Health inspection·June 19, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 1's POLST dated 5/20/25, showed under Section D - Information and Signatures, the physicians name, telephone number, license number, signature, and date were left blank. In addition, review of Resident 1's POLST dated 5/20/25, showed under Section D - the residents responsible party's signature and cosigned by the nurse filling in the form. Resident 1's POLST did not show the words verbal consent, nor was the verbal consent witnessed by a second nurse. Additionally, review of Resident 1's POLST showed the responsible party's mailing address and telephone number were left blank. Resident 1's POLST also showed under Section D- Information and Signatures, the name of the NP was written in the section intended for the name of the NP's supervising physician. RN 2 verified the findings. 2. Medical record review for Resident 2 was initiated on 6/16/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/9/25, showed Resident 2 had the capacity to understand and make medical decisions. Review of Resident 2's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 2's POLST dated 6/8/25, showed under Section C - Artificially Administered Nutrition, was left blank and did not show if the information was discussed with the resident. In addition, review of Resident 2's POLST showed under Section D - Information and Signatures, the NP's telephone number and license number, and the resident's mailing address and telephone number were left blank and undated. RN 2 verified the findings. 3. Medical record review for Resident 3 was initiated on 6/16/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 2/9/25, showed Resident 3 had the capacity to understand and make medical decisions. Review of Resident 3's MDS assessment dated [DATE], showed the resident was cognitively intact. On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 3's POLST dated 2/8/25, showed a verbal consent from Resident 3's responsible party was obtained on 2/8/25, and was initialed by the nurse who took the verbal consent. Resident 3's POLST did not show the verbal consent was witnessed by another nurse. RN 2 stated two nurses were required to cosign a verbal consent, the nurse who receives the verbal consent and a second nurse to witness the consent. RN 2 confirmed the verbal consent was not cosigned by a witness. In addition, review of Resident 3's POLST dated 2/8/25, showed under Section C - Artificially Administered Nutrition was left blank and did not show if the information was discussed with Resident 3's responsible party. Additionally, review of Resident 3's POLST dated 2/8/25, showed under Section D - Information and Signatures, the responsible party's mailing address and telephone number were left blank. RN 2 verified the findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055888 If continuation sheet Page 2 of 3 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 055888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Huntington Valley Healthcare Center 8382 Newman Avenue Huntington Beach, CA 92647 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 On 6/19/25 at 1545 hours, an interview was conducted with the DON. The DON confirmed the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055888 If continuation sheet Page 3 of 3