Health inspection·March 22, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further Review of Resident 505's medical record failed to show the physician's orders for the self-administration of the Emergen-C powder and Vicks VapoRub ointment and for these medications to be stored at the resident's bedside. In addition, there was no care plan problem initiated or developed to address the resident's self-administration of the medications. On 3/19/24 at 0938 hours, an observation and concurrent interview was conducted with the DON. The DON verified Resident 505 had the above medications at bedside. The DON stated she was not aware Resident 505 had the medications at bedside. The DON stated Resident 505 did not have the physician's order to self-administer medications. On 03/19/24 at 1040 hours, an interview was conducted with Resident 505. When asked about the medications at her bedside, Resident 505 stated both medications were brought from home. Resident 505 stated she added the Emergen-C packet to her water daily because she liked the taste of it and applied the Vicks VapoRub ointment to the outside of her nostrils as needed. On 3/20/24 at 1411 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 505 did not have the physician's orders to self-administer and store the above medication at the bedside. RN 1 verified there was no care plan problem addressing the resident's self-administration of the above medications. In addition, RN 1 verified the Medication Self-Administration Screen for Resident 505 showed the licensed nurse would administer all the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 2 of 42 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 03/22/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 physician was notified of the changes in conditions for one of 22 final sampled residents (Resident 305) as evidenced by: * The facility failed to notify the physician for Resident 305's multiple scattered reddish, maroon colored skin discoloration to the bilateral upper extremities. This failure had the potential for Resident 305 not to receive the appropriate treatment to address his medical needs and to have a delay in care and treatments. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised September 2023 showed the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: i. instructions to notify the physician of changes in the resident's condition. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in the resident's medical/mental condition or status. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's P&P titled Pressure Ulcer Risk Assessment revised September 2022 showed under the monitoring section, the staff will perform routine skin inspections (with daily care); nurses are to be notified to inspect the skin if skin changes are identified; and nurses will conduct skin assessments at least weekly to identify changes. Once inspection of skin is completed proceed to the admission Assessment or Weekly Skin Integrity tool (depending on whether this is a new admission or an existing resident) and complete documentation of findings. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Proceed to care planning and interventions individualized for the resident and their particular risk factors. Notification. Document the procedure. During the initial facility tour on 3/19/24 at 0925 hours, Resident 305 was observed with multiple scattered reddish, maroon-colored skin discoloration to bilateral hands and upper extremities. Resident 305 stated he bruised easily but did not bleed. Medical record review for Resident 305 was initiated on 3/19/24. Resident 305 was readmitted to the facility on [DATE]. Review of Resident 305's H&P examination dated 3/15/24, showed Resident 305 had intermittent capacity to understand and make decisions. Review of Resident 305's Order Summary Report for March 2024 showed the following physician's order for Resident 305's skin discolorations: - dated 3/13/24, to monitor the resident's skin bruising on the right hand for skin integrity every shift for 14 days, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 3 of 42 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 03/22/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm - dated 3/13/24, to monitor the resident's skin bruising on the left hand for skin integrity every shift for 14 days. Review of Resident 305's Admission/readmission Screener dated 3/13/24, under the skin integrity section, showed the following skin issues: Residents Affected - Few - redness on scrotum, - left hand bruising, - right hand bruising, - Stage 1 pressure injury on the right buttock, and - Stage 1 pressure injury on the left buttock and scab on the middle of the nose. However, the Order Summary Report for March 2024 did not show the order to monitor for the bilateral upper extremities multiple scattered skin discoloration. Review of Resident 305's SBAR Communication Form and Progress Notes for March 2024 did not show documentation of the resident's multiple scattered reddish, [NAME]-colored skin discoloration to the bilateral upper extremities were identified or the physician was notified of the resident's skin changes. Review of Resident 305's Progress Notes for March 2024 did not show documented evidence to show Resident's 305's multiple scattered reddish, [NAME]-colored skin discoloration to the bilateral upper extremities were identified or the physician was notified of the skin changes. On 3/21/24 at 0824 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 verified Resident 305 had multiple scattered reddish, maroon-colored skin discoloration to the bilateral upper extremities. CNA 4 stated Resident 305's skin discoloration to the bilateral upper extremities were old and had been reported to the charge nurse. On 3/21/24 at 0836 hours, an observation, interview, and concurrent medical record review was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 verified Resident 305 had multiple scattered reddish, maroon-colored skin discoloration to the bilateral upper extremities. LVN 4 stated Resident 305's multiple scattered reddish, maroon-colored discoloration to the bilateral upper extremities were present upon admission. LVN 4 stated she forgot to clarify to add the bilateral upper extremities skin discoloration in the orders and documentation. LVN 4 stated when the residents had new skin issues, she would assess the resident's skin, initiate a change of condition, notify the physician of the changes, and receive recommendation for treatment, notify family of the changes, and initiate a care plan. LVN 4 verified there were no documentation of the change of condition regarding Resident 305's multiple scattered reddish, maroon-colored skin discoloration to the bilateral upper extremities nor the physician was notified of Resident 305's skin changes. On 3/22/24 at 1452 hours, the DON was informed and acknowledged the above findings. Cross reference to F684. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 4 of 42 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 03/22/2024 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 0583 Keep residents' personal and medical records private and confidential. 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 privacy was provided for one of 22 final sampled residents (Resident 18) and three nonsampled residents (Residents 14, 24, and 32). Residents Affected - Few * The privacy curtain was not pulled while providing the ADL care to Residents 14, 18, and 32. * The facility failed to ensure the privacy was provided during the GT medication administration for Resident 24. These failures had the potential to negatively affect the dignity of the residents and violate the residents' right to privacy. Findings: Review of the facility's P&P titled Dignity revised November 2023 showed the residents are always treated with dignity and respect. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. On 3/19/24 at 0822 hours, CNA 5 was observed inside Resident 18's room. Resident 18's privacy curtain was observed open and Resident 18 was observed not wearing pants. Resident 18's disposable underwear was observed visible from the hallway outside the resident's room. CNA 5 was observed inside the resident's bathroom with the door open and Resident 18 was visible from the hallway. Resident 18 was then observed standing up from the toilet. Resident 18's buttocks were then exposed and visible from the hallway. On 3/19/24, at 1135 hours, an interview was conducted with CNA 5. CNA 5 acknowledged she did not provide personal privacy to Resident 18. 2. On 3/19/24 at 1008 hours, LVN 4 and CNA 3 were observed checking Resident 32's disposable underwear. Resident 32's body was exposed. Resident 32's window curtain was observed open and the facility's parking lot was visible from the window. A male passerby was observed walking outside Resident 32's window glancing towards Resident 32's window. The finding was verified with LVN 4. On 3/20/24 medical record review for Resident 32 was initiated. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's H&P examination showed Resident 32 was admitted with diagnoses including dementia and Parkinson's disease. Resident 32 had no capacity to understand and make decisions. 3. Medical record review for Resident 14 was initiated on 3/20/24. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's H&P examination dated 3/21/23, showed Resident 14 had the capacity to understand and make medical decisions. During an interview with the SSD in the hallway near Resident 14's room on 3/20/24 at 0943 hours, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 5 of 42 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 03/22/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 14's privacy curtain was observed pulled halfway of Resident 14's bed. CNA 6 was observed changing Resident 14's upper body clothes. Resident 14's upper body was exposed and seen from the hallway. The SSD verified the findings. On 3/20/24 at 0950 hours, an interview was conducted with Resident 14. Resident 14 stated she would feel bad if someone in the hallway saw her body exposed while being changed. On 3/20/24 at 0955 hours, an interview was conducted with CNA 6. CNA 6 verified the above findings. CNA 6 stated the privacy curtain moved whenever she provided care to Resident 14. CNA 6 stated the resident's privacy curtain should be pulled completely. 4. On 3/19/24 at 0830 hours, a medication administration observation was conducted with LVN 2. LVN 2 exposed Resident 24's abdomen and attempted to administer the medications via GT. LVN 2 left the privacy curtain for Resident 24 open. LVN 2 did not cover Resident 24 with a blanket exposing Resident 24's diaper and legs as well. The room door was also left open showing the medication administration to others in the hallway. Medical record review for Resident 24 was initiated on 3/19/24. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24's MDS assessment dated [DATE], showed Resident 24 was cognitively impaired and totally dependent on the staff for ADL care. Review of Resident 24's H&P examination dated 7/17/23, showed Resident 24 had no capacity to make decisions. On 3/19/24 at 1215 hours, an interview was conducted with LVN 2. LVN 2 verified the privacy curtain should have been used and Resident 24 should have been covered with blanket to provide privacy during medication administration. On 3/20/24 at 1521 hours, an interview was conducted with the DON. The DON stated the staff should always maintain the privacy for the residents during treatment procedures to promote dignity. The DON acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 6 of 42 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 03/22/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **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 provide a summary of the baseline care plan for two of 22 final sampled residents (Residents 304 and 307). This failure had the potential for inappropriate interventions and care for these residents. Findings: Review of the facility's P&P titled Care Plans- Baseline revised March 2022 showed the resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: - the stated goals and objectives of the resident; - a summary of the resident's medications and dietary instructions; - any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and - any updated information based on the details of the comprehensive care plan as necessary. Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. During the initial facility tour on 3/19/24 at 0919 hours, Resident 304 stated she had not received a copy of her baseline care plan or had the staff discussed her plan of care with her. Medical record review for Resident 304 was initiated on 3/19/24. Resident 304 was admitted to the facility on [DATE]. Review of Resident 304's H&P examination dated 2/29/24, showed Resident 304 had the capacity to understand and make decisions. Review of Resident 304's Baseline Care Plan form dated 2/26/24, showed a licensed nurse's signature. However, the form did not show documentation Resident 304 or Resident 304's representative was provided a copy or acknowledgement that the baseline care plan was discussed and received by Resident 304 or Resident 304's representative. Review of Resident 304's Interdisciplinary (IDT) Care Conference dated 2/27/24, showed the checked marks indicating Resident 304 and Resident 304's representative had attended and participated in the meeting. However, the document did not show a signature from Resident 304 and Resident 304's representative that they were provided a copy of the IDT Care Conference, which included a Summary of the Baseline Care Plan and acknowledgement receipt from Resident 304 or Resident 304's representative. Review of Resident 304's All Progress Notes for February and March 2024 did not show documented evidence a copy of Resident 304's Summary of the Baseline Care Plan was provided to Resident 304 or Resident 304's representative. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 7 of 42 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 03/22/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/20/24 at 1134 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings. The MDS Coordinator stated the admission nurse created the assessment for the baseline care plan when a resident was admitted to the facility. The MDS Coordinator stated each IDT member which included the nursing, rehabilitation, activities, dietitian, and social services representative completed a section in the baseline care plan. The MDS Coordinator stated she would print a copy of the baseline care plan and brought the document during the IDT care conference meeting for the resident and resident's representative to sign as proof that the resident's initial plan of care was discussed and provided copy of the baseline care plan summary. The MDS Coordinator verified there was no documentation showing Resident 304 or Resident 304's representative was provided or received copy of Resident 304's Baseline Care Plan Summary. On 3/22/24 at 1446, the DON was informed and acknowledged the above findings. 2. During the initial facility tour on 3/19/24 at 1020 hours, Resident 307 stated he had not attended a care plan meeting. Medical record review for Resident 307 was initiated on 3/19/24. Resident 307 was admitted to the facility on [DATE]. Review of Resident 307's H&P examination dated 3/14/24, showed Resident 307 had the capacity to understand and make decisions. Review of Resident 307's Baseline Care Plan dated 3/12/24, did not show documentation of acknowledgement Resident 307 or Resident 307's representative was provided or received a copy of Resident 307's baseline care plan summary. Review of Resident 307's IDT Care Conference dated 3/13/24, showed Resident 307 and Resident 307's representative attended the meeting. However, the IDT Care Conference form did not show a signature or acknowledgement from Resident 307 and Resident 307's representative as a receipt to show a copy of the IDT Care Conference which included a Summary of the Baseline Care Plan was provided or received by Resident 307 or Resident 307's representative. Review of Resident 307's All Progress Notes for March 2024 did not show documented evidence a copy of Resident 307's Summary of the Baseline Care Plan was provided to Resident 307 or Resident 307's representative. On 3/20/24 at 1124 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings. The MDS Coordinator stated she could not find documentation Resident 307 or Resident 307's representative was provided a copy of Resident 307's baseline care plan summary. On 3/22/24 at 1446 hours, the DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 8 of 42 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 03/22/2024 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, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive plans of care to reflect the individual care needs of three of 22 final sampled residents (Residents 12, 304, and 505). * The facility failed to develop a care plan with goal and interventions to address Resident 12's RNA services. * The facility failed to implement a care plan intervention to place TED hose (Thrombo-Embolic Deterrent, specially designed knee-high, thigh-high or waist high stockings that help prevent blood clots and swelling in your legs) to swollen extremities for Resident 304. * The facility failed to implement a pad alarm in bed/wheelchair for Resident 505. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plans-Comprehensive revised September 2023 showed each resident's comprehensive care plan is designed to incorporate identified problems; incorporate risk factors associated with identified problems; reflect treatment goals, timetables, and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; aide in preventing or reducing decline declines in the resident's functional status and/or functional levels; enhanced the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. 1. Medical record review for Resident 12 was initiated on 3/21/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 5/11/23, showed Resident 12 had the capacity to understand and make decisions. Review of Resident 12's Order Summary Report for March 2024 showed the following physician's orders: - dated 12/29/23, late entry for 12/21/23, for Resident 12 to receive RNA services for passive range of motion to the bilateral upper extremities five times a week as tolerated, - dated 12/30/23, reclarification of RNA services to do range of motion exercises on Resident 12's both lower extremities daily five times a week or as tolerated. Review of Resident 12's Tasks tab for March 2024, under RNA range of motion services to bilateral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 9 of 42 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 03/22/2024 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 upper and lower extremities, showed RNAs were providing range of motion exercises as per the physician's orders. However, review of Resident 12's Comprehensive Plan of Care did not reflect a care plan problem to address the RNA services as per the physician's orders. Residents Affected - Few On 3/21/24 at 1313 hours, an interview was conducted with Resident 12. Resident 12 stated she could move both arms, but her legs were weak. Resident 12 stated the staff did provide range of motion exercises. On 3/21/24 at 1314 hours, an interview was conducted with RNA 1. RNA 1 stated he provided range of motion exercises to Resident 12's bilateral lower extremities when she transferred the resident from the bed to wheelchair and vice versa. On 3/21/24 at 1325 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings. RN 2 stated the rehabilitation department initiated the care plans when a resident was placed in the RNA services. On 3/21/24 at 1333 hours, an interview and concurrent medical record review was conducted with OT 1. OT 1 verified the above findings. OT 1 stated the primary therapist who recommended the RNA services initiated the care plan. OT 1 verified there was no care plan problem developed for Resident 12's RNA services in the comprehensive care plan. 2. Medical record review for Resident 304 was initiated on 3/19/24. Resident 304 was admitted to the facility on [DATE]. Review of Resident 304's H&P examination dated 2/29/24, showed Resident 304 had the capacity to understand and make decisions. Review of Resident 304's Comprehensive Plan of Care showed the following: -a care plan problem initiated on 2/26/24, addressing the risk for occurrence of edema (RLE edema 4+) with an intervention as TED hose as ordered. -a care plan problem initiated on 2/26/24, addressing the risk for occurrence of edema (LLE edema 4+) with an intervention as TED hose as ordered. - a care plan problem initiated on 2/26/24, addressing the risk for occurrence of edema (RUE edema 2+) with an intervention as TED hose as ordered. - a care plan problem initiated on 2/26/24, addressing the risk for occurrence of edema (LUE edema 2 +) with an intervention as TED hose as ordered. Review of Resident 304's Order Summary Report for March 2024 showed the following physician's orders: - dated 2/26/24, to elevate Resident 304's bilateral lower extremities while in bed for edema management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 10 of 42 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 03/22/2024 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 - dated 2/29/24, to apply ace wrap to Resident 304's RLE and LLE for 12 hours daily due to edema, and to apply at 0900 hours, and remove at 2100 hours per schedule. However, there was no physician's order for the use of TED hose to Resident 304's extremities. On 3/21/24 at 0815 hours, Resident 304's right shin was observed with a gauze dressing and elevated with pillows. There was no TED hose observed in Resident 304's BLEs or BUEs. On 3/21/24 at 0952 hours, Resident 304 was observed lying in bed and the resident's bilateral lower extremities wrapped in a brown colored ace bandage and bilateral upper extremities without TED hose. On 3/21/24 at 1036 hours, an observation, interview, and concurrent medical record review was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 stated the intervention for the edema in Resident 12's extremities were incorrect for the use of the TED hose. LVN 4 stated upon admission of a resident, there was a standard care plan initiated by the admission nurse regarding skin and she had not revised the care plan yet. LVN 4 stated the order for Resident 12's BLEs edema was to wrap with an ace bandage and to have all the extremities elevated with pillows. On 3/22/24 at 1450 hours, the DON was informed and acknowledged the findings. 3. Medical record review for Resident 505 was initiated on 3/19/24. Resident 505 was admitted to the facility on [DATE]. Review of Resident 505's H&P examination dated 1/12/24, showed Resident 505 could make needs known but could not make medical decisions. Review of Resident 505's plan of care showed a care plan problem dated 2/21/24, addressing Resident 505's actual fall incident. The plan of care included an intervention to apply pressure pad alarm in bed and wheelchair. On 3/19/24 at 1201 hours, an observation and concurrent interview was conducted with Resident 505 in Room A. Resident 505 was observed sitting on a cushion in the wheelchair. Resident 505 stated the facility placed the cushion on the wheelchair to prevent her from sliding off. On 3/20/24 at 1004 hours, an observation of Resident 505's room was conducted. There was no pressure pad alarm observed on Resident 505's bed and/or wheelchair. However, a thick cushion was observed on Resident 505's wheelchair seat. On 3/20/24 at 1143 hours, an observation, interview, and concurrent medical record review was conducted with RN 1. RN 1 reviewed Resident 505's plan of care addressing her actual fall and verified the interventions included to apply pressure pad alarm in the bed and wheelchair. RN 1 verified there was no pressure pad alarm on Resident 505's bed and/or wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 11 of 42 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 03/22/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 ensure the comprehensive plans of care for one of 22 final sampled residents (Resident 12) was revised to reflect the resident's current care needs and interventions. * The facility failed to ensure Resident 12's plan of care was revised to reflect Resident 12 was discharged from therapy services. This failure posed the risk of not providing Resident 12 with individualized and person-centered care. Findings: Review of the facility's P&P titled Care Plans-Comprehensive revised September 2023 showed the Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans when there had been a significant change in the resident's condition; when the desired outcomes is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly. Medical record review for Resident 12 was initiated on 3/21/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 5/11/23, showed Resident 12 had the capacity to understand and make decisions. Review of Resident 12's MDS dated [DATE], showed Resident 12 had received ST services from 12/23-12/26/23, and OT and PT services from 11/23-12/21/23. Review of Resident 12's Order Summary Report for March 2024 did not show a current physician's order for the therapy services. However, review of Resident 12's Comprehensive Plan of Care showed an active care plan problem addressing Resident 12 requiring SLP, OT, and PT services. On 3/21/24 at 1325 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings. On 3/21/24 at 1333 hours, an interview and concurrent medical record review was conducted with OT 1. OT 1 verified the above findings. OT 1 stated the care plan problems for the SLP, OT, and PT services should have been resolved because the resident was currently not receiving therapy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 12 of 42 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 03/22/2024 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 ensure a non-English speaking resident's communication needs were met for one nonsampled resident (Resident 31) and failed to ensure the translation service contact information was available for staff. These failures had the potential for a delay in the facility's ability to communicate with the resident. Residents Affected - Few Findings: Review of the facility's P&P titled Communication Barriers, Reduction Of, undated, showed the facility will provide methods of communication to assure adequate communication between residents and staff. Medical record review for Resident 31 was initiated on 3/21/24. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's MDS dated [DATE], showed Resident 31 spoke a non-English language and requested an interpreter to communicate with the health care staff. Review of Resident 31's SBAR Communication Form and Progress Note - V 3 dated 3/17/24, showed a change of condition for the resident, and the resident was noted to have skin discolorations on the right forearm and scratches and scabs on their right thigh and the left lower leg. The record also showed the resident had episodes of yelling during incontinent cares. Review of Resident 31's Social Service Note dated 3/18/24 at 1033 hours, showed the Social Services became aware of an incident where Resident 31's roommate stated Resident 31 was moaning and crying while being changed by two CNAs, and the roommate stated the noises happened all the time when staff were changing Resident 31. The Social Service note showed the Social Services staff went to Resident 13's room and due to the language barrier and not being able to communicate using the resident's communication sheets, she gave the resident a thumbs up to ask if everything was okay, and the resident seemed in good spirits and did not show any signs of distress. Review of Resident 31's Social Service Note dated 3/19/24 at 1116 hours, showed the Social Services staff spoke to Resident 31's family member on the telephone about the incident and the family member stated Resident 13 did not express any concerns to the family member. On 3/22/24 at 0935 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated on the morning of 3/18/24, she was notified by the DON of a change of condition for Resident 31. The SSD stated she was told that Resident 31's roommate stated while Resident 31 was receiving incontinent cares from the two CNAs, the resident was moaning and yelling out. The SSD stated they went to speak to Resident 31, but the communication sheets were not effective, so she called the resident's family member and left a message. The SSD stated they gave Resident 31 a thumbs up and smiled at the resident to ask if she was okay, and she smiled back and nodded. When asked if the facility had a translation service available, the SSD replied not that they were aware of, but stated some staff used Google translate, but it was not always accurate. The SSD stated Family Member 1 later called back and told her that Resident 31 did not mention any concerns to them. When asked if the SSD asked Family Member 1 to translate via telephone for her so she could talk to Resident 31 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 13 of 42 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 03/22/2024 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 about her yelling out and moaning during incontinent cares, they stated no. Level of Harm - Minimal harm or potential for actual harm On 3/22/24 at 1038 hours, an observation and concurrent interview was conducted with the Activity Director with Resident 31 in the activity room. Resident 31 was observed in their wheel chair watching TV. The back pocket of the resident's wheelchair had multiple sheets with English and foreign characters. The Activity Director stated the sheets were the resident's communication sheets. The Activity Director stated she was not sure if the resident could read their language on the sheets. This writer pointed to the foreign characters next to the English word good morning, the resident nodded. Then, this writer pointed to the characters next to Nice to meet you, the resident nodded. When this writer pointed to the characters next to no, the resident nodded. Residents Affected - Few On 3/22/24 at 1116 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 31 had the communication sheets in the resident's language. LVN 5 stated they had asked the resident a question several times using the communication sheets and would usually get a head nod or shake for yes or no answers. LVN 5 stated they usually called the resident's family member if they could not figure out what the resident wanted. When asked if they had a translation service, the LVN replied they believed the facility had a language translation service, but they had not used it. On 3/22/24 at 1119 hours, an interview and concurrent observation was conducted with RN 3. RN 3 stated the facility had a translation service available by telephone. When asked where the translation service contact information was located, RN 3 was unable to locate it in Station 1. RN 3 went to Station 3 and stated she was unable to locate the translation service contact information. On 3/22/24 at 1145 hours, a follow-up interview was conducted with LVN 5. LVN 5 stated using the communication sheets for Resident 31 did not work well because the resident nodded to everything. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 14 of 42 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 03/22/2024 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 necessary care and services were provided to attain or maintain the highest practicable well-being for one of 22 final sampled residents (Resident 305). Residents Affected - Few * The facility failed to identify and assess for Resident 305's multiple scattered reddish, maroon-colored skin discoloration to his bilateral upper extremities. This failure had the potential risk of not providing appropriate care for Resident 305. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised September 2023 showed the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: i. instructions to notify the physician of changes in the resident's condition. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/ Charge Nurse will inform the resident of any changes in the resident's medical/mental condition or status. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's P&P titled Pressure Ulcer Risk Assessment revised September 2022 showed under the monitoring section, the staff will perform routine skin inspections (with daily care); nurses are to be notified to inspect the skin if skin changes are identified; and nurses will conduct skin assessments at least weekly to identify changes. Once inspection of skin is completed proceed to the admission Assessment or Weekly Skin Integrity tool (depending on whether this is a new admission or an existing resident) and complete documentation of findings. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Proceed to care planning and interventions individualized for the resident and their particular risk factors. Notification. Document the procedure. During the initial facility tour on 3/19/24 at 0925 hours, Resident 305 was observed with multiple scattered reddish, maroon-colored skin discoloration to the bilateral hands and upper extremities. Resident 305 stated he bruised easily, but did not bleed. Medical record review for Resident 305 was initiated on 3/19/24. Resident 305 was readmitted to the facility on [DATE]. Review of Resident 305's H&P examination dated 3/15/24, showed Resident 305 had intermittent capacity to understand and make decisions. Review of Resident 305's Order Summary Report for March 2024 showed the following physician's order for Resident 305's skin discolorations: -dated 3/13/24, to monitor the skin bruising on the right hand for skin integrity every shift for 14 days, -dated 3/13/24, to monitor the skin bruising on the left hand for skin integrity every shift for 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 15 of 42 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 03/22/2024 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 However, the Order Summary Report for March 2024 did not show an order to monitor for the bilateral upper extremities multiple scattered skin discoloration. Review of Resident 305's Admission/readmission Screener dated 3/13/24, under the skin integrity section, showed the following skin issues: Residents Affected - Few - redness on scrotum, - left hand bruising, - right hand bruising, - Stage 1 pressure injury on the right buttock, and - Stage 1 pressure injury Stage 1 on the left buttock and scab on the middle of the nose. Review of Resident 305's SBAR Communication Form and Progress Notes for March 2024 did not show documentation of the multiple scattered reddish, [NAME]-colored skin discoloration to the bilateral upper extremities were identified or the physician was notified of Resident 305's skin changes. Review of Resident 305's All Progress Notes for March 2024 did not show documented evidence Resident's 305's multiple scattered reddish, [NAME]-colored skin discoloration to the bilateral upper extremities were identified or the physician was notified of the skin changes. On 3/21/24 at 0824 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 verified Resident 305 had multiple scattered reddish, maroon-colored skin discoloration to the bilateral upper extremities. CNA 4 stated Resident 305's skin discoloration to the bilateral upper extremities were old and had been reported to the charge nurse. On 3/21/24 at 0836 hours, an observation, interview, and concurrent medical record review was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 verified Resident 305 had multiple scattered reddish, maroon-colored skin discoloration to the bilateral upper extremities. LVN 4 stated Resident 305's multiple scattered reddish, maroon-colored discoloration to the bilateral upper extremities were present upon admission. LVN 4 stated she forgot to clarify the bilateral upper extremities skin discoloration in the orders and documentation. LVN 4 stated when the residents had new skin issues, she would assess the resident's skin, initiate a change of condition, notify the physician of the changes, and receive recommendation for the treatment, notify the resident's family of the changes, and initiate a care plan. LVN 4 verified there were no documentation the change of condition related to Resident 305's multiple scattered reddish, maroon-colored skin discoloration to the bilateral upper extremities nor the physician was notified of Resident 305's skin changes. On 3/22/24 at 1452 hours, the DON was informed and acknowledged the above findings. Cross reference to F580. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 16 of 42 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 03/22/2024 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 22 final sampled residents (Resident 505) remained free from the accident hazards. * The facility failed to monitor Resident 505 for 72 hours after her fall according to the facility's P&P. This failure had the potential to place the resident at risk for serious injury. Findings: Review of the facility's P&P titled Assessing Falls and Their Causes revised November 2023 showed after a fall observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. Review of the facility's P&P titled Neurological Assessment revised November 2023 showed neurological assessments are indicated: (a) upon physician order; (b) following an unwitnessed fall; (c) following a fall or other accident/injury involving head trauma; or (d) when indicated by resident's condition. Medical record review for Resident 505 was initiated on 3/19/24. Resident 505 was admitted to the facility on [DATE]. Review of Resident 505's MDS dated [DATE], showed Resident 505 had a BIMS score of 8 which indicated moderate cognitive impairment. Review of Resident 505's SBAR Communication Form and progress note dated 2/21/24, showed Resident 505 had an unwitnessed fall. Review of Resident 505's plan of care showed a care plan problem dated 2/21/24, addressing Resident 505's actual fall incident. The plan of care showed an intervention to initiate the 72 hours neuro checks. Review of the facility's 72 Hours Neuro-Checklist showed the following timelines to conduct and document the neuro check assessments: - first 24 hours: two times every 30 minutes, three times every hour, three times every 2 hours, and four times every four hours, and - next 48 hours: six times every eight hours. However, review of Resident 505's Neuro-Checks V2 showed the neuro checks were performed on the following dates and times: - 2/21/24 at 0944 hours; - 2/22/24 at 1715 hours; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 17 of 42 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 03/22/2024 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 - 2/23/24 at 0315 hours; and Level of Harm - Minimal harm or potential for actual harm - 2/24/24 at 1115 hours. Residents Affected - Few On 3/19/24 at 1201 hours, an interview was conducted with Resident 505. Resident 505 stated she tried to pick up the medication off the floor and slid out of the wheelchair. On 3/20/24 at 1138 hours, an interview was conducted with LVN 3. LVN 3 stated when a resident had a fall, the licensed nurse had to complete an assessment, initiate the neuro checks, notify the physician, order an x-ray (diagnostic procedure to detect abnormalities inside the body), and educate the resident. On 3/21/24 at 0913 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated after a fall, the fall packet should be completed by the licensed nurses, which included the 72 Hours Neuro-Checklist. On 3/22/24 at 0935 hours, a follow-up interview was conducted with the DON. The DON stated she could not find the 72 Hours Neuro-Checklist for Resident 505. However, the DON provided the above four Neuro-Checks documents dated 2/21, 2/22, 2/23, and 2/24/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 18 of 42 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 03/22/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 provide the necessary GT care for one nonsampled resident (Resident 24). * The facility failed to ensure the gastric residual volume (volume of fluid remaining in the stomach) was checked before flushing and administering a bolus feeding (a single dose of medication or other substance given over a short period of time) to Resident 24. This failure posed the potential risk for Resident 24 to have aspiration during the medication administration and for developing complications related to GT. Findings: Review of the facility's P&P titled Administering Medications Through an Enteral Tube revised March 2023 showed to check the gastric residual volume (GRV) to assess for tolerance of enteral feeding and when correct tube placement and acceptable GRV had been verified, flush tubing with 15-30 ml warm sterile water (or prescribed amount). On 3/19/24 at 0830 hours, a medication administration observation was conducted with LVN 2. LVN 2 held the tube feeding and attempted to flush the GT with warm water. LVN 2 did not check the GRV prior to flushing the GT. LVN 2 attempted twice to flush the GT but it was unsuccessful. LVN 2 stated the GT might had been clogged. Medical record review for Resident 24 was initiated on 3/19/24. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24's H&P examination dated 7/17/23, showed Resident 24 had no capacity to make decisions. Review of Resident 24's Order Summary Report showed the following physician's orders dated 7/14/23: - Enteral Feed Jevity 1.2 (enteral feeding formula) to run via pump at 70 ml/hr to provide a total of 1400 ml/1680 kcal - Check residual every shift. Hold feeding if greater than 100 ml, recheck in one hour, if greater than 100 ml, notify MD. Document numbers of ml. On 3/19/24 at 1215 hours, an interview and concurrent record review was conducted with LVN 2. LVN 2 stated he should have checked the GRV first before flushing the resident's GT. On 3/20/24 at 1521 hours, an interview was conducted with the DON. The DON stated before flushing or giving medications via GT, the nurse should have checked the residual volume first to assess if the resident was tolerating the feeding and by doing so it could have determined as well if the GT was clogged when resistance was assessed. The DON acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 19 of 42 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 03/22/2024 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 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** 3. Medical record review for Resident 13 was initiated on 3/29/24. Resident 13 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 13's MAR for March 2024 showed an order dated 3/13/24, for a Fleets enema to be administered in the afternoon for bowel management. The MAR showed it was signed as administered on 3/13/24 at 1300 hours. On 3/19/24 at 1038 hours, an interview was conducted with Resident 13. Resident 13 stated they did not receive an enema. On 3/21/24 at 1225 hours, a telephone interview was conducted with LVN 2. LVN 2 stated they did not administer an enema to Resident 13. LVN 2 stated the resident preferred a female nurse to administer the rectal medication and the LVN endorsed it to the oncoming female nurse. On 3/21/24 at 1503 hours, an interview was conducted with LVN 6. LVN 6 stated they did not administer Resident 13's fleets enema. The LVN stated LVN 2 reported to her at the shift change to administer it if the resident needed it. The LVN stated the resident did not ask for it, so they did not administer it. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for three of 22 final sampled residents (Residents 9, 13, and 50) and one nonsampled resident (Resident 51) to meet the needs of each resident as evidenced by: * The facility failed to ensure the controlled drug Percocet (opioid analgesic) 5 mg-325 mg tablet signed out from the controlled drug record was documented as administered on the MAR for Resident 9; and the controlled drug, Norco (opioid analgesic) 5 mg-325 mg tablet signed out from the controlled drug record was documented as administered on the MAR for Resident 50. * The facility failed to the removed and not used controlled drug tablet was properly discard and not placed back into the bubble pack and taped for Resident 51. * Resident 13's Fleets enema (a liquid laxative administered into the rectum) was not administered as ordered by the physician. These failures posed the risk of diversion of the controlled medication and had the potential for poor health outcome. Findings: Review of the facility's P&P titled Administering Medication revised December 2021 showed the following: - The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. - As required or indicted for a medication, the individual administering the medication will record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 20 of 42 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 03/22/2024 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 in the resident's medical record: Level of Harm - Minimal harm or potential for actual harm a. The date and time the medication was administered; b. The dosage; Residents Affected - Few c. The route of administration; d. The injection site if applicable; e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. Review of the facility's P&P titled Controlled Substance revised December 2023 showed unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication should be destroyed and may not be returned to the container. 1. On 3/20/24 at 1044 hours, during the inspection of Medication Cart 2, the Controlled Medication Count Sheet Records were reviewed with LVN 5. a. Resident 9's Controlled Medication Count Sheet Record for Percocet was reviewed with LVN 5. The Controlled Medication Count Sheet Record showed Resident 9 was administered Percocet 5 mg-325 mg one tablet on 3/18/24 at 1204 hours, for pain. Resident 9's MAR for March 2024 was reviewed with LVN 5. Resident 9's MAR did not show an administration documentation of Resident 9's Percocet on 3/18/24 at 1204 hours. LVN 5 verified Resident 9's Controlled Medication Count Sheet Record for Percocet did not match Resident 9's MAR for March 2024. Medical record review of Resident 9 was initiated on 3/20/24. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's Order Summary Report showed a physician's order dated 2/27/24, to administer Percocet oral tab 5 mg-325 mg by mouth one tablet every six hours as needed for moderate pain. b. Resident 50's Controlled Medication Count Sheet Record for Norco was reviewed with LVN 5. The Controlled Medication Count Sheet Record showed Resident 50 was administered Norco 5 mg-325 mg one tablet on 3/13/24 at 1430 hours, for pain. Resident 50's MAR for March 2024 was reviewed with LVN 5. Resident 50's MAR did not show an administration documentation of Resident 50's Norco on 3/13/24 at 1430 hours. LVN 5 verified Resident 50's Controlled Medication Count Sheet Record for Norco did not match Resident 50's MAR for March 2024. Medical record review of Resident 50 was initiated on 3/20/24. Resident 50 was admitted to the facility on [DATE], and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 21 of 42 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 03/22/2024 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 Review of Resident 50's Order Summary Report showed a physician's order dated 3/3/24, to administer Norco oral tablet 5 mg-325 mg by mouth one tablet every six hours as needed for moderate pain and two tablets every six hours as needed for severe pain. On 3/20/24 at 1453 hours, an interview was conducted with the DON. When asked regarding the controlled drug documentation, the DON stated the nurse should sign the Controlled Medication Count Sheet Record and MAR right away when the controlled drug was administered. The DON acknowledged the above findings. 2. On 3/20/24 at 1100 hours, during the inspection of Medication Cart 2, Resident 51's bubble pack for Norco 5 mg-325 mg was observed showing the number 34 tablet was popped out from the bubble pack and put back and the back of the number 34 of the bubble pack had a tape. LVN 5 verified the tablet was popped out and the back of the bubble pack was taped. Resident 51's Controlled Medication Count Sheet Record for Norco was reviewed with LVN 5. The Controlled Medication Count Sheet Record did not show an administration nor wasted documentation for the number 34 tablet from the bubble pack. Medical record review of Resident 51 was initiated on 3/20/24. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's Order Summary Report showed a physician's order dated 2/17/24, to administer Norco oral tablet 5 mg-325 mg by mouth one tablet every four hours as needed for moderate to severe pain. On 3/20/24 at 1453 hours, an interview was conducted with the DON. The DON stated if the controlled drug was not given to the resident, it should be destroyed and never be put back in the bubble pack. The DON acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 22 of 42 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 03/22/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 ensure one of 22 final sampled residents (Resident 2) was provided the management for the use of psychotropic medications (medications that affect the mind, emotions, and behavior). * The facility failed to ensure the non-pharmacological approaches were provided to Resident 2 while receiving alprazolam (to treat anxiety disorders and panic disorders-sudden, unexpected attacks of extreme fear and worry about these attacks), bupropion (to treat depression), citalopram (to treat depression), and Quetiapine (Seroquel, medicine used to treat several kinds of mental health conditions including schizophrenia and bipolar disorder. It helped regulate the mood, behaviors, and thoughts) medications. This failure had the potential to cause harm to Resident 2. Findings: Review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring revised March 2023 showed non-pharmacological approaches would be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. Medical record review for Resident 2 was initiated on 3/21/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary Report for March 2024 showed the following physician's orders: - A physician's order dated 9/25/23, to administer Seroquel oral table by mouth 25 mg one tablet in the evening related to psychosis manifested by continuous screaming or yelling. - A physician's order dated 11/20/23, to administer alprazolam oral tablet 0.25 mg by mouth one tablet at bedtime for verbalization of feeling anxious related to anxiety disorder. - A physician's order dated 12/11/23, to administer bupropion oral tablet 75 mg by mouth one tablet one time a day related to major depressive disorder manifested by verbalization of feeling sad. - A physician's order dated 12/24/22, to administer citalopram hydrobomide oral tablet 10 mg by mouth one tablet one time a day related to major depressive disorder manifested by crying spells. Further review of Resident 2's care plan problem addressing the use of alprazolam, bupropion, citalopram, and Seroquel medications failed to show documentation of the interventions for non-pharmacological implementation for the use of the above medications. Further review of Resident 2's MAR failed to show non-pharmacological interventions were provided for the use of alprazolam, bupropion, citalopram, and Seroquel medications. On 3/21/24 at 1016 hours, a concurrent observation and interview with Resident 2 was conducted. Resident 2 was sitting in bed. Resident 2 stated she was feeling fine today but yesterday she just wanted to be in bed. Resident 2 stated she liked to attend the bingo activity in the facility and her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 23 of 42 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 03/22/2024 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 0758 daughter usually visited her. Level of Harm - Minimal harm or potential for actual harm On 3/21/24 at 1406 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated they had a behavior note for the residents who were on psychotropics medications, which was documented every week. However, the DON failed to show non-pharmacological interventions were provided to the residents with psychotropic medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 24 of 42 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 03/22/2024 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 0759 Ensure medication error rates are not 5 percent or greater. 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 medication error rate was below 5%. The facility's medication rate was 10.34%. One of two licensed nurses (LVN 2) observed administering the medications was found to have errors while administering the medications to two nonsampled residents (Residents 24 and 404). Residents Affected - Few * The facility failed to ensure Resident 24 received the prescribed nasal gel and correct amount of the diclofenac sodium topical gel (to relieve pain from arthritis in certain joints such as those of the knees, ankles, feet, elbows, and hands). * LVN 2 prepared the expired vitamin D3 for Resident 404 during the medication pass observation. These failures had the potential for the residents to receive ineffective therapeutic effects of the medications and had negatively affect the residents' health. Findings: 1. Review of the facility's P&P titled Administering Medications revised date December 2021 showed the individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On 3/19/24 at 0805 hours, a medication administration observation was conducted with LVN 2. LVN 2 administered nasal spray on each nostril of Resident 24. LVN 2 applied the diclofenac topical gel approximately one inch to Resident 24's right knee and two drops on the left knee. Medical record review of Resident 24 was initiated on 3/19/24. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24's H&P examination dated 7/17/23, showed Resident 24 had no capacity to make decisions. Review of Resident 24's Order Summary Report for March 2024 showed: - a physician's order dated 7/14/23, to apply Ocean Nasal Moisturizer Nasal Gel in both nostrils one strip three times a day - a physician's order dated 8/10/23, to apply diclofenac sodium external Gel 1% to the left knee topically 4 grams four times a day for pain management - a physician's order dated 8/10/23, to apply diclofenac sodium external Gel 1% to the right knee topically 4 grams four times a day for pain management On 3/19/24 at 1215 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated the nasal spray was different from the nasal gel. LVN 2 stated he would use the medicine cup to measure how much diclofenac topical gel 4 grams was and the box would show the equivalent of 4 grams. LVN 2 showed the diclofenac box with the manufacturer instruction showing to use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 25 of 42 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 03/22/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few enclosed dosing card to measure a dose. Lower body dose 4.5 inches were equivalent to 4 grams. LVN 2 stated he did not use the enclosed dosing card to measure a dose and he did not apply 4.5 inches of the topical gel to each knee of Resident 24. On 3/20/24 at 1521 hours, an interview was conducted with the DON. The DON stated before administering the medication, the licensed nurse should double check in the PCC for the right prescribed medication and dosage, and to follow the manufacturer's specification for the equivalence of the customary units. The DON acknowledged the above findings. 2. Review of the facility's P&P titled Administering Oral Medications revised date October 2010 showed to check the expiration date on the medication and return any expired medications to the pharmacy. On 3/19/24 at 0859 hours, a medication administration observation was conducted with LVN 2. LVN 2 verified he would give vitamin D3 two tablets to Resident 404. LVN 2 showed the vitamin D3 bottle; however, the bottle's label showed an expiration date of 12/2023. At 0907 hours, LVN 2 was observed going to Resident 404 to administer the medication. LVN 2 was stopped and asked about the expiration date of vitamin D3, LVN 2 read the bottle label and stated it was expired. LVN 2 stated he would discard the expired medicine and get a new bottle of vitamin D3. Medical record review of Resident 404 was initiated on 3/19/24. Resident 404 was admitted to the facility on [DATE]. Review of Resident 404's H&P examination dated 3/12/24, showed Resident 404 had the capacity to understand and make her own decisions. Review of Resident 404's Order Summary Report showed a physician's order dated 3/10/24, to administer cholecalciferol oral capsule 50 mcg by mouth one capsule in the morning. On 3/20/2 at 1521 hours, an interview was conducted with the DON. The DON stated the administering nurse should always check the expiration date on the medicine bottle. The DON stated the residents should never receive an expired medication. The DON acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 26 of 42 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 03/22/2024 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, facility record review, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled for two of 22 sampled residents (Residents 307 and 505) and one nonsampled resident (Resident 37); and failed to ensure the medication room refrigerator temperatures were monitored in accordance with the facility's P&P. * The facility failed to dispose the insulin pen beyond the used by date for Resident 37. * The facility failed to dispose the medication and medical supplies after the expiration date. * The facility failed to dispose the opened sterile packages of Collagen dressing and disposable urinary drainage bag. * The facility failed to appropriately label the Apokyn Pen, blood glucose strips, and Miralax bottle with an open date. * The facility failed to monitor the temperatures of the medication room refrigerator. * The facility failed to ensure the medications for Resident 307 were not left unattended at the bedside. * The facility failed to ensure Resident 505's medications were not kept at the bedside. These failures had the potential to negatively impact the residents' well-being and potential access of other residents to the medications. Findings: 1. Review of the facility's P&P titled Administering Medications revised date December 2021 showed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. On 3/19/24 at 1141 hours, a concurrent medication administration observation and interview was conducted with LVN 3. LVN 3 stated she would give Lantus (insulin, used for diabetic) to Resident 37 for blood sugar level of 186 mg/dl. LVN 3 was observed checking the Lantus insulin pen 100 units. When asked when it was opened, LVN 3 stated the open date label was 2/12/24. LVN 3 stated it was the only Lantus insulin pen in Medication Cart 1 and she would have to get a new one from the medication room. LVN 3 stated the insulin pen was good only for 28 days after the open date. LVN 3 further stated the insulin pen passed the 28 days after the open date and should not be in the active medication cart anymore, and it should have been discarded. Medical record review of Resident 37 was initiated on 3/19/24. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated 3/13/23, showed Resident 37 had the capacity to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 27 of 42 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 03/22/2024 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 understand and make her own decisions. Level of Harm - Minimal harm or potential for actual harm Review of Resident 37's Order Summary Report showed a physician's order dated 3/12/23, to administer Insulin Lispro per sliding scale subcutaneously before meals and at bedtime. Residents Affected - Few On 3/20/24 at 1453 hours, an interview was conducted with the DON. The DON stated the insulin pen should be discard after the 28 days of the open date and it should never be kept in the active medication cart because there was a potential for it to be reused. 2. Review of the facility's P&P titled Storage Medications revised April 2023 showed the facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. On 3/20/24 at 0850 hours, an inspection of the medication storage and labeling of the treatment cart was conducted with LVN 4 with the following findings verified with LVN 4: - one Packing Strip Iodoform (used for sterile drainage of open and/or infected wounds) had expired on 10/20/23, - one culture swab had expired on 11/30/23, - one opened sterile Collagen Dressing Powder (used to treat wounds or pressure ulcers), partially used, and - one opened sterile disposable urinary drainage bag. On 3/20/24 at 1044 hours, an inspection of the medication storage and labeling of Medication Cart 2 was conducted with LVN 5. The following findings were verified with LVN 5: - one insulin Lantus Kwik Pen with an open date of 1/26/24, passed the 28 days after the opened date, and LVN 5 verified it was still being used for a resident. - Apokyn Pen (medicine used to treat hypomobility in people with Parkinson's disease) with no open date, and LVN 5 verified it was still being used for a resident. - Blood glucose strips bottle with 29 strips (of 50 strips total) left inside had no open date. - Miralax (used as laxative) bottle had no open date, and LVN 5 verified it was still being used for a resident. Review of the manufacturer specification (Assure Platinum Blood Glucose Test Strips by Arkray), undated, showed to use the blood glucose strips within 90 days (three months) of first opening. On 3/20/24 at 1453 hours, an interview was conducted with the DON. The DON stated all the items which were expired and had no label for open date and all sterile items which were opened should not be in the treatment and medication carts because it was in infection control issue. The DON also stated for the medications supplied by the residents' family members, they would ask the residents' family to bring new medications so they could properly label it. The DON acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 28 of 42 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 03/22/2024 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 3. Review of the facility's P&P titled Medication Refrigerator Temperature Log (undated) showed the licensed nurse on 11 PM -7 AM and 7 AM - 3 PM shifts would check the presence of the refrigerator thermostat to obtain the temperatures. The temperatures would be recorded in the refrigerator medication log on the 11 PM -7 AM and 7 AM -3 PM shifts for both the fridge and the freezer. The licensed nurse had to ensure the temperatures were kept in the ranges from 15 °C (59° F) to 30° C (86° F). The licensed nurses to report to the maintenance supervisor in any deviation from the required temperature ranges. The Nursing supervisor on the 3 PM -11 PM shift was to check the log at least on a weekly basis for compliance and to ensure the temperatures were within the required range. On 3/20/24 at 0808 hours, an inspection of the medication storage and labeling in Station 1 medication room and concurrent interview was conducted with RN 1. RN 1 stated the medication refrigerator temperatures should be checked twice a day. Review of the March 2024 medication room refrigerator temperature log showed no documented evidence of the temperature monitoring at 12 PM on 3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/17, 3/18, and 3/19/24. On 3/20/24 at 1605 hours, an interview was conducted with the DON. The DON stated the medication refrigerator temperature should be checked once for 11 PM -7 AM shift and once for 7 AM -3 PM shift by any licensed nurse. The DON acknowledged the above findings. 4. Review of the facility's P&P titled Administering Oral Medications revised date October 2010 showed the nurse must remain with the resident until all the medications have been taken. On 3/19/24 at 1558 hours, a medication administration observation was conducted with LVN 1. LVN 1 was observed to administer glipizide (medicine used for diabetes) 5 mg, lacosamide (medicine used to treat seizures) 100 mg, levetiracetam (medicine used to treat seizures) 750 mg, metformin (medicine used for diabetes) 500 mg, and warfarin (medicine used to treat and prevent blood clots) 4 mg to Resident 307. LVN 1 left the medications with Resident 307 unattended when she went to the medication cart to sanitize her hands and donned on gloves. LVN 1 verified she left the medications unattended when she went outside the room. Medical record review of Resident 307 was initiated on 3/19/24. Resident 307 was admitted to the facility on [DATE]. Review of Resident 307's H&P examination dated 3/14/24, showed Resident 307 had the capacity to understand and make his own decisions. Review of Resident 307's Order Summary Report showed the following: - a physician's order dated 3/12/24, to administer glipizide oral tablet 5 mg by mouth one tablet two times a day - a physician's order dated 3/12/24, to administer metformin HCl oral tablet 500 mg by mouth one tablet two times a day, take with food - a physician's order dated 3/12/24, to administer lacosamide oral tablet 100 mg by mouth one tablet two times a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 29 of 42 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 03/22/2024 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 - a physician's order dated 3/12/24, to administer levetiracetam oral tablet 1500 mg by mouth two times a day - a physician's order dated 3/12/24, to administer warfarin sodium oral tablet 4 mg by mouth one tablet every Monday, Tuesday, Wednesday, Friday, and Sunday Residents Affected - Few - a physician's order dated 3/12/24, to administer warfarin sodium oral tablet 6 mg by mouth one tablet every Thursday On 3/30/24 at 1520 hours, an interview was conducted with the DON. The DON stated the licensed nurses should never leave the medications at the bedside unattended. The DON further stated the nurses should bring the medications with them if they needed to step out of the resident's room. The DON acknowledged the above findings. 5. Review of the facility's P&P titled Storage of Medication revised April 2023 showed the drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems, and only persons authorized to prepare and administer medication shall have access to the medication. Review of the facility's P&P titled Self-Administration of Medication revised December 2023 showed the staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for bedside storage to return to the family or responsible party. On 3/19/24 at 0923 hours, an observation of Resident 505's room was conducted. There were two tubes of Aspercream (use for pain) 5 ounces, six individual bags of vitamin C (supplement) 1000 mg, one jar of Vicks Vaporub (nasal decongestant) 6 ounces, one jar of Treat - Antifungal powder 3 ounces, 11 capsules of Probiotic, one tube of zinc oxide 4 ounces, and one tube of skin cream 2 ounces at Resident 505's bedside dresser. On 3/19/24 at 0938 hours, an interview with the DON was conducted. The DON verified all the medications at Resident 505's bedside dresser and stated she was not aware of the resident having the medications at the bedside. On 3/19/24 at 1040 hours, an interview with Resident 505 was conducted in her room. When asked about the medications at her bedside, she stated she brought all the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 30 of 42 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 03/22/2024 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 for one of 22 final sampled residents (Resident 13) was complete and accurate. This failure had the potential for the resident's accurate clinical status not being available and communicated to care team. Findings: Medical record review for Resident 13 was initiated on 3/29/24. Resident 13 was admitted to the facility on [DATE]. a. Review of Resident 13's MAR for March 2024 showed an order dated 3/13/24, for a Fleets enema (a liquid laxative administered into the rectum) to be administered in the afternoon for bowel management. The MAR showed it was signed as administered on 3/13/24 at 1300 hours. On 3/19/24 at 1038 hours, an interview was conducted with Resident 13. Resident 13 stated she did not receive an enema. On 3/21/24 at 1225 hours, a telephone interview was conducted with LVN 2. LVN 2 stated he did not administer an enema to Resident 13, and if the MAR showed a check mark for administered, it was done in an error. On 3/21/24 at 1511 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 reviewed Resident 13's MAR for March 2024 and verified the medical record showed a fleets enema was administered to Resident 1 on 3/13/24. b. Review of Resident 13's MAR for March 2024, showed the following physician's orders dated 2/28/24: - Miralax Powder (a laxative), 17 grams, to be administered with Senna (a laxative), as needed for no bowel movement for two days. The record showed it was administered on 3/20/24 at 1937 hours. - Senna 8.6 mg, to be administered with Miralax as needed for no bowel movement for two days. The record showed it was administered on 3/20/24 at 1937 hours. Review of Resident 13's CNA cares Documentation Survey Report dated 2/21/24, showed Resident 13 had a bowel movement on 3/20/24 at 1426 hours. While hovering over the electronic documentation, the record showed it was entered by CNA 4. On 3/21/24 at 1034 hours, a telephone interview was conducted with CNA 4. When asked about Resident 13's bowel movement documented by CNA 4 on 3/20/24 at 1426 hours, CNA 4 stated he did not have the resident yesterday and must have documented the roommate's bowel movement incorrectly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 31 of 42 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 03/22/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 3/20/24 at 1145 hours, LVN 5 was observed performing a blood sugar check on Resident 16. Resident 16's room was observed with signage outside his room indicating Resident 16 was on enhanced standard precaution. The signage showed the PPE needed to provide direct care to Resident 16 included wearing a gown. LVN 5 was observed not wearing a gown while checking Resident 16's blood sugar. LVN 5 verified she was not wearing a gown while directly touching Resident 16's body. Residents Affected - Some On 3/20/24, medical record review for Resident 16 was initiated. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's physician's progress note dated 3/18/24, showed Resident 16's diagnoses included diabetic wound infection to her left foot, post status amputation, and right foot diabetic pressure sore. Review of Resident 16's March 2024 Order Summary Report showed Resident 16 had an order dated 1/20/24, for enhanced standard precautions due to the resident's left foot infection. 7. On 3/19/24 at 0800 hours, LVN 2 was observed inside Resident 24's room. LVN 2 was accessing Resident 24's GT. Resident 24's room was observed with signage outside his room showing Resident 24 was on enhanced standard precaution. Per this signage, the PPE were needed to provide direct care to Resident 16 included wearing a gown. On 3/19/24 at 1045 hours, an interview was conducted with LVN 2. When asked about the PPE needed for Resident 24, LVN 2 verbalized he did not need to wear a gown. 8. On 3/19/24 at 1031 hours, LVN 4 and CNA 3 were observed providing direct care to Resident 32. Resident 32's room was observed with signage outside his room indicating Resident 32 was on enhanced standard precaution. The signage showed the PPE were needed to provide direct care to Resident 32 included wearing a gown. Both LVN 4 and CNA 3 were observed not wearing a gown while providing direct care to Resident 32. When asked about the PPE needed when providing direct care to Resident 32, LVN 4 stated a gown was only needed when touching the residents' open skin. On 3/20/24, medical record review for Resident 32 was initiated. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's H&P dated 10/23/23 showed Resident 32's diagnoses included leukopenia. Review of Resident 32's March 2024 MAR showed Resident 32 had an order for enhanced standard precaution. 9. On 3/19/24 at 0832 hours, CNA 5 was observed cleaning Resident 18's buttocks after Resident 18 finished using the toilet. CNA 5 was observed removing the gloves she used to wipe Resident 18's buttocks. CNA 5 was then observed pinching her nose with her hands, touching one of the ear pieces of a headset she wore, and touching Resident 18's clean clothes, without performing hand hygiene after removing the gloves used on Resident 18. On 3/19/24 at 1135 hours, an interview was conducted with CNA 5. CNA 5 acknowledged she did not do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 32 of 42 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 03/22/2024 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 hand hygiene after removing her dirty gloves.10. Review of the facility's Contact Precaution signage showed the following: Level of Harm - Minimal harm or potential for actual harm - Everyone must clean their hands before entering and when leaving the room. Residents Affected - Some - Put on gloves before room entry, discard gloves before room exit. - Put on gown before room entry, discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. - Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Medical record review for Resident 45 was initiated on 3/20/24. Resident 45 was admitted to the facility on [DATE]. Review of Resident 45's Order Summary Report for March 2024 showed a physician's order dated 3/12/24, to place Resident 24 in contact isolation due to positive for stool for Clostridioides difficile (C. difficile or C. diff, a germ that causes diarrhea and inflammation of the colon) until 3/25/24. Review of Resident 45's MAR for March 2024 showed the licensed nurses monitored for contact isolation precautions every shift until 3/25/24. On 3/20/24 at 0811 hours, a signage for contact precautions was observed posted in Resident 45's wall near the room door wall with a three-tier cart which contained disposable gowns, equipment, gloves, and sanitization wipes. Resident 45 was calling out for help. CNA 1 was observed wearing a surgical mask. CNA 1 was observed donning a disposable yellow gown and gloves. CNA 1 was observed entering room [ROOM NUMBER]'s room to attend to him. However, CNA 1 was not observed cleaning her hands prior to entering Resident 45's room per contact precautions signage. On 3/20/24 at 0815 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified the above findings. CNA 1 stated she should had performed alcohol-based hand rub prior to donning on PPE and entering Resident 45's room. On 3/20/24 at 0833 hours, an observation and concurrent interview was conducted with the DON. The DON verified the above findings. The DON stated Resident 45 was on contact precaution for C. diff. The DON stated all staff should wash hands before and after care of the residents. 3. Review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment revised date July 2022 showed the reusable care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. On 3/19/24 at 0805 hours, a medication administration observation was conducted with LVN 2. LVN 2 checked Resident 24's vital signs and used the portable BP machine. LVN 2 did not clean or disinfect the BP machine after used. On 3/19/24 at 0857 hours, a medication administration observation was conducted with LVN 2. LVN 2 used the unclean BP machine to check the vital signs of Resident 404. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 33 of 42 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 03/22/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/19/24 at 1215 hours, an interview was conducted with LVN 2. LVN 2 stated he forgot to disinfect the BP machine used between Residents 24 and 404. On 3/20/24 at 1521 hours, an interview was conducted with the DON. The DON stated the reusable equipment like the BP machine should be disinfected between the residents otherwise it would be an infection prevention issue if it was not done. The DON acknowledged the above findings. 4. Review of the facility's P&P titled Blood Sampling-Capillary (Finger Sticks) revised November 2023 showed to always ensure the blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Review of the facility's P&P titled Standard Precautions revised date December 2023 showed to change the gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another or when moving from a dirty site to a clean one. On 3/19/24 at 1141 hours, a medication administration observation was conducted with LVN 3. LVN 3 checked the blood sugar level using the blood glucose monitoring device of Resident 37. LVN 3 placed back the blood glucose monitoring device in Medication Cart 1 without cleaning or disinfecting it after used. On 3/19/24 at 1205 hours, a medication administration observation was conducted with LVN 3. LVN 3 did hand hygiene and donned gloves; however, LVN 3 did not change the gloves after touching the overbed table and privacy curtain in Resident 37's room prior to administering Resident 37's insulin injection. On 3/19/24 at 1441 hours, an interview was conducted with LVN 3. LVN 3 stated she forgot to disinfect the blood glucose monitoring device she used for Resident 37. LVN 3 further stated she should have changed gloves to prevent contamination prior to administering the insulin injection to Resident 37 since she touched the environment. 5. Review of the manufacturer's (Techdow, USA) instruction for Lovenox administration, undated, showed to clean the injection site with an alcohol wipe and let the skin dry before injecting. On 3/19/24 at 0911 hours, a medication administration observation was conducted with LVN 2. LVN 2 wiped the resident's left lower quadrant abdomen with alcohol and administered right away the Lovenox injection without letting the skin to dry. Medical record review of Resident 404 was initiated on 3/19/24. Resident 404 was admitted to the facility on [DATE]. Review of Resident 404's Order Summary Report showed a physician's order dated 3/11/24, to administer enoxaparin sodium (anticoagulant) solution 30 mg/0.3 ml by subcutaneous one time a day. On 3/19/24 at 1215 hours, an interview was conducted with LVN 2. LVN 2 stated he thought he aired the abdomen out a little bit but he should have waited until the skin was completely dried before injecting the Lovenox (brand name for enoxaparin sodium) to Resident 404. On 3/20/24 at 1521 hours, an interview was conducted with the DON. The DON stated for any medication given by injection, after wiping with alcohol, the skin should dry first before administering the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 34 of 42 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 03/22/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication. The DON acknowledged the above findings.Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to include the residents who exhibited sign and symptoms of infection who were not prescribed antibiotics on the Surveillance program from January 2023 to February 2024. * CNA 3 failed to perform hand hygiene after touching Resident 35's shoulder and prior to serving a meal tray to Resident 50. * The facility failed to clean and disinfect the blood pressure machine between Resident 24 and Resident 404's use. * The facility failed to disinfect the blood glucose monitoring device after being used and the LVN did not change gloves prior to insulin administration for Resident 37. * The facility failed to allow the alcohol to dry prior to Lovenox (Enoxaparin Sodium, a medicine used to treat or prevent a type of blood clot called deep vein thrombosis or DVT) injection for Resident 404. * The staff failed to wear gowns in isolation rooms while providing direct resident care to Residents 16, 32, and 24. * The staff failed to perform hand hygiene after providing toileting care to Resident 18. * The facility failed to ensure the staff practiced the contact precautions when entering Resident 45's room that had a posted signage out the room for contact precautions. These failures posed the risk for not identifying infections and controlling the transmission of communicable disease to other residents throughout the facility. Findings: Review of the facility's undated P&P titled Infection Control Program showed the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. Surveillance of residents and their family members will include: maintenance of an infectious disease log by facility's staff; reporting individual incidents of infection; monthly recording of incidents by infection sites; and auditing medical records of diagnostic tests, lab and x-ray reports and screening exams. Further review of the facility's P&P showed to designate responsibility for completion of an infection report for all resident infections, according to the infection criteria using the Infection Surveillance Information 1. Review of the facility's monthly infection control surveillance forms from January 2023 through February 2024 showed the following surveillance data: - January 2023: total of 41 cases which were 10 HAI and 31 CAI (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 35 of 42 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 03/22/2024 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 - February 2023: total of 30 cases which were 14 HAI and 16 CAI Level of Harm - Minimal harm or potential for actual harm - March 2023: total of 27 cases which were 3 HAI and 24 CAI - April 2023: total of 37 cases which were 19 HAI and 18 CAI Residents Affected - Some - May 2023: total of 23 cases which were 10 HAI and 13 CAI - June 2023: total of 42 cases which were 14 HAI and 28 CAI - July 2023: No data - August 2023: total of 31 cases which were 4 HAI and 27 CAI - September 2023: total of 60 cases which were 12 HAI and 33 CAI - October 2023: tottal of 40 cases which were 7 HAI and 23 CAI - November 2023: total of 49 cases which were 13 HAI and 24 CAI - December 2023: total of 71 cases which were 16 HAI and 48 CAI - January 2024: total of 49 cases which were 4 HAI and 36 CAI - February 2024: total of 46 cases which were 5 HAI and 21 CAI Review of the facility's Monthly Infection Surveillance Report from January 2023 through February 2024 showed data specific to the facility's total monthly infected residents with prescribed antibiotics. All residents who had signs and symptoms of infections and did not receive antimicrobials were not included in the facility's infection control surveillance program from January 2023 to February 2024. On 3/21/24 at 1107 hours, an interview was conducted with the DON and RN 2 When asked if the residents with symptoms of infections who were not prescribed antibiotic therapy were included the in the facility's infection surveillance log, the DON and IP stated those residents were not included; however, the residents were documented in the COC log for the nurses to monitor them. 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 8/2022 showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (anticobial or non-antimicrobial) and water before and after assisting a resident with meals. On 3/19/24 at 1236 hours, a dining observation was conducted. CNA 3 placed a meal tray in front of Resident 35 and touched the resident's shoulder. CNA 3 then proceeded to serve Resident 50 his meal tray, which was handed to CNA3 by another staff, uncovered the drinks and meal plate, and touched the utensils without performing hand hygiene. On 3/19/24 at 1238 hours, an interview was conducted with CNA 3. CNA 3 verified she did not perform (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 36 of 42 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 03/22/2024 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 Level of Harm - Minimal harm or potential for actual harm hand hygiene after touching Resident 35's shoulder and prior to serving the meal tray to Resident 50. CNA 3 stated she would have normally used hand sanitizer in between serving the residents' meal trays; however, another staff handed Resident 50's meal tray to her, and she gave and prepared the meal tray for Resident 50. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 37 of 42 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 03/22/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview, medical record review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. Residents Affected - Some Findings: Review of the facility's P&P titled Antibiotic Stewardship revised 12/2021 showed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of the facility's infection control binder showed McGeer's Infection Surveillance form or Surveillance Data Collection Form being used to assess for McGeer's criteria to determine the true infection. Review of the facility's monthly infection control surveillance forms from 6/2023 through 2/2024, showed the following surveillance data. However, the facility failed to show documentation the McGeer's/Surveillance Data Collection form was done to assess for the true infection: - June 2023: 42 infected residents with antibiotics; - July 2023: no data documented - August 2023: 31 infected residents with antibiotics, - September 2023: 60 infected residents with antibiotics, - October 2023: 40 infected residents with antibiotics, - November 2023: 49 infected residents with antibiotics, - December 2023: 71 infected residents with antibiotics, - January 2024: 49 infected residents with antibiotics, and only 14 assessments were done. - February 2024: 46 infected residents with antibiotics, On 3/21/24 at 1107 hours, an interview was conducted with RN 2. RN 2 stated the facility used the McGeer's criteria tool; however, transitioned to the electronic records in 2/2023. The residents with symptoms were logged, physicians were notified, carried out the orders for antibiotic, and the licensed nurses completed the McGeer's criteria tool (Survillance Data) and let the physician know whether it met or did not meet the McGeer's criteria. On 3/21/24 at 1412 hours, an interview and concurrent medical record review was conducted with RN 2. The 2023 infection control binder showed no surveillance log for 6/2023 and 7/2023. There were no copies of McGeer's criteria forms for June through December 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 38 of 42 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 03/22/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 3/21/24 at 1527 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the facility had a designee to assist with the IP surveillance and completed the surveillance log from January through May 2023; however left in June of 2023. The DON was informed the infection control binder for June through December 2023 did not have McGeer's assessment to show met versus not met for true infection and antibiotic use. The DON verified the findings. The DON also verified July 2023 did not have surveillance log for infections. Event ID: Facility ID: 555671 If continuation sheet Page 39 of 42 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 03/22/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to maintain the essential equipment in a safe operating condition. Residents Affected - Some * The facility failed to ensure the ice machine located in the dining room was cleaned and sanitized as per the manufacturer's instruction manual. This failure had the potential for the ice machine not being maintained in a safe operating condition and posed the risk of equipment to function improperly. Findings: According to the USDA Food Code 4-501.11 Equipment 4-501.11 Good Repair and Proper Adjustment, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. Review of the ice machine manufacturer's instruction manual, Section B showed in part, cleaning and sanitizing instructions. The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions. - Step 9. In bad or severe water conditions, turn off the power supply, then remove, clean (cleaning solution = 5 oz. Hoshizaki Scale Away per gallon of warm water), rinse, and replace the cube guide, float switch, water supply tubes, spray tubes, and spray guides; turn on the power supply when complete. Otherwise, continue to step 10. - Step 12. Remove the front insulation panel, then pour 0.6 fl. oz. (18 ml) of an 8.25% sodium hypochlorite solution (chlorine bleach) into the water tank. Replace the front insulation panel. IMPORTANT! Use regular bleach with no additives. Using a bleach with additives causes excessive foaming during sanitizing, reducing the effectiveness of sanitizing. - Step 15. Clean the dispenser unit/ice storage bin liner using a neutral cleaner. Rinse thoroughly after cleaning. On 3/19/24 at 0854 hours, an observation of the ice machine located in the facility dining room and concurrent interview with the ED was conducted. The ED stated he cleaned the inside of the ice machine monthly. The ED stated he used [Hoshizaki] scale remover to clean the ice machine and bleach to sanitize the ice machine. The ED stated he put the scale remover into the tank of the ice machine and ran it through the ice machine. The ED stated he drained the ice machine and ran water through the machine. The ED stated he sprayed the inside of the ice storage bin with a solution of water with a little bleach. The ED stated he rinsed the ice storage bin with water and dried it with a clean cloth. On 3/19/24 at 1431 hours, an interview and concurrent facility document review was conducted with the ED. The [Hoshizaki] ice machine manufacturer's instruction manual on cleaning and sanitizing the ice machine was reviewed with the ED. The ED explained the process he followed to clean the portion of the ice machine that produced ice. The ED confirmed he did not follow the ice machine manufacturer's instructions to sanitize the portion of the ice machine that produced the ice. The ED further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 40 of 42 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 03/22/2024 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 0908 Level of Harm - Minimal harm or potential for actual harm explained he cleaned the ice storage bin with a solution of water and bleach. The ED was asked how he cleaned the ice storage bin. The ED stated the solution of water and bleach was the cleaning agent he used to clean the ice storage bin. The ED was asked if he received training on the ice machine manufacturer's instruction. The ED confirmed he did not receive the ice machine manufacturer's training but had 18 years of experience as a maintenance technician. Residents Affected - Some On 3/19/24 at 1517 hours, an interview and concurrent facility document review was conducted with the ED and RD. The [Hoshizaki] ice machine manufacturer's instruction manual on cleaning and sanitizing the ice machine was reviewed with the RD and ED. The ED confirmed he ran the internal components of the ice machine that produced ice through the facility dish machine. The ED confirmed he did not follow the step number nine for cleaning the internal components of the ice machine that produced ice per the ice machine manufacturer's instruction manual. The step number 15 of the ice machine manufacturer's instruction manual which showed to clean the dispenser unit/ice storage bin liner using a neutral cleaner was reviewed with the RD. The RD stated she would contact the ice machine manufacturer to get clarification on the term neutral cleaner. On 3/20/24 at 0831 hours, an interview was conducted with the RD. The RD shared a video from the ice machine manufacturer which showed how to clean the ice storage bin. The video showed to clean the ice storage bin with the [Hoshizaki] scale remover and sanitize the ice storage bin with the bleach solution. The RD confirmed the ED did not follow the manufacturer's guidelines to clean the ice storage bin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 41 of 42 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 03/22/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure the call light in the resident's room was functioning for one of 22 final sampled residents (Resident 204). This failure had the potential for a delay in assisting the resident. Residents Affected - Few Findings: Medical record review for Resident 204 was initiated on 3/19/24. Resident 204 was admitted to the facility on [DATE]. On 3/19/24 at 0816 hours, an interview and concurrent observation was conducted with Resident 204. Resident 204 stated they would like their television volume turned up. When asked if the resident pressed her call light button for the staff's assistance, the resident stated she just did. An observation of the call light illuminator in the hallway, above the resident's doorway, was not illuminated to show the call-light button was activated. The resident was asked to push the call light button again, and it was observed that the resident used her thumb to press the call light button. However, there was still no indicator light illuminated above the resident's doorway. On 3/19/24 at 0820 hours, an interview and concurrent observation was conducted with the Unit Coordinator. The Unit Coordinator stated when the call lights was on, the room light went up on the display panel on the nurses' station wall and pointed to a black rectangular panel on the wall. The Unit Coordinator stated the panel did not show any call-lights were on. The Unit Coordinator was asked to go check Resident 204's call light. The Unit Coordinator went to Resident 204's room and pressed the call light, verified the resident's call light indicator did not illuminate above the resident's doorway, and tried the call light button again. On 3/19/24 at 0830 hours, the Unit Coordinator stated she was not able to get the call light button to work and notified the maintenance staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 42 of 42