record review for Resident 14 was initiated on 5/8/23. Resident 14 was admitted to the facility on [DATE]. Review of the Medication Self-Administration Screen dated 9/27/21, showed the following: - For question 1, Does the resident choose to participate in a self medication administration program? The answer documented was No. - For question 7, Is the resident a candidate for self-administration of his/ her own medicine? The answer documented was No. - For question 8, Does the resident's attending physician give permission for the resident to self-administer his/ her own medication? The answer documented was No. - For question 9, If resident is a candidate for self-administration, have you indicated on the Physician's Order sheet MAY SELF- ADMINISTER MEDICATIONS? The answer documented was No. On 5/9/23 at 1120 hours, LVN 4 was summoned to the room. Resident 14 was observed having three packages of Calmoseptine at the bedside. Resident 14 stated she self-administered the ointment to her bottom area to prevent sore from the diaper, and the nurse gave it to her. LVN 4 verified the findings. On 5/11/23 at 0945 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the resident's medication self-administration screening dated 9/27/21, showed the resident could not self-administer medicine. The DON was informed and verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 2 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Potential for minimal harm Based on interview and facility record review, the facility failed to ensure the State Survey Agency's contact information provided to the residents was correct. This posed the risk of the residents not being able to contact the state should the residents require the state services. Residents Affected - Some Findings: Review of the facility's Resident Rights packet provided to the residents showed the contact information for State Survey Agency. On 5/11/23 at 1030 hours, an interview and concurrent facility document review was conducted with the SSD. An attempt to call the phone number of the State Survey Agency showing on the resident's right document was made with the presence of the SSD. However, no one picked up the call and the recorded voice stated this number was for a transportation company. The SSD stated she was not aware the documented phone number on the packet was inaccurate. The SSD further stated no one had informed her about the incorrect phone number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 3 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to obtain a copy of an advance directive for inclusion in the medical record for two of 18 final sampled residents (Residents 300 and 302). * The facility documented Resident 300's healthcare directives were clearly stated on Resident 300's POLST form. However, the facility failed to obtain or review Resident 300's advance directive for healthcare. * The facility documented Resident 302 had formulated and advance directive and a copy was maintained within Resident 302's medical record. However, Resident 302's medical record did not contain a copy of Resident 302's advance directive, rather, a copy of Resident 302's DNR order from the hospital was obtained by the facility and referred to as Resident 302's advance directive. These failures had the potential for the residents' advanced care planning decisions regarding their health care and treatment not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 12/2020 showed upon admission, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 1. Medical record review for Resident 300 was initiated on 5/8/23. Resident 300 was admitted to the facility on [DATE]. On 5/8/23 at 1015 hours, an interview was conducted with Resident 300. Resident 300 stated she had formulated an advance directive specific to her healthcare, and her family member had a copy of her advance directive. Review of Resident 300's Advance Directive Acknowledgement dated 4/7/23, showed documentation added by the SSD dated 5/8/23, which showed the SSD spoke with Resident 300, and Resident 300 indicated she had formulated a health care directive. The SSD documented Resident 300's directives were clearly stated on Resident 300's POLST. Review of Resident 300's POLST dated 4/7/23, failed to show documentation specific to whether Resident 300 had formulated an advance directive and failed to show documentation specific to what was contained in Resident 300's advance directive. On 5/9/23 at 0954 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD reviewed Resident 300's medical record and verified a copy of Resident 300's advance directive was not obtained, therefore, it was not included in Resident 300's medical record. The SSD verified she documented on Resident 300's Advance Directive Acknowledgement form dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 4 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/7/23, that on 5/8/23, she spoke with Resident 300, and Resident 300's directives were clearly stated on Resident 300's POLST dated 4/7/23. The SSD then reviewed Resident 300's POLST dated 4/7/23, and stated the POLST was not considered an advance directive. The SSD stated the facility had not obtained a copy of or reviewed Resident 300's advance directive. The SSD stated since she had not reviewed Resident 300's advance directive, she therefore did not know what information was contained in Resident 300's advance directive. The SSD was asked to explain the differences between an advance directive and a POLST. The SSD stated one difference between an advance directive and a POLST was the POLST did not contain information specific to whether a resident wished to donate their organs; however, this information could be included in the advance directive for healthcare. The SSD stated she did not speak to Resident 300 regarding her organ donation wishes. The SSD verified having documented on 5/8/23 (on Resident 300's Advance Directive Acknowledgement form dated 4/7/23), that Resident 300's directives were clearly stated on Resident 300's POLST was inaccurate information. Cross reference to F842, example #1 2. Medical record review for Resident 302 was initiated on 5/8/23. Resident 302 was admitted to the facility on [DATE]. Review of Resident 302's Advance Directive Acknowledgment dated 4/8/23, showed documentation that per Resident 302, an advance directive was formulated at the hospital and a copy was contained in Resident 302's medical record. Review of Resident 302's medical record showed a copy of Residents 302's DNR order dated 4/3/23, was obtained by the facility from the hospital and placed in Resident 302's medical record. However, Resident 302's medical record failed to contain a copy of Resident 302's advance directive. Review of Resident 302's Social Services assessment dated [DATE], showed Resident 302 had formulated an advance directive and the assessment also contained documentation specific to Resident 302's designated Power of Attorney. On 5/9/23 at 1038 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified she documented on Resident 302's Advance Directive Acknowledgment form dated 4/8/23, that per Resident 302, an advance directive was formulated at the hospital, and a copy was contained in Resident 302's medical record. The SSD reviewed Resident 302's medical record and located Resident 302's DNR order from the hospital, dated 4/3/23. The SSD then stated this was the document she referenced as being the advance directive formulated at the hospital (as per her documentation on Resident 302's Advance Directive Acknowledgment dated 4/8/23). Further review of Resident 302's DNR order from the hospital dated 4/3/23, was conducted with the SSD. The SSD then verified Resident 302's DNR order from the hospital dated 4/3/23, was not an advance directive formulated by Resident 302. The SSD verified her Social Services assessment dated [DATE], showing Resident 302 had formulated an advance directive and designated a Power of Attorney. The SSD reviewed Resident 302's medical record and verified a copy of Resident 302's advance directive was not contained in Resident 302's medical record. The SSD further reviewed Resident 302's medical record and stated she had not documented having followed up with Resident 302's Power of Attorney, in an attempt to obtain a copy of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 5 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0578 302's advance directive. Level of Harm - Minimal harm or potential for actual harm Cross reference to F842, example #2 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 6 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview, facility P&P review, and facility document review, the facility failed to implement the facility's grievance/complaint P&P. * The facility failed to post on the facility's consumer board the information regarding the facility's grievance procedure. * The facility's Grievance Official failed to provide the residents who filed a grievance with the written result within the 10 days from the date when the complaint was submitted for three nonsampled residents (Residents 31, 602, and 603) and one of 18 final sampled residents (Resident 303). These failures posed the risk for the residents' grievances not being addressed and resolved timely and unaware of the grievance outcome. Findings: Review of the facility's undated P&P titled Grievance/Complaints showed that information regarding the facility's Grievance procedures is provided upon admission and is posted on the Consumer Board in the main lobby area. Further review of the P&P also showed within 10 days from the date complaint was submitted, the person submitting the grievance/complaint will be informed orally and in writing, of the results of the grievance investigation by the Grievance Official, Social Services, or other department head as appropriate as related to the nature of the complaint. Review of the medical records for Residents 31, 303, 602, and 603 was initiated on 5/8/23. The medical records showed the following: - Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE]. - Resident 303 was admitted to the facility on [DATE]. - Resident 602 was admitted to the facility on [DATE]. - Resident 603 was admitted to the facility on [DATE]. Review of the facility's Grievance/Complaint Log dated 5/2021 showed two grievances were filed by Resident 31 on 5/12 and 9/22/21. The section for the date when informed Resident 31 of the findings was blank. Review of the facility's Grievance/Complaint Log dated 3/2022, showed the grievances filed by Resident 602 on 3/3/22, and Resident 603 on 3/3/23. Review of the facility's Grievance/Complaint Log dated 5/2023, showed a grievance filed by Resident 303 on 5/8/23. On 5/9/23 at 1530 hours, an interview and concurrent review of the facility's Consumer Boards was conducted with the DON. The DON verified the procedure for grievance/complaints was not posted on two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 7 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0585 consumer boards in the main lobby. Level of Harm - Minimal harm or potential for actual harm On 5/9/23 at 1605 hours, an interview was conducted with the SSD. The SSD was asked regarding the facility's process to address the grievance/complaints received. The SSD stated there was a grievance form to be filled out and the nature of the grievance was documented on the form. The SSD further stated she gave the grievance form to the person in charge of the department, based on a grievance filed, to conduct the investigation. The SSD stated the facility informed the residents about the action taken and asked the residents to let her know if there were any other concerns. Residents Affected - Few On 5/11/23 at 0947 hours, a follow-up interview was conducted with the SSD. When the SSD was asked if she had informed the residents in writing about the outcome of the grievance investigation, the SSD stated she had not and was not aware that she had to provide a written information to the residents about the resolution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 8 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the level 1 PASRR screening (utilized to ensure a resident with a mental illness is evaluated and receives care in a setting appropriate to meet their needs) contained accurate information for one of 18 final sampled residents (Resident 303). Residents Affected - Few * Resident 303 had a diagnosis of bipolar disorder {a disorder associated with episodes of extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)} and was prescribed Depakote (mood stabilizer medication); however, the level 1 PASRR screening showed Resident 303 had no diagnosed mental illness and was not prescribed psychotropic medications. This failure posed the risk for inappropriate placement in a long-term care nursing home if a PASRR level 2 (used to determine if residents with a mental disorder are placed in an appropriate setting and receive necessary recommendations for specialized services) was indicated, and the facility subsequently could not provide the resident with the necessary mental health services. Findings: Medical record review for Resident 303 was initiated on 5/8/23. Resident 303 was admitted to the facility on [DATE]. Review of Resident 303's Level 1 PASRR screening dated 5/5/23, showed Resident 303 had no diagnosis of mental illness and no prescribed psychotropic medications. The form showed the PASRR level 1 screening was negative, and a level 2 evaluation was not required for reasons, which included Resident 303 did not have a mental illness. Review of Resident 303's acute care hospital Progress Note dated 5/4/23 at 1211 hours, showed Resident 303 had a diagnosis of bipolar disorder. Review of Resident 303's physician's order dated 5/6/23, showed an order for Depakote 1500 mg at bedtime for mood lability from pleasant to angry outbursts related to bipolar disorder. On 5/10/23 at 1113 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 303 had a diagnosis of bipolar disorder and was prescribed Depakote; however, the level 1 PASSR screening showed Resident 303 did not have a diagnosed mental disorder and was not prescribed psychotropic medications. RN 1 verified the information contained on Resident 303's level PASRR 1 screening was inaccurate which could potentially prevent Resident 303 from receiving a PASRR level 2 evaluation. RN 1 stated a PASRR level 2 evaluation was conducted by the state-designated authority. The state-designated authority would determine whether a resident had a mental illness, determine the appropriate setting for the resident, and recommend any specialized services the resident may need. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 9 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 18 final sampled residents (Resident 15). * The facility failed to implement the floor mats as per the fall risk care plan. This failure placed the resident at risk for not being provided appropriate and individualized care. Findings: Medical record review for Resident 15 was initiated on 5/8/23. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 15's care plan titled At Risk for Fall or Injury Due to Generalized Weakness initiated 4/3/22, showed an intervention for floor mats for fall preventive measures, initiated 4/28/22. On 5/10/23 at 1600 hours, an observation and concurrent interview was conducted with RN 1. Resident 15 was observed lying in bed with no floor mats in place. RN 1 stated Resident 15 had a history of falls and sustained a fracture resulting from a fall in 2021. RN 1 stated Resident 1 remained at risk for falls. RN 1 verified Resident 15's care plan titled Risk for Fall or Injury Due to Generalized Weakness showed an intervention for floor mats was initiated on 4/28/22, for fall prevention. RN 1 verified there were no floor mats in place for Resident 15. RN 1 stated Resident 15 should have the floor mats in place adjacent to both sides of her bed to reduce the chance of injury, should Resident 15 fall from her bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 10 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to accommodate the needs of one of 18 final sampled residents (Resident 37). Residents Affected - Few * The direct staff did not know what language Resident 37 to communicate. A Korean communication board was not available when required by Resident 37 for communication. This had the potential to impede the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Findings: Review of the facility's P&P titled Language Barrier, Communication dated 11/20 showed when encountering Limited English Proficiency residents, activity director, social service director/ designee or staff members will assess the language that resident speak, identify facility staff who speaks the same language, family members and friends are encouraged for visiting and or helping the translation on the phone, utilize communication board, phone app for translation, activity director or social services will coordinate the language access program when needed. All LEP residents shall receive a written or oral notice in their primary language of their rights to obtain competent oral translation service free of charge. Medical record review of Resident 37 was initiated on 5/8/23. Resident 37 was admitted to the facility on [DATE]. On 5/8/23 at 1215 hours, Resident 37 was observed laying in his back in bed with the head of the bed at 30 degrees. Resident 37 had spoken foreign language when CNA 2 helped to reposition the resident facing the window. CNA 2 stated there was language barrier, I do not understand. Then CNA 2 proceeded to help the resident's roommate. CNA 2 was asked if there was any communication board. There was no communication board was observed in the room. On 5/8/23 at 1230 hours, an interview was conducted with LVN 3. LVN 3 was asked if she had communicated with Resident 37. LVN 3 stated Resident 37 spoke in Korean and did not respond when she speaks English to him. LVN 3 stated she observed the family speaking Korean with Resident 37 and never heard they communicated in English. On 5/8/23 at 1315 hours, an interview was conducted with CNA 2. CNA 2 stated the resident could talk few words in foreign language but CNA 2 did not know what language Resident 37 had spoken. CNA 2 did not understand Resident 37 so she did not inform CNA 3. CNA 2 acknowledged there was no communication board in the room. CNA 2 verified the finding. On 5/8/23 at 1445 hours, an interview was conducted with CNA 3. CNA 3 was asked regarding the resident's language. CNA 3 stated he did not know what language Resident 37 speaking. CNA 3 stated he still explained to the resident in English when provided the care. CNA 3 was asked if he knew any staff speaking same language with the resident. CNA 3 stated he did not know. There was no communication board in the room. CNA 3 verified the findings. On 5/9/23 at 1515 hours, an interview was conducted with Resident 37's family member. Resident 37's family member was asked about the communication with Resident 37. The family member of Resident 37 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 11 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated most of the time, they communicated to the resident in Korean and the resident could understand very little English. On 5/9/23 at 1530 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked if she could show a care plan to address the resident's problem with communication or language. The DON was unable to provide the documentation. The DON verified the above findings. The DON stated to address the resident's communication, the nursing interventions should include to provide a staff who could speak the same language, communication board, and translation application. The DON stated they had a Korean speaking staff which included the charge nurse who was also a treatment charge nurse working in the weekend and a MDS staff during Monday to Friday. Both of the staff were working in the morning. When asked regarding during the evening and night shifts. The DON stated the nurse knew some words and knew to call the resident's family member. Event ID: Facility ID: 555671 If continuation sheet Page 12 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff reported the skin discolorations for three of 18 final sampled resident (Residents 4, 14, and 502) in a timely manner. Residents Affected - Few * Residents 14 had the right hand and forearm skin discolorations; however, the CNAs failed to report these skin discolorations to the licensed nurses to conduct a thorough assessments and seek orders for appropriate treatment. * Resident 4 had a bruise to the right forearm. There was no documented evidence of the resident's right forearm bruise identified in the medical record and there was no care plan addressing the resident's right forearm bruise. * Resident 502 did not have a back brace applied when up in the upright position as ordered. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Medical record review for Resident 14 was initiated on 5/8/23. Resident 14 was admitted to the facility on [DATE]. Review of the facility's P&P titled Resident Skin Check dated May 2022 showed the CNAs will check the resident's skin during ADL care (dressing and undressing, toileting, pericare, bathing, etc.) for any changes. Under section 4 showed to follow the change in condition procedure for any identified skin problem; A. MD notification, B. Responsible party notification, C. Implementation of intervention including treatment if ordered, D. Care plan, and E. monitoring. Applicable skin sheet report will be initiated and weekly progress documented until skin problem is resolved. Review of the H&P examination dated 12/7/22, showed Resident 14 had the capacity to understand and make decisions. Review of the resident's skin assessment dated [DATE] showed Resident 14 had normal, warm, and dry skin. Review of the skin or wound notes dated 4/25 and 5/2/23, showed the weekly skin assessment was done, and all other skin were dry, warm, and intact. On 5/8/23 at 0830 hours, Resident 14 was observed having purple skin discoloration to the right hand. Resident 14 was asked regarding the skin discoloration. Resident 14 stated she hit the wheel chair when she propelled herself last week. On 5/9/23 at 1015 hours, an interview was conducted with CNA 4. CNA 4 stated she was working with Resident 14 last Friday, but she did not seethe skin discoloration, and did not see it either this morning. On 5/9/23 at 1030 hours, an interview and medical record review was conducted with LVN 4. LVN 4 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 13 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked if the resident had any skin issues. LVN 4 stated Resident 14 had no pressure sore and had the right hand discoloration. LVN 4 was asked when did she found out Resident 14 had right hand skin discoloration, LVN 4 stated she just found out about it. LVN 4 was not aware of it. LVN 4 was asked to provide the documentation for the skin assessment regarding the skin discoloration on the right hand. LVN 4 was unable to provide the documentation. LVN 4 stated the CNA providing the shower and never reported the resident's right hand discoloration to her. LVN 4 was asked if there was any care plan to address Resident 14's right hand skin discoloration. LVN 4 was unable to provide the documentation and stated the intervention was to give the resident's gloves. LVN 4 was informed the resident's right hand discoloration was observed since yesterday (5/8/23). LVN 4 verified the findings. On 5/9/23 at 1120 hours, LVN 4 was summoned to Resident 14's room. LVN 4 was asked regarding Resident 14's skin discoloration. Resident 14 stated she hit her hand while she was propelling her wheelchair. Further review of Resident 14's progress note dated 5/9/23, showed the weekly skin assessment with new discoloration on the right hand, new order to monitor the skin integrity; and all other skin was dry, warm, and intact. On 5/11/23 at 1515 hours, an interview and concurrent medical record review was conducted LVN 2. LVN 2 was asked how they assessed the resident's skin discoloration. LVN 2 stated they did not document the size of the skin discoloration. LVN 2 was asked how the other nurse knew if the skin discoloration was getting better or worse or just the same. LVN 2 acknowledged the size should be documented. LVN 2 verified the findings. On 5/15/23 at 1445 hours, an interview was conducted with the DON. The DON was asked how the nurse should assess the skin discoloration. The DON stated the nurse should assess the skin color, size, and signs and symptoms of infection. 2. Medical record review for Resident 4 was initiated on 5/8/23. Resident 4 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of the H&P examination dated 12/31/22, showed Resident 4 had the capacity to understand and make decisions. Review of the skin or wound note dated 4/25/23, showed the weekly skin evaluation was done, and all skin were intact, warm and dry. The note showed the resident continued to have redness between the buttocks. Review of the skin or wound notes dated 5/4 and 5/9/23, showed the weekly skin evaluation was done, all skin were intact, warm, and dry. The note showed the resident continued to have redness between the buttocks and right great toenail evulsion monitoring. On 5/8/23 at 1527 hours, Resident 4 was observed with bruising on the right forearm. On 5/15/23 at 0845 hours, Resident 4 was sitting up in wheel chair and observed having purplish discoloration on the right forearm. However, review of the medical record showed no documented evidence of the resident's right forearm bruise identified or possible cause of the bruise. There was no care plan developed to address the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 14 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0684 resident's bruise. Level of Harm - Minimal harm or potential for actual harm On 5/15/23 at 0900 hours, an interview was conducted with LVN 4. LVN 4 was asked if she knew about Resident 4's right forearm purplish discoloration. LVN 4 stated she just found out today, this morning. Residents Affected - Few On 5/15/23 at 0945 hours, an interview was conducted with LVN 4. LVN 4 was asked about the resident's right forearm skin discoloration. LVN 4 stated a new bruise normally was purplish red, and Resident 4's right forearm skin discoloration was an old bruise because the color was blue and green. LVN 4 asked Resident 4 but the resident could not state where she got it. LVN 4 assessed Resident 4's discoloration and stated it was not from a blood draw, but there was a possibility the resident had bumped into something. LVN 4 acknowledged no care plan was developed to address the bruise or the resident's discoloration. LVN 4 verified the findings. On 5/15/23 at 1418 hours, an interview was conducted with CNA 4. CNA 4 was asked regarding the skin discoloration to the resident's right forearm. CNA 4 stated he saw it yesterday, but he thought the other nurse had reported the skin discoloration to the charge nurse. CNA 4 verified the findings. 3. On 5/9/23 at 1110 hours, Resident 502 was observed sitting up in a wheelchair inside her room, not wearing a back brace. Medical record review for Resident 502 was initiated on 5/8/23. Resident 502 was admitted to the facility on [DATE]. Review of Resident 502's Order Summary Report dated 5/10/23, showed an order dated 5/6/23, to apply TLSO to the back, wear brace at all times when upright and out of bed; and okay to take off brace when laying down flat. On 5/9/23 at 1113 hours, Resident 502 was asked if she was wearing the back brace daily. Resident 502 stated she should wear the back brace all the times when out of bed. On 5/9/23 at 1113 hours, CNA 1 verified Resident 502 while up in wheelchair in her room was not wearing the ordered back brace. CNA 1 stated the nurse was supposed to apply the back brace to the resident. On 5/10/23 at 1530 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked who was supposed to apply Resident 502's back brace. LVN 1 stated the resident, nurse or physical therapist could apply the back brace to the resident. LVN 1 verified Resident 502 should have the back brace to wear at all times when upright and out of bed, and okay to take off the brace when laying down flat. On 5/10/23 at 1600 hours, an interview and concurrent record review was conducted with the DON. The DON verified the resident's back brace had to be worn at all times when upright and out of bed, and okay to take off when laying down flat. The DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 15 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 15) remained free from accident hazards. * The facility failed to implement the floor mats as per the physician's order for Resident 15. This failure had the potential to place the resident at risk for serious injury. Findings: Medical record review for Resident 15 was initiated on 5/8/23. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 15's Physician Discharge Summary from the acute care hospital dated 12/2/21 at 1009 hours, showed Resident 15 was admitted to the acute care hospital for a fall resulting in a hip fracture. Review of Resident 15's Order Summary Report showed a physician's order dated 4/28/22, for floor mats for fall preventive measures every shift. Review of Resident 15's care plan titled At Risk for Fall or Injury Due to Generalized Weakness initiated 4/3/22, showed an intervention for floor mats for fall preventive measures was initiated on 4/28/22. On 5/10/23 at 1515 hours, an observation of Resident 15 was conducted. Resident 15 was observed lying in bed with no floor mats in place. On 5/10/23 at 1600 hours, an observation and concurrent interview was conducted with RN 1. Resident 15 was observed lying in bed with no floor mats in place. RN 1 stated Resident 15 had a history of falls and sustained a fracture resulting from a fall in 2021. RN 1 stated Resident 1 remained at risk for falls. RN 1 verified Resident 15 had a physician's order for floor mats for fall prevention. RN 1 verified no floor mats were in place for Resident 15. RN 1 stated Resident 15 should have floor mats in place adjacent to both sides of her bed, to reduce the chance of injury, should Resident 15 fall from her bed. Cross reference to F656. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 16 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility P&P review, and medical record review, the facility failed to ensure the necessary care and services were provided for one of 18 final sampled resident (Resident 600). Residents Affected - Few * The facility failed to accurately document Resident 600's dialysis access site. * The facility failed to ensure the fluid restriction order was followed and accurately documented Resident 600's intake in the MAR. * The facility failed to notify Resident 600's physician regarding the fluid intake exceeding the fluid restriction ordered. These failures had the potential to result in health complications to the resident. Findings: Review of the facility's P&P titled Dialysis Care revised 5/11/23, showed the facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility regarding dialysis care and services. Further review of the P&P showed to monitor intake and output as ordered; observe fluid restrictions as ordered by the physician; notify physician of any change in mental or physical status; and obtain vital signs of resident upon return from dialysis an complete the Pre/Post Dialysis Communication Form. Review of the facility's P&P titled Hemodialysis Access Care revised 9/2020 showed the general medical nurse should document in the resident's medical record for the location of the catheter and observation post-dialysis. Review of the facility's P&P titled Intake and Output Policy showed the 3-11 shift licensed nurse will be responsible for recording the total daily intake and output at the end of the shift and complete weekly average intake and output every 7 days. Medical record review for Resident 600 was initiated on 5/8/23. Resident 600 was admitted to the facility on [DATE]. a. On 5/8/23 at 1135 hours, Resident 605 was observed with dialysis access site on her right upper chest. Review of the facility's dialysis communication forms dated 4/21, 4/24, 4/26, 4/28, 5/3, and 5/5/23, showed the dialysis center documented Resident 600's dialysis access site was the CVC on the right upper chest. Review of the facility's Dialysis Forms dated 4/21, 4/24, 4/26, 4/28, 5/1, 5/3, and 5/5/23, showed an AV (ateriovenous shunt - connects an artery to a vein in preparation for dialysis) access with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 17 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0698 Level of Harm - Minimal harm or potential for actual harm associated bruit (swishing sound of blood flowing through a narrowed portion of an artery) and thrill (a vibration felt on the skin overlying an area of turbulence) assessment. Review of the facility's dialysis form dated 4/26/23, showed no documentation of the post dialysis assessment from the facility. The post dialysis section was blank. Residents Affected - Few On 5/11/23 at 1425 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 600's dialysis access site was a perma-cath (flexible tube used for dialysis treatment) on the right upper chest. LVN 2 also verified Resident 600's dialysis communication forms had inaccurate documentation of the dialysis site as the AV shunt. LVN 2 stated she checked Resident 600's dialysis access site; however, she made a mistake when documenting the resident had an AV shunt instead of a perm-a-cath. When asked what could potentially happen with the inaccurate information on the dialysis communication forms, LVN 2 stated a consequence of the mistake could be for the dialysis center to be confused with the correct site leading to the resident not receiving proper treatment. LVN 2 also verified she made a documentation error for three days on the dialysis form on 4/21, 4/28, and 5/3/23. On 5/11/23 at 1511 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 600 had a perma-cath on the right upper chest. b. Review of Resident 600's Order Summary Report showed a physician's order dated 5/1/23, to monitor intake and output due to fluid restriction of 1000 ml/24 hours. Another physician's order 5/4/23, for fluid restriction of 1000 ml/day: nursing to provide 280 ml, 120 ml for AM shift, 120 ml for PM shift, and 40 ml for NOC shift; and dietary to provide 720 ml: breakfast 360 ml, lunch 120 ml, and dinner 240 ml. Review of the MAR from 5/1-5/31/23, showed the resident's intakes for each shift as follows: - 5/1/23, 40 ml for the NOC Shift - 5/2/23, 500 ml for the AM and PM shifts and 40 ml for the NOC shift (total of 1040 ml) - 5/3/23, 550 ml for each shift (total of 1650 ml) - 5/4/23, 550 ml for each shift (total of 1650 ml) - 5/5/23, 550 ml for the AM shift, 200 ml for the PM shift, and 40 ml for the NOC shift (total of 790 ml) - 5/6/23, 500 ml for the AM and PM shifts and 40 ml for the NOC shift (total of 1040 ml) - 5/7/23, 500 ml for the AM shift, 360 ml for the PM shift, and 40 ml for the NOC shift (total of 900 ml) - 5/8/23, 600 ml for the AM and PM shifts and 40 ml for the NOC shift (total of 1240 ml) - 5/9/23, 600 ml for the AM and PM shifts and 40 ml for the NOC shift (total of 1240 ml) - 5/10/23, 600 ml for the AM shift, 120 ml for the PM and NOC shifts (total of 840 ml) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 18 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0698 - 5/11/23, 600 ml for the AM and PM shifts, and 40 ml for the NOC shift (total of 1240 ml) Level of Harm - Minimal harm or potential for actual harm - 5/12/23, 550 ml for the AM shift, 200 ml for the day shift, and 40 ml for the NOC shift (total of 790 ml) - 5/13/23, 600 ml for the AM shift, 200 ml for the PM shift, and 40 ml for the NOC shift (total of 840 ml) Residents Affected - Few - 5/14/23, 600 ml for the AM shift, 200 ml for the PM shift, and 40 ml for the NOC shift (total of 840 ml) In addition, another section of the MAR showed the following total daily intakes which were not consistent with the above recorded intakes: - 180 ml for 5/1, 5/2, 5/3, and 5/4/23 - 200 ml for 5/5 and 5/6/23 - 900 ml each day from 5/7 to 5/14/23 On 5/15/23 at 1523 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 600's documented Intake & Output in the MAR were incorrect. The DON stated the facility staff were in-serviced on how to document fluid intake. On 5/15/23 at 1613 hours, a follow-up interview and concurrent medical record review was conducted with the DON. The DON verified the discrepancies of the total daily fluid intakes documented in the MAR. The DON also verified Resident 600's intakes were over the fluid restriction of 1000 ml/day as ordered by the physican on 5/2, 5/3, 5/4, 5/8, 5/9, and 5/11/23. When asked what could potentially happen when the resident received more than the fluids ordered by the physician, the DON stated Resident 600 could be at risk for fluid overload. The DON also verified Resident 600's physician was not notified when the resident received fluid more than the fluid restriction ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 19 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the licensed nurses had specific competencies and skill sets needed to care for two of three sampled residents (Residents 503 and 600) as evidenced by: * The facility failed to conduct the staff competency assessment annually. LVN 2 was not aware on how to respond in the event of an emergency if Resident 600 were to bleed from the dialysis access site. * The facility failed to ensure the licensed nurses assessed Resident 600's dialysis access site and documented accurately. * The facility failed to ensure LVN 1 received competency skill checks after his orientation to the facility when newly hired. These failures had the potential to put the residents at risk for care not provided in a safe and competent manner. Findings: Review of the facility's P&P titled Hemodialysis Access Care revised 9/2020 showed hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices. Review of the facility's P&P titled Nursing Staff revised 2/2022 showed it is the policy of the facility to assist nursing staff developing skills and evaluate their skills competency after orientation within 90 days of hire and annually. 1. On 5/11/23 at 1449 hours, an observation and concurrent interview was conducted with LVN 2. When asked how she would respond in the event Resident 600 started to bleed from her dialysis access site (perma-cath on the right upper chest), LVN 2 stated in the event Resident 600 began bleeding from her dialysis access site, LVN 2 stated she would need more tape and a longer tourniquet to wrap around Resident 600's chest to stop the bleeding. LVN 2 further stated she needed more dialysis training. On 5/15/23 at 1414 hours, an interview was conducted with the DON. The DON verified the competency checks must be done within 90 days of hire and annually. The DON also verified there was no competency checks done regarding dialysis care with any of the licensed staff since 11/2021. 2. Medical record review for Resident 600 was initiated on 5/8/23. Resident 600 was admitted to the facility on [DATE]. Review of the facility's dialysis communication forms dated 4/21, 4/24, 4/26, 4/28, 5/3, and 5/5/23, showed the dialysis center documented Resident 600's dialysis access site was the CVC on the right upper chest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 20 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's Dialysis Forms dated 4/21, 4/24, 4/26, 4/28, 5/1, 5/3, and 5/5/23, showed an AV access with an associated bruit and thrill assessment. On 5/11/23 at 1425 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 600's dialysis access site was a perma-cath (flexible tube used for dialysis treatment) on the right upper chest. LVN 2 also verified Resident 600's dialysis communication forms had inaccurate documentation of the dialysis site as the AV shunt. LVN 2 stated she checked Resident 600's dialysis access site; however, she made a mistake when documenting the resident had an AV shunt instead of a perm-a-cath. When asked what could potentially happen with the inaccurate information on the dialysis communication forms, LVN 2 stated a consequence of the mistake could be for the dialysis center to be confused with the correct site leading to the resident not receiving proper treatment. LVN 2 also verified she made a documentation error for three days on the dialysis form on 4/21, 4/28, and 5/3/23. 3. Medical record review for Resident 503 was initiated on 5/8/23. Resident 503 was admitted on [DATE]. Review of Resident 503's Order Summary Report showed a physician order dated 4/11/23, to monitor the dialysis shunt site for presence of bruit and thrill every shift. Review of Resident 503's plan of care showed a focus care plan problem dated 4/11/23, addressing the diagnosis of renal failure and at risk for infection or bleeding at the catheter insertion site to the left upper arm AV shunt. The interventions included to monitor for presence of bruit and thrill every shift. On 5/9/ 23 at 0821 hours, an interview was conducted with LVN 1. When LVN 1 was asked how the dialysis access site was checked, LVN 1 stated to feel the blood with stethoscope and he did not really know how to check the thrill and bruit, only did one time before. LVN 1 stated the facility did not conduct a competency skill check after his orientation to the facility when he was newly hired. On 5/15/23 at 1439 hours, an interview was conducted with the DON. The DON stated the left upper arm AV shunt was assessed by feeling the thrill and listening to the bruit using a stethoscope. The DON verified the above findings and stated the licensed nurses knew how to assess the dialysis access site but was confused of what it was called or what they were assessing for. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 21 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to meet the residents' needs. * The facility failed to ensure the medications for two nonsampled residents (Residents 20 and 45) were administered with meal and food as per the physician's orders. This posed the risks for Residents 20 and 45 to experience side effects from the medications. * The facility failed to ensure a physical inventory of the controlled medications were conducted by two licensed nurses as per the facility's P&P, creating the risk for drug diversion. Findings: 1. Medical record review for Resident 20 was initiated on 5/8/23. Resident 20 was admitted to the facility on [DATE], with a diagnosis of DM. Review of Resident 20's Order Summary Report for May 2023 showed to administer metformin (antidiabetic medication) 500 mg one tablet orally two times a day with breakfast. On 5/10/23 at 1003 hours, a medication administration observation for Resident 20 and concurrent interview was conducted with LVN 3. LVN 3 was observed administering metformin 500 mg tablet with yogurt to Resident 20 after the breakfast meal. When asked, LVN 3 confirmed this medication should have been given with the breakfast meal. On 5/10/23 at 1620 hours, an interview was conducted with the DSS. The DSS confirmed the breakfast meal was served this morning at 0715 hours. 2. Medical record review for Resident 45 was initiated on 5/8/23. Resident 45 was admitted to the facility on [DATE]. Review of Resident 45's Order Summary Report for May 2023 showed to administer aspirin (antiplatelet medication) 325 mg one tablet by mouth two times a day with food. On 5/10/23 at 0846 hours, a medication administration observation for Resident 45 was conducted with LVN 3. LVN 3 was observed administering aspirin 325 mg. However, LVN 3 did not administer aspirin with food as per the physician's order. During an interview with LVN 3 on 5/10/23 at 1533 hours, LVN 3 verified she did not administer aspirin with food to Resident 45 during the morning medication administration. 3. Review of the facility's P&P titled Medication Storage, Controlled Substance Storage dated January 2017 showed at each shift, or when keys are transferred, a physical inventory of all controlled controlled substances including the emergency supply, is conducted by two licensed nurses and is documented. On 5/15/23 at 1503 hours, the Narcotic Count Log for Station 1 dated 5/2023 was reviewed with LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 22 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 3. LVN 3 verified the record showed a missing outgoing licensed nurse's signature on 5/12/23. LVN 3 stated the narcotic medications should be accounted and signed for by both the incoming and outgoing licensed nurses. On 5/15/23 at 1622 hours, an interview and concurrent record review was conducted with the DON. The DON stated the incoming and outgoing licensed nurses should ensure the narcotic medication counts were reconciled, once the count was confirmed, the incoming and outgoing licensed nurses had to sign the shift narcotic count log and the keys would be endrosed. The DON verified the above findings. Event ID: Facility ID: 555671 If continuation sheet Page 23 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one nonsampled resident (Resident 20) was free of significant medication errors. Residents Affected - Few * Resident 20 received hydralazine 25 mg one tablet from 4/21/23 to 5/10/23, instead of 50 mg of hydralazine as ordered. This failure posed the risk for adverse consequences to the resident. Findings: Medical record review for Resident 20 was initiated on 5/8/23. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Order Summary Report for May 2023 showed an order dated 4/19/23, to administer hydralazine hcl (antihypertensive medication) 25 mg two tablets by mouth three times a day for hypertension. However, review of Resident 20's MARs for April and May 2023 showed hydralazine 25 mg one tablet was administered from 4/24 to 4/28/23, 5/1 to 5/5/23, and 5/8 to 5/12/23 at 0900 and 1300 hours. Review of Resident 20's three medication bubble packs (30 tablets each pack) showed dispense dates of 4/20 and 4/21/23, for hydralazine 25 mg one tablet by mouth three times daily for hypertension. There were 43 tablets observed in the bubble packs which meant 47 doses had already been administered. During an interview with LVN 2 on 5/10/23 at 0931 hours, LVN 2 stated the physician's order for the hydralazine was a total of 50 mg; however, the label on the medication card was 25 mg one tablet by mouth daily for hypertension. LVN 2 verified the direction on the medication bubble packs for the hydralazine medication was incorrect. On 5/10/23 at 1213 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the nurses were not administering the correct dose of 25 mg two tablets of hydralazine (a total dose of 50 mg). RN 1 stated if Resident 20 did not receive the correct dose, the patient could develop high blood pressure or other complications such as chest pain. RN 1 confirmed she would look for the right dosage when carrying out a physician's order. During an interview with LVN 3 on 5/10/23 at 1515 hours, LVN 3 acknowledged from 4/21 until today (5/10/23), LVN 3 administered hydrazaline 25 mg one tablet to Resident 20. On 5/10/23 at 1711 hours, a follow-up interview and concurrent medical record review was conducted with RN 1. RN 1 stated she did not know how this error was overlooked by the nursing staff. RN 1 stated the medication nurses should check the electronic medical record for the medication order against the medication bubble packs and notify the pharmacy for any discrepancies. RN 1 stated the LVN who was assigned to the medication cart was responsible for ensuring accurate dosing by matching the medication bubble packs. On 5/11/23 at 0747 hours, RN 1 provided a copy of the Multipurpose Drug Disposition Record which showed on 4/24/23, one bubble pack with 27 tablets of hydralazine 50 mg and another bubble pack with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 24 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0760 30 tablets of hydralazine 50 mg were disposed. RN 1 stated the facility had disposed of the incorrect medication bubble packs and the hydralazine 25 mg supply should have been disposed. 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: 555671 If continuation sheet Page 25 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medication for one non-sampled residents (Resident 45) was labeled in accordance with currently accepted professional principles. This posed the risk for Resident 45 to be administered with the incorrect dosage resulting in undesirable side effects. Findings: Medical record review for Resident 45 was initiated on 5/8/23. Resident 45 was admitted to the facility on [DATE]. Review of Resident 45's Order Summary Report for May 2023 showed an order dated 5/10/23, to apply diclofenac sodium (nonsteroidal anti-inflammatory medication) external gel 1% 2 grams to the left and right knees four times a day and apply diclofenac sodium external gel 1% 2 grams to the right knee four times a day for pain management. On 5/10/23 at 0915 hours, a medication administration observation for Resident 45 was conducted with LVN 3. LVN 3 was observed applying diclofenac to Resident 45's left and right knees. However, review of the medication label showed to apply diclofenac sodium 1% gel 4 grams instead of 2 grams as ordered. During an interview with LVN 3 on 5/10/23 at 1547 hours, LVN 3 acknowledged the label on Resident 45's diclofencac showed to apply 4 grams of diclofenac to the left/right knees instead of 2 grams as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 26 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: Residents Affected - Some * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the cutting board was in sanitary condition and with cleanable surface. * The facility failed to ensure the countertop mounted can opener was in sanitary condition and free of residue. * The facility failed to ensure the kitchen equipment was air dried prior to storage. * The facility failed to ensure the kitchen utensils had smooth cleanable surface and were not worn out. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the DON dated 5/8/23, showed 51 of 54 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-601.11, the equipment food-contact surfaces and utensils shall be clean to sight and touch. On 5/8/23 at 0849 hours, an observation, interview, and concurrent facility record review was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the facility had one ice machine for the residents used located in the residents' dining room. The Maintenance Supervisor stated he was in charge of cleaning and maintenance of the ice machine. Review of the Ice Machine Preventive Maintenance log showed the ice machine was last cleaned, disinfected, and filter was changed on 4/10/23. Observation of the inside of the ice machine bin was made with the Maintenance Supervisor. The ice bin was observed full of ice. Inside the ice bin back panel adjacent to the evaporator located directly above the ice bin, a black residue was observed. The ice machine top cover was observed with yellow residue. The Maintenance Supervisor verified the findings and stated the ice bin needs to be cleaned to protect the ice from getting contaminated with molds. On 5/11/23 at 1343 hours, an observation with concurrent interview was conducted with the Administrator. A picture of the black residue from the ice machine bin was shown to the Administrator and verified the findings. The Administrator stated he was uncertain what the black residue was and unsure how long it had been in the ice machine bin. The Administrator was asked if he would serve the ice from the ice machine bin to the residents and he replied, he would not serve ice until the ice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 27 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0812 machine was clean. Level of Harm - Minimal harm or potential for actual harm On 5/15/23 at 1757 hours, an observation with concurrent interview was conducted with RD 2. A picture of the black residue from the ice machine bin was shown to RD 2 who verified the findings. RD 2 stated she had called the ice machine manufacturer and was told the ice machine was clean and the black residue was a scale. RD 2 was uncertain what the black residue was in the ice machine bin. RD 2 was asked if she would serve the ice from the ice machine bin to the resident and she replied no. Residents Affected - Some 2. According to the 2017 FDA Food Code 2017, Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. Review of the facility's P&P titled FOOD PREPARATION SUBJECT: FOOD PREPARATION dated 2018, under Procedures, showed cutting boards may be nonporous acrylic or wooden, and in good condition without deep cuts. During the initial kitchen tour on 5/8/23 at 0828 hours, a concurrent observation and interview was conducted with the DSS. A brown cutting board was observed with deep groves, heavily marred, and fuzzy. The DSS verified the findings and stated the cutting board should have been replaced because the bacteria could grow on the creases, and the cutting board could not be cleaned properly. 3. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 5/8/23 at 0831 hours, an observation and concurrent interview was conducted with the DSS. The countertop mounted can opener was observed with rusty residue on the blade. The DSS acknowledged the findings and verbalized uncertainty as to when the can opener was last replaced. The DSS stated the can opener should have been changed to prevent bacteria from getting mixed to the food. 4. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. During the initial kitchen tour on 5/8/23 at 0825 hours, a concurrent observation and interview was conducted with the DSS. Two measuring water pitchers were stored wet in the metal shelf, and traces of water were observed inside the pitchers. The DSS verified the findings and stated the pitchers should have been air dried to prevent the growth of bacteria. 5. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 28 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0812 Level of Harm - Minimal harm or potential for actual harm On 5/8/23 at 0837 hours, four spatulas with partially melted red handles were observed to be discolored and chipped on the edges. In addition, one basting brush with white handle was observed to be dirty and bristles were spread out with rusty discoloration and worn out. The DSS verified the findings. The DSS stated the basting brush was used for garlic bread spread, and the basting brush and spatulas should have been changed to avoid from getting mixed with the food. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 29 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the garbage lid and refuse was properly stored for one of two garbage dumpsters. The lid of one garbage dumpster were left partially open. The failure of the facility to ensure the garbage was contained and covered had the potential to attract pests or rodents that carried diseases. Residents Affected - Some Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 5/10/23 at 0919 hours, an observation and concurrent interview with the DSS was conducted. One of two garbage dumpsters located outside of the facility's back parking lot adjacent to the kitchen was observed to have the lid partially propped open by garbage, preventing the lid from fully closing. The DSS verified the findings and stated the maintenance were responsible for the dumpsters. On 5/10/23 at 0927 hours, an observation and concurrent interview with the Maintenance Supervisor was conducted. The Maintenance Supervisor acknowledged the dumpster lids were left partially open. The Maintenance Supervisor stated the lid had to be fully closed to prevent flies, rats, insects from getting to it and for infection control purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 30 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was accurately maintained for two of 18 final sampled residents (Residents 300 and 302). * Residents 300 and 302's POLST failed to show documentation as to whether the residents had formulated an advance directive. This failure had the potential for the residents' care needs not being met as the medical record was incomplete. Findings: 1. Medical record review for Resident 300 was initiated on 5/8/23. Resident 300 was admitted to the facility on [DATE]. On 5/9/23 at 0942 hours, an interview and concurrent medical record review was conducted with RN 1. Review of Resident 300's POLST, Section D (advance directive) dated 4/7/23, failed to show documentation as to whether Resident 300 had formulated an advance directive. RN 1 verified the findings and stated the POLST form was utilized when a resident was transferred emergently to the hospital, at which time the hospital may utilize the POLST form to obtain information as to whether Resident 300 had formulated an advance directive for healthcare, providing the hospital with the necessary information to ensure the resident's wishes specific to healthcare were honored. 2. Medical record review for Resident 302 was initiated on 5/8/23. Resident 302 was admitted to the facility on [DATE]. On 5/9/23 at 1038 hours, an interview and concurrent medical record review was conducted with the SSD. Review of Resident 302's POLST, Section D (advance directive) dated 4/8/23, failed to show documentation as to whether Resident 302 had formulated an advance directive. The SSD verified the findings and stated the advance directive section of the POLST should be filled out to provide the healthcare providers with information specific if Resident 302 had formulated an advance directive, to ensure Resident 302's healthcare wishes were honored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 31 of 32 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 555671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment were implemented for one nonsampled resident (Resident 605). This failure posed the risk of transmission of disease causing microorganisms. Residents Affected - Few Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene revised 8/2020 showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Further review of the P&P showed to perform hand hygiene after removing gloves. On 5/10/23 at 0837 hours, during the medication pass observation, LVN 3 placed a nebulizer mask with gloved hands to Resident 605's face to administer a breathing treatment. During the administration of the breathing treatment to Resident 605, LVN 3 removed her gloves. LVN 3 did not perform handwashing after removing the gloves and was observed touching Resident 605's nebulizer mask with her left hand while Resident 605 was receiving the breathing treatment. At 0843 hours, LVN 3 was observed donning gloves. LVN 3 did not perform handwashing prior to donning gloves. LVN 3 removed the nebulizer mask from Resident 605's face and placed inside a plastic bag. On 5/11/23 at 0826 hours, LVN 3 verified she did not wear gloves while touching Resident 605's nebulizer mask and did not wash her hands in between procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 32 of 32