Health inspection·January 16, 2025

F 0568 Level of Harm - Potential for minimal harm quarterly statements for Resident 5's trust fund. The BOM stated Resident 5's last quarterly trust fund statement was in November 2024. The BOM stated she personally handed the copies of the statement to Resident 5 on November 2024; however, she did not keep the copy of the statement provided and did not document when Resident 5 was provided with the quarterly statement. The BOM verified there was no documented evidence the resident had received the November 2024 quarterly statement. Residents Affected - Some On 1/3/25 at 1102 hours, an interview and a concurrent facility's document review was conducted with the Administrator. The Administrator was unable to show documented evidence if Resident 5 was provided with the quarterly statement in November 2024. The Administrator acknowledged the above findings. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide thequarterly trust fund statements to one of two residents reviewed for personal funds (Resident 5). This failure had the potential for loss and misuse of Resident 5's personal funds. Findings: Review of the facility's P&P titled Management of Residents' Personal Funds revised 3/2021 showed should the facility be appointed the resident's representative payee, and directly receive monthly benefits to which the resident is entitled, such funds are managed in accordance with established policies and federal/state requirements. On 1/2/25 at 0833 hours, an interview was conducted with Resident 5. Resident 5 stated she did not remember receiving her quarterly trust fund statement from the BOM. Resident 5 stated she had not received any statements from the facility or the BOM in years. Resident 5 further stated she probably received her statement when she got admitted in the facility and started her trust account. Medical record review for Resident 5 was initiated on 1/2/25. The Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 9/11/24, showed Resident 5 had the capacity to make medical decisions. Review of Resident 5's MDS dated [DATE], showed Resident 5 was cognitively intact. Review of Resident 5's Trust Statement for September 2024 showed the amount of money debited and credited from Resident 5's money with a closing balance. On 1/2/25 at 0904 hours, a telephone interview and concurrent facility document review was conducted with the Account Receivable Consultant. The Account Receivable Consultant stated she worked offsite and managed the resident's trust account. The Account Receivable Consultant stated the quarterly statement for Resident 5 was printed on 10/31/24; however, she was not able to verify if it was handed to the resident. On 1/2/25 at 0935 hours, a telephone interview was conducted with the BOM. The BOM verified Resident 5 had a trust fund (funds that belong to the resident, such as social security checks, pension checks or personal funds) handled by the facility. The BOM stated she was responsible for providing the quarterly statements for Resident 5's trust fund. The BOM stated Resident 5's last quarterly trust (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055585 If continuation sheet Page 2 of 7 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 055585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capistrano Beach Care Center 35410 Del Rey Dana Point, CA 92624 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 0568 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete fund statement was in November 2024. The BOM stated she personally handed the copies of the statement to Resident 5 on November 2024; however, she did not keep the copy of the statement provided and did not document when Resident 5 was provided with the quarterly statement. The BOM verified there was no documented evidence the resident had received the November 2024 quarterly statement. On 1/3/25 at 1102 hours, an interview and a concurrent facility's document review was conducted with the Administrator. The Administrator was unable to show documented evidence if Resident 5 was provided with the quarterly statement in November 2024. The Administrator acknowledged the above findings. Event ID: Facility ID: 055585 If continuation sheet Page 3 of 7 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 055585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capistrano Beach Care Center 35410 Del Rey Dana Point, CA 92624 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **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 develop and/or implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an abuse allegation in a timely manner for one of two residents sampled for abuse (Resident1). * The facility failed to ensure an allegation of physical abuse was reported timely when Resident 1 stated the pillows were put on her face by Resident 2. This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation revised 9/2022 showed all the allegations of abuse (including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The findings of all the investigations are documented and reported. The section for Reporting Allegations to the Administrator and Authorities showed the following: 1. For the resident abuse, neglect, exploitation, misappropriation of the resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055585 If continuation sheet Page 4 of 7 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 055585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capistrano Beach Care Center 35410 Del Rey Dana Point, CA 92624 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility Letter to CDPH, L&C dated 12/20/24, showed a facility notification to the CDPH, L&C for an allegation of abuse involving Residents 1 and 2 which occurred on 12/13/24. The letter further showed LVN 1 heard someone calling for help and immediately went to Room A and saw Resident 1 with two pillows on her face. LVN removed the pillows from Resident 1's face. When asked who put the pillows on her face, Resident 1 stated the pillows were put on her face by Resident 2 and Resident 2 told her to be quiet. a. Medical record review for Resident 1 was initiated on 12/27/24. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1's H&P examination dated 9/16/24, showed Resident 1 had the capacity to make and understand decisions. b. Medical record review for Resident 2 was initiated on 12/27/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/17/24, showed Resident 2 had the capacity to make and understand decisions. Review of the facility's investigative summary dated 12/17/24, showed the alleged abuse involving Residents 1 and 2 took place on 12/13/24 at approximately 1900 hours. RN 1 contacted the Administrator on 12/13/24 at 1930 hours, regarding the allegations of abuse reported by Resident 1. The summary of the investigation further showed the law enforcement agency and ombudsman office were notified. However, the investigation summary failed to show documented evidence the facility had contacted the CDPH, L&C Program on 12/13/24, regarding the abuse allegations. On 1/2/25 at 1151 hours, an interview was conducted with RN 1. RN 1 verified she contacted the Administrator, law enforcement agency, and ombudsman office on 12/13/24, to report the abuse allegations made by Resident 1. RN 1 verified she did not contact the CDPH, L&C Program regarding the alleged abuse. RN 1 acknowledged the facility should have contacted the CDPH, L&C Program of any abuse allegation. On 1/3/25 at 0920 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 verified Resident 1's Progress Note dated 12/13/24, showed the facility contacted the Administrator, law enforcement agency, Resident 1's physician, and ombudsman office regarding the abuse allegation made by Resident 1. However, Resident 1's medical record showed no documented evidence the facility had contacted the CDPH, L&C Program on 12/13/24, regarding the allegations of abuse made by Resident 1. RN 2 verified the above findings. On 1/3/25 at 1102 hours, an interview was conducted with the Administrator. The Administrator verified there was no documentation the facility had contacted the CDPH, L&C Program regarding the abuse allegation made by Resident 1 on 12/13/24. The Administrator verified the facility had notified the CDPH, L&C Program regarding Resident 1's alleged abuse on 12/20/24, seven days later. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to develop and/or implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an abuse allegation in a timely manner for one of two residents sampled for abuse (Resident1). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055585 If continuation sheet Page 5 of 7 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 055585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capistrano Beach Care Center 35410 Del Rey Dana Point, CA 92624 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 0609 Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure an allegation of physical abuse was reported timely when Resident 1 stated the pillows were put on her face by Resident 2. This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Residents Affected - Few Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation revised 9/2022 showed all the allegations of abuse (including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The findings of all the investigations are documented and reported. The section for Reporting Allegations to the Administrator and Authorities showed the following: 1. For the resident abuse, neglect, exploitation, misappropriation of the resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the facility Letter to CDPH, L&Cdated 12/20/24, showed afacility notification to the CDPH, L&C for an allegation ofabuse involving Residents 1 and 2 which occurred on 12/13/24. The letter further showed LVN 1 heard someone calling for help and immediately went to Room A and saw Resident 1 with two pillows on her face. LVN removed the pillows from Resident 1's face. When asked who put the pillows on her face, Resident 1 stated the pillows were put on her face by Resident 2 and Resident 2 told her to be quiet. a. Medical record review for Resident 1 was initiated on 12/27/24. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055585 If continuation sheet Page 6 of 7 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 055585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capistrano Beach Care Center 35410 Del Rey Dana Point, CA 92624 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 0609 Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's H&P examination dated 9/16/24, showed Resident 1 had the capacity to make and understand decisions. b. Medical record review for Resident 2 was initiated on 12/27/24. Resident 2 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 2's H&P examination dated 7/17/24, showed Resident 2 had the capacity to make and understand decisions. Review of the facility's investigative summary dated 12/17/24, showed the alleged abuse involving Residents 1 and 2 took place on 12/13/24 at approximately 1900 hours. RN 1 contacted the Administrator on 12/13/24 at 1930 hours, regarding the allegations of abuse reported by Resident 1. The summary of the investigation further showed the law enforcement agency and ombudsman office were notified. However, the investigation summary failed to show documented evidence the facility had contacted the CDPH, L&C Program on 12/13/24, regarding the abuse allegations. On 1/2/25 at 1151 hours, an interview was conducted with RN 1. RN 1 verified she contacted the Administrator, law enforcement agency, and ombudsman office on 12/13/24,to report the abuse allegations made by Resident 1. RN 1 verified she did not contact the CDPH, L&C Program regarding the alleged abuse. RN 1 acknowledged the facility should have contacted the CDPH, L&C Program of any abuse allegation. On 1/3/25 at 0920 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 verified Resident 1's Progress Note dated 12/13/24, showed the facility contacted the Administrator, law enforcement agency, Resident 1's physician, and ombudsman office regarding the abuse allegation made by Resident 1. However, Resident 1's medical record showed no documented evidence the facility had contacted the CDPH, L&C Program on 12/13/24, regarding the allegations of abuse made by Resident 1. RN 2 verified the above findings. On 1/3/25 at 1102 hours, an interview was conducted with the Administrator. The Administrator verified there was no documentation the facility had contacted the CDPH, L&C Program regarding the abuse allegation made by Resident 1 on 12/13/24. The Administrator verified the facility had notified the CDPH, L&C Program regarding Resident 1's alleged abuse on 12/20/24, seven days later. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055585 If continuation sheet Page 7 of 7