Health inspection·October 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) reviewed for falls was accurately assessed for the risk for falls. * Residents 1's Fall Risk assessment dated [DATE], showed multiple inaccurate entries, which resulted for the resident to have a lower score for a fall risk. This failure had the potential for the resident to experience adverse events related to falls.Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 10/2024 showed the staff will identify specific risks and causes to try and prevent falls. Closed medical record review for Resident 1 was initiated on 10/28/25. Resident 1 was admitted to the facility on [DATE], and was discharged to home on 6/28/25. Further review of Resident 1's closed medical record showed the resident had an unwitnessed fall on 6/2/25, at 2310 hours. Review of Resident 1's Fall Risk assessment dated [DATE] at 0441 hours, showed multiple inaccurate entries for Resident 1 including no falls for the resident when the resident had two falls in the past three weeks. Resident 1 had a fall in the facility on 6/2/25 at 2310 hours; and one on 5/11/25, in the community, which resulted in severe injury and subsequent hospitalization and transfer to the facility. Additionally, the high risk medication screening section of the Fall Risk Assessment showed no medications taken by Resident 1, however, Resident 1 had a physician's orders for a diuretic (medications to help the body get rid of excess salt and water by increasing urine production) medication, an antihypertensive (medication to lower blood pressure) , a narcotic (controlled medications which require prescription from the physician) medication and a sedative (medications to provide calming or sleep-inducing effect). On 10/29/25 at 0640 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 3. LVN 3 verified Resident 1's Fall Risk Assessment had multiple inaccuracies, which included the number of falls and the medications Resident 1 was taking. LVN 3 stated the resident's fall risk score would have been higher if it had been scored accurately. On 10/29/25 at 1445 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON verified Resident 1's Fall Risk Assessment contained multiple inaccuracies, which included the number of falls and the medications Resident 1 was taking. The DON stated the resident's fall risk score would be higher if it had been assessed and scored accurately. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555671 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 10/29/2025 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)