Health inspection·October 9, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete telephone interview was conducted with Resident Representative 1. Resident Representative 1 stated on 9/28/25 at around 0600 hours, he received a call from Resident 1 stating he would call police. Resident Representative 1 stated he asked the resident why he wanted to call police. Resident 1 told Resident Representative 1 he was tied to the wheelchair. Resident Representative 1 stated he lived close to the facility, so he drove to the facility. Resident Representative 1 stated he saw Resident 1 in the dining room sitting in the wheelchair which was wrapped with the bed sheet and tied at the back of the wheelchair. Resident Representative 1 stated Resident 1 was restricted from freely moving, and CNA 1 was next to the resident working on the computer. Resident Representative 1 stated he asked CNA 1 to untie Resident 1 and reported the incident to a charge nurse. On 10/9/25 at 1001 hours, a telephone interview was conducted with CNA 1. CNA 1 stated on around 9/28/25, during the night shift, Resident 1 frequently got out of his bed without asking for staff assistance. CNA 1 stated Resident 1 had risk of falling and the CNA also had to take care of other residents. CNA 1 stated he decided to put Resident 1 on the wheelchair on 9/28/25, at around 0500 hours. CNA 1 further stated for Resident 1's safety, he put the bed sheet around Resident 1's waist and loosely tied it to the wheelchair so he could not stand on his own. CNA 1 further stated he should not have tied Resident 1 to the wheelchair, and he should have reported the resident's condition of getting out of bed to the charge nurse assigned to the resident. On 10/9/25 at 1202 hours, a telephone interview was conducted with LVN 1. LVN 1 stated on around 9/28/25 at 0630 hours, she was looking for CNA 1 and saw them in the dining room documenting on the computer with Resident 1. LVN 1 stated she saw the resident sitting in the wheelchair which was wrapped around with the bed sheet. LVN 1 stated bed sheet was covering the wheelchair; however, she did not see if it was tied with the knot from where she was standing. LVN 1 stated then she reported the incident to the charge nurse assigned to Resident 1, which happened to be the same time Resident Representative 1 had reported to the charge nurse. LVN 1 stated she did not check if the resident was tied to the wheelchair with a bedsheet. LVN 1 stated she should have checked to make sure Resident 1 was not tied with the bed sheet to the wheelchair. On 10/9/25 at 1414 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Event ID: Facility ID: 555671 If continuation sheet Page 2 of 6 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 10/09/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **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 thoroughly investigate an allegation of abuse for one of four sampled residents (Resident 1). * The facility failed to interview Resident 1 (alleged victim) and CNA 1 (alleged perpetrator) when Resident Representative 1 reported Resident 1 was tied to his wheelchair with a bedsheet, and when Resident 1 alleged CNA 1 hit him in the face and kicked him in the stomach. This failure had the potential to put the resident at risk for further abuse.Findings: Review of the facility's P&P titled Elder/Dependent Adult Abuse dated 2/2023 showed under the section Investigation/Action, the facility will:- identify and interview all persons involved including alleged victim, perpetrator, witness, others who may have knowledge of alleged violation;- focus on determining if abuse, neglect, exploitation or mistreatment has occurred and the extent/cause;- document evidence that all alleged abuse violations are thoroughly investigated; and,- take all necessary action as a result of the investigation. On 9/28/25, the CDPH, L&C Program received a report from the facility. The report showed Resident Representative 1 found Resident 1 with a sheet of linen wrapped around him and tied at the back of the wheelchair. Resident Representative 1 also reported Resident 1 alleged he was hit, slapped on the head and kicked on the stomach. On 10/8/25 at 1231 hours, an interview was conducted with Resident 1 in his room with translation from Resident Representative 2 at the bedside. Resident 1 stated the staff in the facility tied him in the wheelchair and he could not move freely. Resident 1 stated he did not remember the date and time or how long he was tied by the bed sheet in the wheelchair. Resident 1 stated he was scared and called his son. On 10/8/25 at 1328 hours, a telephone interview was conducted with Resident Representative 1. Resident Representative 1 stated on 9/28/25 at around 0600 hours, he received a call from Resident 1 stating he would call police. Resident Representative 1 stated he asked the resident why he wanted to call police. Resident 1 told Resident Representative 1 he was tied to the wheelchair. Resident Representative 1 stated he lived close to the facility, so he drove to the facility. Resident Representative 1 stated he saw Resident 1 in the dining room sitting in the wheelchair which was wrapped with the bed sheet and tied at the back of the wheelchair. Resident Representative 1 stated Resident 1 was restricted from freely moving, and CNA 1 was next to the resident working on the computer. Resident Representative 1 stated he asked CNA 1 to untie Resident 1 and reported the incident to a charge nurse. Resident Representative 1 further stated Resident 1 also claimed a facility staff hit, slapped his head and kicked his abdomen. On 10/8/25 at 1338 hours, an interview was conducted with Resident 1 with translation from the OT . Resident 1 stated the facility staff had hit, slapped his head and kicked his stomach. Resident 1 stated he had not seen the staff after the incident, but was scared that the staff would come back. Medical record review for Resident 1 was initiated on 10/8/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 9/19/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had moderate cognitive impairment and required maximum staff assistance for his activities of daily living. Review of the facility's investigation and interviews conducted from 9/28/25 to 9/29/25, did not show Resident 1 (alleged victim) was interviewed. Additionally, there was no documented evidence CNA 1 (alleged perpetrator) was interviewed regarding the incident. Review of the facility's document titled Investigation Report Statement dated 10/2/25, showed on 9/28/25, Resident Representative 1 reported observing Resident 1 in the wheelchair with a bedsheet wrapped around him in the dining room beside a CNA who was charting. Resident 1 called Resident Representative 1 via phone and said he was hit, slapped on his head and kicked on the stomach. The document further Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 3 of 6 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 10/09/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete showed based on clinical record review, interview and thorough assessment, there were no witnesses who were able to validate the allegation. Further review of the report showed the facility took the following steps to investigate the incident:- interviewed resident's family member- interviewed resident through family member's assistance- thoroughly assessed resident for injury, skin discoloration or other skin issue and daily body check was done for five days- interviewed all the staff of the shift when incident was reported and all the staff who had direct care to the resident for the past 72 hours prior to the incident- interviewed appropriate staff or individuals that may or may not directly involvement or knowledge of the incident On 10/9/25 at 1115 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated she investigated the allegation reported by Resident Representative 1 involving Resident 1 and CNA 1. The DON explained Resident 1 was hard of hearing and did not speak English. The DON stated she waited for the evening staff who spoke the resident's language, to assist with the interview and then interviewed the resident. However, the DON was unable to provide documentation confirming an interview was conducted with the resident. The DON stated she spoke to Resident Representative 1 in detail and Resident Representative 1 also provided a written the statement regarding the incident and allegation made by Resident 1. The DON acknowledged the alleged victim interview was crucial in an abuse investigation to determine the extent of the alleged abuse. The DON stated the facility obtained a written statement from CNA 1 (alleged perpetrator), but she did not interview him. The DON stated CNA 1 was terminated, and she could have conducted a telephone interview. The DON acknowledged a written statement was not equivalent to an interview. On 10/9/25 at 1414 hours, the DON was informed and acknowledged the above findings. Event ID: Facility ID: 555671 If continuation sheet Page 4 of 6 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 10/09/2025 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 interview, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for one of four sampled residents (Resident 1). * The facility failed to ensure the physician was notified in a timely manner when Resident Representative 1 reported Resident 1 was tied to his wheelchair with a bedsheet, and when Resident 1 alleged CNA 1 hit him in the face and kicked him in the stomach * The facility failed to ensure the physician and resident representative were notified when Resident 1 was found on the floor and was observed with purplish discoloration on his left thigh. In addition, the facility failed to ensure monitoring of the neurological status was conducted when the resident had unwitnessed fall. These failures had the potential for Resident 1 not to receive appropriate care and treatment.Findings: Review of the facility's P&P titled Acute Condition Changes- Clinical Protocol dated 12/2024 showed the physician will help identify individuals with a significant risk for having acute changes of condition during their stay. The nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request prompt response (within approximately one-half hour or less). The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition or status. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. 1. On 10/8/25 at 1328 hours, a telephone interview was conducted with Resident Representative 1. Resident Representative 1 stated on 9/28/25 at around 0600 hours, he received a call from Resident 1 stating he would call police. Resident Representative 1 stated he asked the resident why he wanted to call police. Resident 1 told Resident Representative 1 he was tied to the wheelchair. Resident Representative 1 stated he lived close to the facility, so he drove to the facility. Resident Representative 1 stated he saw Resident 1 in the dining room sitting in the wheelchair which was wrapped with the bed sheet and tied at the back of the wheelchair. Resident Representative 1 stated Resident 1 was restricted from freely moving, and CNA 1 was next to the resident working on the computer. Resident Representative 1 stated he asked CNA 1 to untie Resident 1 and reported the incident to a charge nurse. Resident Representative 1 further stated Resident 1 also claimed a facility staff hit, slapped his head and kicked his abdomen. Medical record review for Resident 1 was initiated on 10/8/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 9/19/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had moderate cognitive impairment and required maximum staff assistance for his activities of daily living. Review of Resident 1's SBAR dated 9/28/25, showed at 0700 hours, Resident Representative 1 found Resident 1 with bedsheet around his waist tied at the back of the wheelchair. Resident 1 was in the dining room with CNA 1 beside him charting. The SBAR further showed Resident Representative 1 reported Resident 1 claimed he was hit, slapped on the head and kicked on the stomach. The SBAR further showed Resident 1 was assessed with no visible injury at the time; however, a full skin assessment on 9/28/25 at 1000 hours, showed discoloration was observed on Resident 1's bilateral legs and arms. Further review of the SBAR showed the incident was reported to the Primary Care Clinician on 9/28/25 at 1400 hours (approximately seven hours after the incident and the allegation was reported to the facility staff). On 10/9/25 at 1414 hours, an interview and medical record review for Resident 1 was conducted with the DON. The DON verified the physician was not notified timely when Resident Representative 1 reported that he observed Resident 1 being tied to the wheelchair by bedsheet and an allegation made by Resident 1 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555671 If continuation sheet Page 5 of 6 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 10/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace View Care Center 201 East Bastanchury Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that CNA 1 hit, slapped him in his head, and kicked him in the stomach. The DON verified the above incident was notified to the physician approximately seven hours after the incident and should have been notified timely. 2. Review of the facility P&P titled Falls- Clinical Protocol dated 9/2024 showed under the section monitoring and follow up, the staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complication such as late fracture or subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull) have been ruled out or resolved. Review of the facility's P&P titled Neurological assessment dated 10/2024 showed under the section general guidelines neurological assessment are indicated:- upon physician order;- following an unwitnessed fall;- following a fall or other accident/injury involving head trauma; orwhen indicated by resident's condition. Review of Resident 1's Progress Notes dated 9/28/25 at 0031 hours, showed Resident 1 was found sitting on the floor mat, bed was in the lowest position and Resident 1 had appeared to be crawling out of bed. A staff had assisted Resident 1 to the restroom and back to bed safely. Further review of the progress note showed Resident 1 had purplish/greenish discoloration on the left hip. Further review of Resident 1's medical record did not show if the physician and resident representative were notified of the discoloration, and whether neurological monitoring was conducted when Resident 1 was found sitting on the floor. On 10/9/25 at 1202 hours, a telephone interview was conducted with LVN 1. LVN 1 stated on 9/27/25 at around 2300 hours, Resident 1 was observed sitting on the floormat. LVN 1 stated she did not see Resident 1 crawling out of the bed. LVN 1 stated that incident of Resident 1 being found on the floor was unwitnessed fall. LVN 1 stated she also observed purplish green discoloration on the left side of Resident 1, around the size of the palm of a small adult hand. LVN 1 stated she reported the incident to LVN 2 (assigned nurse for Resident 1). When asked if she reported the incident to the physician and resident representative of Resident 1, LVN 1 stated she did not report the incident to Resident 1's physician nor their representative and did not initiate the neurological evaluation. On 10/9/25 at 1347 hours, a telephone interview was conducted with the LVN 2. LVN 2 stated LVN 1 reported she found Resident 1 sitting on the floor mat. LVN 2 stated she did not remember LVN 1 reporting skin discoloration on Resident 1's left hip. LVN 2 stated she was busy that night and did not report the above incident to the physician. LVN 2 further stated she reported the incident to Resident Representative 1 on 9/28/25 at around 0630 hours (seven hours after the incident); however, she did not document it. LVN 2 verified she did not do the neurological evaluation after the unwitnessed fall incident. On 10/9/25 at 1414 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified Resident 1 was found sitting on the floor and was observed with purplish greenish discoloration on his left thigh. The DON stated she could not find documentation the physician and resident representative for Resident 1 were notified, and if neurological evaluation was conducted after the above incident. The DON stated the above incident was unwitnessed fall and Resident 1 was found with purplish greenish discoloration on his left thigh. The DON further stated change in condition evaluation should have been initiated which included notification of physician and resident representative for Resident 1. The DON stated a neurological evaluation should have been initiated for Resident 1 after the above incident. Event ID: Facility ID: 555671 If continuation sheet Page 6 of 6