Terrace View Care Center

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet