Health inspection·January 30, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to label and date a resident's intravenous (IV-the infusion of liquid substances directly into a vein) antibiotic (medications used to treat infections) medication bag per the facility's policy for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential for medication administration errors. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2021 with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 10/1/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 1's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 1 required total dependence on staff for assistance with activities of daily living (ADLs - activities related to personal care). During a review of Resident 1's Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility) dated 1/2025, the MAR indicated Resident 1 had a physician order for cefepime hydrochloride (a medication used to treat infections) two (2) grams (gm-unit of measurements) IV two times a day starting on 1/28/2025. During an observation on 1/29/2025 at 1:50 p.m., observed Resident 1's cefepime hydrochloride IV bag located next to Resident 1's bed without the date, time, and signature of the nursing staff that administrated the cefepime hydrochloride. During a concurrent observation and interview on 1/29/2025 at 2:00 p.m., with the Director of Nursing (DON), observed Resident 1's cefepime hydrochloride IV bag located next to Resident 1's bed. The DON confirmed by stating that Resident 1's cefepime hydrochloride should have had the registered nurses' initials, date, and time labeled on the medication when it was administered. The DON stated that the correct process when administering an IV medication is for the nurse to initial the mediation (continued on next page) 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 3 Event ID: 555738 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 555738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace Post Acute 7447 Sepulveda Blvd Van Nuys, CA 91405 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)