Terrace View Care Center

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 REDACTED], 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 REDACTED], 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 REDACTED] 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

Event ID:

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

10/29/2025

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)

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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, medical record review, and facility P&P review, the facility failed to ensure the resident's medical

record was complete and accurate for one of three sampled residents (Resident 1). * Resident 1's 72 Hour Neuro Check - List had incorrect time intervals between the one hour and two hour neuro check section, which resulted in all subsequent time entries to be delayed by one hour. This failure posed the risk for the resident's care needs not being met as his medical record information was inaccurate.Findings: Review of

the facility's P&P titled Neuro Assessment revised 10/2024 showed neuro assessments will be conducted

after any unwitnessed fall. Closed medical record review for Resident 1 was initiated on 10/28/25. Resident 1 was admitted to the facility on [DATE REDACTED], and was discharged to home on 6/28/25. Review of Resident 1's 72 Hour Neuro Check - List dated 6/2/25, at 2310 hours showed Resident 1 had an unwitnessed fall.

Review of Resident 1's 72 Hour Neuro Check - List dated 6/3/25, showed the time entries for the required time intervals for neuro checks for Resident 1. The interval between the three one-hour required neuro checks showed time entries of 0140, 0240, and 0340 hours. The neuro check time intervals then changed to every two hours and the next time interval for the neuro check would have been at 0540 hours. The time interval on the neuro check sheet showed an entry at 0640 hours, which was an incorrect time interval by one hour. 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 72 Hour Neuro Check - List entry was inaccurate. 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 the time entry on the 72 Hour Neuro Check List had incorrect time entry.

Event ID:

Facility ID:

If continuation sheet