Inspection·October 5, 2023

F 0554 self-administration of medication. Level of Harm - Minimal harm or potential for actual harm On 10/2/23 at 1030 hours, an observation and concurrent interview for Resident 443 was conducted with the Treatment Nurse. The Treatment Nurse verified Resident 443 had two medicine cups containing Calmoseptine cream at the bedside. The Treatment Nurse stated the staff was responsible for applying the Calmoseptine cream for Resident 443. The treatment nurse further stated the cream should not be left at bedside. Residents Affected - Few On 10/3/23 at 1423 hours, a follow-up interview and concurrent medical record review was conducted with the Treatment Nurse. The Treatment Nurse verified Resident 443 did not have a physician's order to self-administer medication. The Treatment Nurse also verified there were no assessments for selfadministration of medication found in Resident 443's medical record. On 10/5/23 at 1330 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the medication should not have been left at bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 2 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Potential for minimal harm Based on observation, interview, record review, and facility P&P review, the facility failed to ensure the personal privacy was provided during care for one of 23 sampled residents (Resident 543). This failure had the potential to negatively affect the dignity of the resident and violate the resident's rights to privacy. Residents Affected - Some Findings: Review of the facility's P&P titled Resident Rights revised 10/2009 showed the employees shall treat all residents with kindness, respect, and dignity. The policy also showed the federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to have privacy and confidentiality. On 10/03/23 at 1110 hours, an observation was conducted with Resident 543. The OTA was providing care for Resident 543 with the door and curtains open, and Resident 543 was observed in bed with her stomach exposed. On 10/03/2023 at 1118 hours, an interview was conducted with the OTA. The OTA acknowledged Residents 543's stomach was exposed and stated the curtain or door should have been closed while providing care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 3 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **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 accurately complete the MDS assessment for one of 23 final sampled residents (Resident 11). Residents Affected - Some * Resident 11 was a smoker. The facility failed to code Resident 11's use of tobacco in the quarterly MDS dated [DATE]. This failure posed the risk of Resident 11 not receiving the individualized plan of care based on the resident's specific needs. Findings: Review of the facility's P&P titled Resident Assessment Instrument revised 10/2010 showed all persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information. On 10/2/23 at 1139 hours, an interview was conducted with Resident 11. Resident 11 stated he usually smoked two cigarettes every day. Medical record review for Resident 11 was initiated on 10/2/23. Resident 11 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 9/4/20, showed Resident 11 had the capacity to understand and make decisions. Review of Resident 11's quarterly smoking assessment titled LN- Smoking Evaluation dated 3/29/23, showed Resident 11 smoked two to five times per day with one-on-one assistance. However, review of Resident 11's MDS dated [DATE], under Section J1300 Tobacco Use, showed 0 was coded which indicated Resident 11 did not have any current tobacco use. On 10/4/23 at 1004 hours, an interview and concurrent medical record review for Resident 11 was conducted with the MDS Nurse. The MDS Nurse verified the above findings. The MDS Nurse verified she coded 0 and stated the MDS was not coded accurately to reflect Resident 11's tobacco use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 4 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0655 Level of Harm - Potential for minimal harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **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 provide and explain a summary of the baseline care plan for one of 23 final sampled residents (Resident 347). This had the potential for inappropriate interventions and care for Resident 347. Findings: Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed a baseline care plan shall be developed within 48 hours of admission. The resident, the resident's family and/or responsible party should participate in the development of the care plan. During the initial facility tour on 10/2/23 at 1159 hours, Resident 347 stated no staff had discussed her plan of care since she came to the facility for the past two days. Medical record review for Resident 347 was initiated on 10/2/23. Resident 347 was admitted to the facility on [DATE]. Review of Resident 347's H&P examination dated 10/1/23, showed Resident 347 had the capacity to understand and make decisions. Review of Resident 347's Initial Care Plan dated 10/1/23, showed the cognition, skin, ADL care, nutrition, pain, falls, infection, initial goals, and discharge plans were initiated and completed. However, the Initial Care Plan did not show documented evidence the plan of care was explained or provided a copy to Resident 347. Further medical review of Resident 347 did not show documented evidence the initial baseline care plan was explained or provided a copy to Resident 347. On 10/3/23 at 1554 hours, an interview was conducted with the SSD. The SSD verified the above finding. The SSD stated they were responsible in arranging the care plan conferences with the resident or the resident's representative. The SSD stated the licensed nurses completed the resident's initial baseline care plan and provided the copy of the baseline care plan to the resident. On 10/3/23 at 1602 hours, an interview was conducted with the DON. The DON stated the resident's baseline care plan was completed within 48 hours of admission to the facility. The DON stated the licensed nurses completed a initial care plan as the baseline care plan summary. The DON stated the social services staff provided the copy of the baseline summary care plan to the residents. On 10/3/23 at 1631 hours, a follow-up interview was conducted with Resident 347. Resident 347 stated no staff had provided her a copy or explained the information regarding her plan of care. On 10/3/23 at 1637 hours, a follow-up interview and concurrent interview was conducted with the DON. The DON verified the above finding. The DON verified there was no documented evidence to show the initial baseline plan of care was explained or provided a copy to Resident 347. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 5 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed and/or implemented for five of 23 final sampled residents (Residents 21, 29, 37, 344, and 543). * The facility failed to ensure the bilateral floor mats were implemented in accordance with Residents 21 and 37's care plan. * The facility failed to develop a comprehensive person-centered care plan to address the use of CPAP machine for Resident 29. * The facility failed to ensure to follow a plan of care intervention to monitor and document intake and output for Resident 344's use of suprapubic catheter. * The facility failed to initiate a care plan to address the use of duloxetine HCL (an antidepressant medication) and trazodone (an antidepressant medication and sleep aid) including specific behavioral manifestations to be monitored by staff for Resident 543 These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Care Plans-Comprehensive revised 10/2010 showed each resident's comprehensive care plan is designed to incorporate risk factors associated with identified problems; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. 1. Medical Record Review for Resident 21 was initiated on 10/2/23. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's Fall Risk Evaluation dated 9/3/23 at 1139 hours, showed Resident 21 was at high risk for falls. Review of Resident 21's care plan problem titled Actual Fall initiated 8/27/23, due to poor balance, poor communication/comprehension, and unsteady gait, showed an intervention for floor mats. On 10/3/23 at 1100 hours, an observation and concurrent interview was conducted on Resident 21. Resident 21 was observed lying in bed. Resident 21 stated she had fallen in the past at home and in the facility. Resident 21's bed was observed with two floor mats positioned underneath her bed. On 10/3/23 at 1135 hours, an observation and concurrent interview was conducted with PTA 1. Resident 21 was observed lying in bed. Resident 21's bed was observed with two floor mats positioned underneath her bed. PTA 1 verified the floor mats should be positioned adjacent to each side of Resident 21's bed rather than positioned underneath Resident 21' s bed. PTA 1 stated Resident 21 was at risk for falls due to generalized weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 6 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0656 Cross reference to F656, example #2. Level of Harm - Minimal harm or potential for actual harm 3. Medical record review for Resident 29 was initiated on 10/2/23. Resident 29 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 29's H&P examination dated 8/14/23, showed Resident 29 had the capacity to understand and make decisions. Resident 29 had a diagnosis of obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep). Review of Resident 29's MAR for October 2023 showed a physician's order dated 10/3/23, to apply CPAP at setting of 15 cmH2O every night. Review of Resident 29 Comprehensive Plan of Care failed to address the use of Resident 29's CPAP machine. On 10/3/23 at 1506 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the resident's rehabilitation therapy services, medications, nursing services, and any treatment provided would be include in the resident's comprehensive care plan. RN 1 verified Resident 344's comprehensive plan of care did not address the use of Resident 344's CPAP machine. Cross reference to F695, example #3. 4. Review of the facility's P&P titled Catheter Care, Urinary revised 10/2010 showed under input and output, to observe thr resident's urine level for noticeable increases or decreases. If levels stay the same, or increase rapidly, report it to the physician or supervisor; and maintain accurate record of the resident's daily output. Medical record review for Resident 344 was initiated on 10/2/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated 9/25/23, showed Resident 344 was alert and oriented x3 and was able to follow commands. Resident 344 had neurogenic bladder (a term for urinary conditions in people who lack bladder control due to brain, spinal cord or nerve problem) or urinary retention, which a new suprapubic catheter (a thin, flexible rubber or plastic tube use to drain urine from the urinary bladder when a person cannot void on their own) was in placed. Review of Resident 344's Order Summary Report for September 2023, showed the following physician's orders regarding Resident 344's suprapubic catheter: - dated 9/25/23, for suprapubic catheter due to urinary incontinence, - dated 9/25/23, to perform indwelling catheter care every shift, - dated 9/25/23, to change catheter drainage bag as needed if soiled or leaking, - dated 9/25/23, to follow up with the urologist due to new suprapubic catheter, and - dated 10/2/23, to cleanse suprapubic catheter site with NS, pat dry, apply split gauze, and tape into place daily shift and as needed for if soiled or dislodged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 7 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident 344's Care Plan Problem titled Suprapubic Catheter due to Urinary Neurogenic Bladder with Urinary Retention revised 10/2/23, showed an intervention to monitor and record intake and output. Review of Resident 344's CNA Task, under Fluid Intake, for September and October 2023, showed the record of fluid intakes, for example: Residents Affected - Few -on 9/25/23 at 0559 hours, 120 ml; at 1359 hours, 680 ml; and at 2146 hours, 120 ml. -on 9/26/23 at 0222 hours, 120 ml; at 1259 hours, 880 ml; and at 2108 hours, 580 ml. -on 10/3/23 at 0109 hours, 120 ml; at 1359 hours, 680 ml; and at 2158 hours, 480 ml. Review of Resident 344's CNA Task, under Fluid Output, for September and October 2023 showed the fluid output amount was recorded as No Data Found. Review of Resident 344's CNA Task, under Bladder Continence Output, for September and October 2023 showed checked marks for example: -on 9/25/23 at 0559 and 2146 hours, the continence not rated due to indwelling catheter had a check mark, and at 1359 hours, the continence not rated due to urinary ostomy had a check mark. -on 9/26/23 at 0222 hours, the continence not rated due to indwelling catheter had a check mark, and at 1359 and 2059 hours, the continence not rated due to urinary ostomy had a check mark. -on 10/3/23 at 0109 and 1359 hours, the continence not rated due to indwelling catheter had a check mark, and at 2159 hours, the continence not rated due to urinary ostomy had a check mark. On 10/4/23 at 0912 hours, an interview and medical record review was conducted with CNA 4. CNA 4 stated his responsibility regarding if a resident had a urinary drainage catheter was to empty the bag where the urine was collected. CNA 4 further stated he record the amount of urine collected in the resident's urinary bag electronically in the facility's POC (electronic based system where CNAs document performed tasks done for each resident) system under the resident's name and in the fluid output section. On 10/4/23 at 0920 hours, an interview was conducted with the Treatment Nurse. The Treatment Nurse stated the CNAs were responsible to record the resident's fluid output. However, the Treatment Nurse further stated if the resident had a physician's order to monitor for a fluid intake and output, she would record the resident's fluid intake and output. On 10/4/23 at 0944 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 344's Fluid Output section showed, No Data Found. The DON stated the CNAs did not have to record the exact amount of Resident 344's urine output collected in her urinary drainage bag. The DON stated if there was a check mark under the resident's Bladder Continence section in the CNA Task tab, it meant the resident was having an output. On 10/4/23 at 1014 hours, a follow-up interview was conducted with the DON. The DON was asked if Resident 344's urine out should be recorded. The DON stated normally, a person would have an output of 30 ml/hr and multiply to 24 hours and that would be the amount of urine that a person urinated. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 8 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON further stated if a resident had a significant increase or decrease urine output, then she would be able to identify a concern. The DON was asked if she would be able to identify the accurate amount of Resident 344's urine output with the documented check marks under the CNA Task tab in the Bladder Continence section. The DON stated, I don't know. 2. Medical record review for Resident 37 was initiated on 10/2/23. Resident 37 was admitted to the facility on [DATE], with a diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following a cerebral infarction (a stroke) affecting the right dominant side. Review of Resident 37's MDS dated [DATE], showed Resident 37 had severely impaired cognition (a person has trouble remembering, learning new things, concentrating or making decisions that affect everyday life), total dependence on functional status (individual's ability to perform normal daily activities required to meet basic needs) and on a feeding tube. Review of Resident 37's fall risk assessment titled LN-Fall Risk Evaluation dated 6/27/23, showed Resident 37 was at high risk for falls. Review of Resident 37's plan of care showed a care plan problem initiated on 7/4/23, addressing Resident 37's risk for falls related to confusion, gait/balance problems, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The intervention included to implement floor mats. On 10/3/23 at 0920 hours, an observation and concurrent interview was conducted with CNA 1. Resident 37 was observed lying in bed with no bilateral floor mats. CNA 1 verified the findings. On 10/3/23 at 1220 hours, an observation, interview, and concurrent medical record review for Resident 37 was conducted with LVN 3. LVN 3 stated Resident 37 had a stroke with right sided weakness. LVN 3 verified Resident 37's care plan titled at risk for falls initiated on 7/4/23, showed an intervention to implement floor mats. LVN 3 verified Resident 37 did not have floor mats in place. On 10/5/23 at 1600 hours, the Administrator and DON were notified and acknowledged the above findings. Cross reference to F689, example #1. 5. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's Order Summary Report dated 9/20/23, showed a physician's order dated 9/20/23, for duloxetine HCL oral capsule delayed release particles 30 mg in the morning for anxiety m/b verbalizations of feeling nevous. Review of Resident 543's Order Summary Report dated 9/20/23, showed a physician's order dated 9/20/23, for trazodone HCL oral tablet 50 mg one tablet by mouth Q HS as needed for depression m/b inability to sleep. Review of Resident 543's plan of care failed to show a specific care plan was initiated to address the use of duloxetine HCL and trazodone; and failed to show specific behavioral manifestations for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 9 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0656 the staff to monitor regarding the use of duloxetine HCL and trazodone. Level of Harm - Minimal harm or potential for actual harm On 10/3/23 at 1432 hours, an interview and concurrent medical record review was conducted with the SSD and DON. The DON verified no patient centered care plans were developed to address Resident 543's use of Duloxetine and Trazadone. The DON further stated the care plan should be specific to Resident 543's plan of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 10 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **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 provide the necessary care and services to ensure one of 23 final sampled residents (Resident 543) attained and maintained highest practicable physical well being. Residents Affected - Few * The facility failed to ensure Resident 543's blood pressure and pulse rate were assessed and documented as ordered. * The facility failed to address Resident 543's complaints of constipation, notify physician of the change in condition, provide bowel regimen for constipation, and follow the care plan for pain medication and constipation monitoring. These failures had the potential to adversely affect the physical health and create the risk of not providing appropriate and consistent care to the resident. Findings: a. Review of the facility's P&P titled Administering Medications revised 12/2012 showed medications shall be administered in a safe and timely manner and as prescribed. Medical record review for Resident 543 was initiated on 10/3/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, for hydralazine HCL (medication to treat high blood pressure) oral tablet 25 mg one tablet by mouth two times a day for HTN, hold if SBP <110 mmHg or P <60 beats per minute. Review of Resident 543's MAR for September and October 2023 showed a physician's order dated 9/20/23, for hydralizine HCL oral tablet 25 mg one tablet by mouth two times a day for HTN, hold if SBP <110 mmHg or P <60 beats per minute. However, the MAR showed no documented Resident 543's blood pressure and pulse rate were monitored and recorded as follows: - no blood pressure monitoring at 0900 hours on 9/28 and 9/29/23; and at 1700 hours on 9/21 and 9/29/23. - no pulse rate monitoring at 0900 hours, on 9/21, 9/22, 9/25, 9/28, 9/29, and 10/1/23; and 1700 hours on 9/21 and 9/29/23. Further review of the MAR showed on 9/21/23 at 0900 hours, Resident 543's blood pressure was 108/62 mmHg; however, the medication was administered to Resident 543 when the blood pressure was below the parameter of SBP < 110 mmHg. On 10/3/23 at 1432 hours, an interview and concurrent record review was conducted with the DON. The DON acknowledged the findings and stated the blood pressure and pulse rate should have been recorded for Resident 543. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 11 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 b. On 10/2/23 at 1208 hours, an interview was conducted with Resident 543. Resident 543 stated her bowel movements had been hard to get out. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, for Norco (controlled medication to treat pain) oral tablet 5-325 mg one tablet by mouth every six hours as needed for severe pain (a pain level 7-10). Review of Resident 543's MAR dated 9/1-9/30/23, showed Resident 543 received Norco on the following dates and times: - 9/21/23 at 0200 and 0930 hours - 9/22/23 at 0222 and 0945 hours - 9/23/23 at 1353 and 2033 hours - 9/24/23 at 1149 and 2046 hours - 9/25/23 at 0350, 1241, and 2124 hours - 9/26/23 at 0530, 1302, and 2127 hours - 9/27/23 at 0836 and 1715 hours - 9/28/23 at 0219, 1029, and 2111 hours - 9/29/23 at 0951 and 2355 hours - 9/30/23 at 0748, 1425, and 2147 hours Review of Resident 543's plan of care showed a care plan problem for acute/chronic pain dated 9/21/23. The care plan interventions showed to monitor/document for side effects of pain medication and to observe for constipation. Review of Resident 534's bowel movements documentation showed Resident 543 did not have a bowel movement from 9/25/23-9/30/23. On 10/05/23 at 1134 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 543 complained of constipation on 9/25/23. CNA 2 stated an LVN was notified and Resident 543 also reported to the LVN about constipation. On 10/05/23 at 1330 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated if a resident did not have a bowel movement for three or more days, the PCC would trigger and provide a notification. LVN 3 stated did not receive a notification. LVN 3 verified Resident 543 did not have documentation of bowel movements from 9/25/23-9/30/23; no physicians' orders for bowel management; and no interventions were given for Resident 543's complaints of constipation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 12 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 LVN 3 further stated the nursing intervention would be to call the physician for a PRN order to address Resident 543's constipation. On 10/05/23 at 1604 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged Resident 543 did not have a bowel movement for five days. DON stated the standard of care was to notify the physician. Event ID: Facility ID: 555027 If continuation sheet Page 13 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Potential for minimal harm **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 23 final sampled residents (Resident 24) with an existing pressure ulcer received the necessary treatment and services consistent with professional standards of practice. Residents Affected - Some * The Treatment Nurse did not date, time, and initial Resident 24's left heel wound treatment dressing when performed wound care. This failure had the potential for Resident 24 to not receive appropriate care and services to prevent the wound to worsen. Findings: Review of the facility's P&P titled Wound Care dated 10/2010 showed to mark tape with initials, time, and date; and apply to dressing. Review of the facility's matrix showed Resident 24 had developed a Stage 4 pressure ulcer on her left heel at the facility. Medical record review for Resident 24 was initiated on 10/2/23. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24's H&P examination dated 6/30/23, showed Resident 24 did not have the capacity to understand and make decisions. Review of Resident 24's Order Summary Report dated 10/3/23, showed a physician's order dated 9/4/23, to cleanse the left heel Stage 4 pressure injury with normal saline, pat dry, apply Tetracyte (a topical antibiotics) and pack with an alginate silver (an antimicrobial dressing), and wrap with Kerlix (a bandage roll) every day shift every other day. On 10/4/23 at 0846 hours, a wound care observation for Resident 24 was conducted with the Treatment Nurse. The Treatment Nurse was observed preparing wound care supplies on an established clean field. The Treatment Nurse performed hand hygiene using soap and water, donned a pair of clean gloves, cleaned the wound with gauze pads and normal saline and dried the surrounding areas of the wound with dry gauze pads. The Treatment nurse performed hand hygiene and donned a pair of clean gloves, applied Tetracyte wound spray to the left heel wound, packed wound with calcium alginate silver dressing, wrapped with Kerlix, and secured with tape. On 10/4/23 at 1434 hours, an interview was conducted with the Treatment Nurse. The Treatment Nurse verified the wound dressing was not dated and initialed. The Treatment Nurse stated it had been her practice not to date and initial on the wound dressing because she had been doing the wound treatments all the time. On 10/5/23 at 1329 hours, an interview was conducted with the DON. The DON verified the above findings and stated she spoke with the Treatment Nurse. The DON stated the wound dressing should have been dated and initialed to know when it was last changed and who changed the dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 14 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0689 Level of Harm - Minimal harm or potential for actual harm 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** 2. Medical Record Review for Resident 21 was initiated on 10/2/23. Resident 21 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 21's Change of Condition Note dated 9/3/23 1131 hours, showed during a therapy session, Resident 21 attempted to stand up and she fell back, having sustained an assisted fall. Review of Resident 21's Fall Risk Evaluation dated 9/3/23 1139 hours, showed Resident 21 was at high risk for falls. Review of Resident 21's care plan problem titled Actual Fall dated 8/27/23, due to poor balance, poor communication/comprehension, and unsteady gait, showed an intervention for floor mats initiated on 8/27/23. On 10/3/23 at 1100 hours, an observation and concurrent interview was conducted on Resident 21. Resident 21 was observed lying in bed. Resident 21 stated she had fallen in the past at home and in the facility. Resident 21's bed was observed with two floor mats positioned underneath her bed. On 10/3/23 at 1135 hours, an observation and concurrent interview was conducted with PTA 1. Resident 21 was observed lying in bed. Resident 21's bed was observed with two floor mats positioned underneath her bed. PTA 1 verified the floor mats should be positioned adjacent to each side of Resident 21's bed rather than positioned underneath Resident 21' s bed. PTA 1 stated Resident 21 was at risk for falls due to generalized weakness. Cross reference to F656, example #1. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 23 final sampled residents (Residents 10, 21, and 37) remained free from accident hazards. *The facility failed to implement bilateral floor mats as per the physician's order and as care planned for Resident 37. *The facility failed to ensure the bilateral floor mats were implemented as per the care plan for Resident 21. *The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 10. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Review of the facility's P&P titled Falls and Fall Risk, Managing revised 12/2007, showed staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and to try to minimize complications from falling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 15 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medical record review for Resident 37 was initiated on 10/2/23. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's MDS dated [DATE], showed Resident 37 had severely impaired cognition (a person has trouble remembering, learning new things, concentrating or making decisions that affect everyday life), total dependence on functional status (individual's ability to perform normal daily activities required to meet basic needs) and on a feeding tube. Review of Resident 37's fall risk assessment titled LN- Fall Risk Evaluation dated 6/27/23, showed Resident 37 was at high risk for falls. Review of Resident 37's plan of care showed a care plan problem, initiated on 7/4/23 addressing Resident 37's risk for falls related to confusion, gait/balance problems, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The interventions included to implement floor mats for Resident 37. Review of Resident 37's Order Summary Report showed a physician's order dated 7/21/23, for bilateral floor mats. On 10/3/23 at 0920 hours, a concurrent observation was conducted with CNA 1. Resident 37 was observed lying in bed with no bilateral floor mats at bedside. CNA 1 verified these findings. On 10/3/23 at 1220 hours, an interview and concurrent observation and medical record review for Resident 37 was conducted with LVN 3. LVN 3 stated Resident 37 had a stroke with right sided weakness. LVN 3 verified the facility did not implement bilateral floor mats as per the physician's order and Resident 37's plan of care. Cross reference to F656 example 2. 3. Review of facility's P&P titled Change of Condition Reporting revised 5/2019, showed the licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two hours or until condition has stabled. Medical record review for Resident 10 was initiated on 10/2/23. Resident 10 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Anxiety Disorder, Immune Thrombocytopenic Purpura (blood disorder characterized by abnormal decrease in the number of platelets in the blood) and Hypertension (high blood pressure) among others. Review of Resident 10's History and Physical examination dated 8/19/23, showed Resident 10 had no capacity to make decisions. Review of Resident 10's MDS dated [DATE], showed Resident 10's BIMS (brief interview of mental status) was documented as never really understood, and Resident 10 needed extensive two person assist for mobility, transfer, and toileting. Review of Resident 10's fall risk assessment titled LN- Fall Risk Evaluation dated 8/17/23, showed Resident 10 was at high risk for falls. On 10/2/23 at 1009 hours, a concurrent observation and interview was conducted with Resident 10 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 16 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0689 Level of Harm - Minimal harm or potential for actual harm Resident 10's family member. Resident 10 was observed awake and lying on his bed. Resident 10's family member was at bedside. Resident 10's family member stated Resident 10 did not speak English. A floor mattress was observed on the floor at the right side of the bed. Resident 10's family member stated she was informed by the facility that Resident 10 was found kneeling on the floor, but she did not think he fell. Resident 10's family member was unable to remember when did the incident happened. Residents Affected - Few Review of Resident 10's Change of Condition Note dated 9/14/23 at 2212 hours, showed Resident 10 fell on 9/14/23 at 2020 hours. Resident 10 fell from the bed (in lowest position) to floor mattress, had no injuries from fall and was stable. Resident 10's level of consciousness was within baseline. Resident 10's primary care physician and family member were notified. No new orders. Review of Resident 10's Progress Notes dated 9/14-9/17/23, failed to show documented evidence of continued monitoring to assess for negative impact from the fall incident. On 10/4/23 at 1401 hours, an interview with CNA 4 was conducted. CNA 4 stated a fall was considered a change of condition that he needed to report to the licensed nurse. On 10/5/23 at 1112 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated a resident's fall incident was considered as change of condition. LVN 2 stated if there was a fall incident, the COC was initiated by the licensed nurses, and every shift monitoring and assessment done by the licensed nurse for the COC for 72 hours. LVN 2 also stated for a fall incident, the nurses had to assess and document neuro check every shift for 72 hours. LVN 2 stated the DON had the neuro check form that they used. LVN 2 verified there were missing assessment or monitoring every shift for 72 hours. On 10/5/23 at 1604 hours, an interview with the DON was conducted. The DON stated the nurses had to assess and document neuro check and document assessment every shift for 72 hours for COC in progress note. The DON was made aware that there were missing nursing assessment for Resident 10's COC regarding fall. The DON acknowledged the above finding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 17 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0693 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 the appropriate care and services for the G-tube for one of 23 final sampled residents (Resident 37). * The Treatment Nurse failed to follow the facility's P&P to date, time, and initial the G-tube dressing when performing the dressing changes. This failure had the potential for the resident to not receive the appropriate care and services to prevent infection at the G-tube site. Findings: Review of the facility's P&P titled Wound Care revised 10/2010 showed after dressing the wound, staff should mark the tape with initials, time, and date and apply to the dressing. Medical record review for Resident 37 was initiated on 10/2/23. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's Order Summary Report dated 10/3/23, showed Resident 37 had a G-tube. The Order Summary Report also showed the following physician's orders: - dated 8/25/23, wound consult with the physician for hypergranulation (overgrowth of granulation tissue) at G-tube site - dated 9/10/23, cleanse the G-tube site with NS (normal saline), pat dry apply Bacitracin (topical antibiotic ointment) then Calcium Alginate (used to absorb wound fluid and promote wound healing) then place split gauze and tape in place every day shift On 10/3/23 at 0918 hours, the Treatment Nurse stated the treatment for Resident 37's G-tube site was done. On 10/3/23 at 0920 hours, an observation of Resident 37 was conducted with CNA 1. Resident 37 was observed lying in bed. Resident 37's G-tube site was observed to have a white gauze dressing with tape. No date, time, or initials were noted on the G-tube dressing. On 10/3/23 at 1025 hours, an interview was conducted with the Treatment Nurse. The Treatment Nurse was asked the purpose of dating and timing a dressing after dressing changes. The Treatment Nurse stated to ensure treatments were done at the proper times. The Treatment Nurse stated she did not typically date, time, or initial G-tube dressings. The Treatment Nurse verified she did not date, time, or initial the G-tube dressing for Resident 37. On 10/4/23 at 1134 hours, a follow-up interview and concurrent medical record and facility P&P review for Resident 37 was conducted with the Treatment Nurse. The Treatment Nurse verified Resident 37 had an order for wound treatment for the G-tube site. Concurrent review of the facility's P&P titled Wound Care revised 10/2010 was conducted with the Treatment Nurse. The Treatment Nurse stated she should have labeled the G-tube dressing with the date, time of dressing change, and initials after completing the wound treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 18 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0693 Level of Harm - Potential for minimal harm On 10/5/23 at 1335 hours, an interview was conducted with the DON. The DON stated if there was a treatment order for the G-tube site, then the Treatment Nurse should date, time, and initial the dressing after dressing changes. The DON verified the above findings. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 19 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review was initiated on 10/2/23. Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE]. Residents Affected - Few Review of Resident 24's H&P examination dated 6/30/23, showed Resident 24 did not have the capacity to understand and make decisions. Review of Resident 24's Order Summary Report dated 10/3/23, did not show a physician's order to administer oxygen at 3 L/min via nasal cannula continuously. Review of Resident 24's plan of care showed a care plan focus dated 7/25/23, addressing altered respiratory status/difficulty breathing. The interventions/tasks included to provide oxygen as ordered. During the initial tour of the facility on 10/2/23 at 0934 hours, Resident 24 was observed with oxygen at 3 L/min via nasal cannula. On 10/2/23 at 1317 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 reviewed the physician's orders which did not show an order for oxygen administration. LVN 4 verified the findings. On 10/2/23 at 1321 hours, a concurrent interview and medical record review was conducted with the DON. The DON reviewed and verified the physician's orders did not show an order for oxygen administration. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for five of 23 final sampled residents (Residents 10, 24, 29, 344, and 543) and one nonsampled resident (Resident 43). * The facility failed to administer oxygen therapy treatment as ordered by the physician for Resident 344. * The facility failed to ensure Resident 43's nebulizer mask was stored properly. * The facility failed to ensure Resident 29's CPAP mask was stored properly. * Resident 24 received continuous oxygen at 3 L/min via nasal cannula without a physician's order. * The facility to administer oxygen therapy as ordered by the physician for Resident 543. * The facility failed to ensure that nebulizer mask and tubing were changed and labeled as per the facility's policy for Resident 10. These failures had the potential risk for residents' respiratory equipment to become contaminated and negatively affect the residents' medical condition. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 20 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify that there is a physician's order for the procedure and to review the physician's order or facility protocol for oxygen administration. Review of the facility's P&P titled Disposition of Respiratory Equipment Disposables revised 8/2019 showed each facility will stock disposable supplies adequate to provide safe respiratory care to respiratory patients. Supplies will be clearly dated when initially set up or changed. 1. On 10/2/23 at 1037 hours, Resident 344 was observed not wearing her oxygen nasal cannula attached to an oxygen machine that was off. Medical record review for Resident 344 was initiated on 10/2/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated 9/25/23, showed Resident 344 was alert and oriented x3 and was able to follow commands. Review of Resident 344's Order Summary Report for September 2023 showed a physician's order dated 9/25/23, to administer continuous oxygen at 2L/min via nasal cannula to keep oxygen saturation level above 90%. On 10/2/23 at 1044 hours, an observation, interview, and concurrent medical record review was conducted with the DON. The DON verified the above finding. The DON stated the oxygen machine should be on and the oxygen nasal cannula should be worn in Resident 344's nose. 2. During the initial tour of the facility on 10/2/23, Resident 43's nebulizer mask was observed on top of her bedside drawer. Resident 43 stated she received treatment a few times each day. Medical record review for Resident 43 was initiated on 10/2/23. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Order Summary Report for September 2023 showed a physician's order dated 9/30/23, to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml 3 ml inhale orally every four hours as needed for SOB or wheezing via nebulizer. Review of Resident 43's MAR for September 2023 showed Resident 43 received the Ipratropium-Albuterol Solution treatment via nebulizer on 9/1/23 at 1355 hours. On 10/2/23 at 0937 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above finding. The IP stated the nebulizer mask should be stored in a labeled and dated plastic bag when not in use to prevent infection. 3. During the initial tour of the facility on 10/2/23 at 0828 hours, Resident 29's CPAP mask was observed on top of his bedside drawer. Resident 29 stated he used his CPAP during the night while sleeping. Medical record review for Resident 29 was initiated on 10/2/23. Resident 29 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 21 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0695 Level of Harm - Minimal harm or potential for actual harm Review of Resident 29's H&P examination dated 8/14/23, showed Resident 29 had the capacity to understand and make decisions. Review of Resident 29's MAR for October 2023 showed a physician's order dated 10/3/23, to apply CPAP at setting of 15 cmH2O every night. Residents Affected - Few On 10/2/23 at 0934 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above finding. The IP stated the CPAP mask should be stored in a labeled and dated plastic bag when not in use. Cross reference to F656, example #3. 6. Review of the facility's P&P titled Disposition of Respiratory Equipment Disposables revised 8/2019 showed supplies will be clearly dated when initially set up or changed. On 10/2/23 at 1023 hours, during the initial tour of the facility, Resident 10's nebulizer mask was observed on top of his bedside drawer. Resident 10's daughter was at bedside stated Resident 10 received breathing treatments few times each day. The nebulizer mask was inside a plastic bag with no name, label, and the tubing was dated 8/23/23. Medical record review for Resident 10 was initiated on 10/2/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's MAR dated 9/1-9/30/23, showed the following: - a physician's order dated 8/16/23, for Albuterol Sulfate (medication to help with breathing) Nebulization Solution (2.5 mg/3 ml) 0.083% 3 ml inhale orally via nebulizer every 4 hours for shortness of breath administer 1 vial via face mask nebulizer every 4 hours around the clock; - a physician's order dated 8/28/23, for budesonide inhalation suspension (medication to help with breathing) 0.5 mg/2 ml one vial inhale orally two times a day for COPD, administer one vial via face nebulizer for COPD; and - a physician's order dated 8/28/23, for Brovana (medication to help with breathing) Inhalation Nebulization Solution 15 mcg/2 ml 1 vial inhale orally via nebulizer two times a day for COPD administer 1 vial via face mask nebulizer every 12 hours around the clock. On 10/2/23 at 1030 hours, an interview was conducted with LVN 2. LVN 2 stated that the facility's process was to change the mask and tubing every week on Sunday night by a nurse. LVN 2 stated it should be labeled with the resident's name and date. LVN 2 verified Resident 10's nebulizer mask and tubing were last changed on 8/23/23. LVN 2 stated if the mask and tubing were not changed, the resident might develop infection and could lead to hospitalization. On 10/5/23 at 1354 hours, an interview was conducted with the IP. The IP verified the respiratory care items, including the nebulizer mask and tubing should be changed every Sunday night by a licensed nurse to prevent infection. The IP stated the nebulizer mask and tubing should be stored in a plastic bag with the resident's name and date when it was last changed. 5. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 22 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0695 Level of Harm - Minimal harm or potential for actual harm this procedure is to provide guidelines for safe oxygen administration and verify that there is a physician's order for this procedure. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, to administer continuous oxygen at 2 L/min via nasal cannula/mask to keep oxygen saturation above 90% every shift. On 10/3/23 at 1114 hours, Resident 543 was observed on oxygen via nasal cannula. Upon checking oxygen concentrator, Resident 543 received oxygen at 1.5 L/min. On 10/3/23 at 1120 hours, an interview and concurrent observation was conducted with the OTA. The OTA stated Resident 543 was on 2 L/min. However, when the OTA was asked to verify the readings on the oxygen concentrator, the OTA verified Resident 543 was receiving 1.5 L/min. On 10/3/23 at 1121 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 543 was receiving 1.5 L/min. LVN 3 verified the physician's orders showed to administer continuous oxygen at 2 L/min FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 23 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the availability of the prescribed supplements for one nonsampled resident (Resident A). * Resident A had a physician's order for garlic supplement and glucosamine supplement. The licensed nurse was unable to administer the garlic and glucosamine supplements as ordered due to the unavailability of the supplements. This failure posed the risk for inhibiting the therapeutic effects of the supplements and had the potential to negatively affect the resident's health. Findings: Medical record review for Resident A was initiated on 10/2/23. Resident A was admitted to the facility on [DATE]. Review of Resident A's Order Summary Report showed a physician's order dated 9/26/23, to administer garlic tablet 1 mg orally once a day for supplement. Review of Resident A's Order Summary Report showed a physician's order dated 9/26/23, to administer a glucosamine capsule 500 mg orally twice a day for supplement. On 10/5/23 at 0809 hours, a medication administration observation for Resident A was conducted with LVN 3. LVN 3 prepared and administered Resident A's medications and supplements. LVN 3 verified Resident A had a physician's order dated 9/26/23, to administer garlic tablet 1 mg orally once a day for supplement (at 0900 hours), and a physician's order dated 9/26/23, to administer a glucosamine capsule 500 mg orally twice a day (at 0900 hours and 1700 hours) for supplement. LVN 3 stated she was unable to administer Resident A's garlic tablet 1 mg and glucosamine capsule 500 mg due to the unavailability of the supplements. Review of Resident A's MAR dated 10/2023 showed documentation Resident A had not received his garlic 1 mg tablet orally on 10/3, 10/4, or 10/5/23 at 0900 hours, as ordered by the physician. On 10/5/23 at 1425 hours, a follow-up interview was conducted with LVN 3. LVN 3 was asked if the facility had obtained Resident A's garlic 1 mg tablet and glucosamine 500 mg capsule (which was ordered to be administered at 0900 hours this morning). LVN 3 stated Resident A had not yet received his ordered garlic 1 mg tablet and glucosamine 500 mg capsule as the pharmacy had not delivered Resident A's garlic and glucosamine supplements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 24 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **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 Pharmacy Consultant's recommendations from drug regimen review in August 2023 were acted upon for one of 23 final sampled residents (Resident 9). This failure placed the resident at risk for receiving unnecessary medications, increasing their risk for side effects. Findings: Review of the facility's P&P titled Medication Therapy revised date 4/2007 showed the Consultant Pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. The Physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: when a medication is being given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale; when the results of ongoing assessment, or the presence of clinically significant adverse consequences monitoring, suggest that a medication should be reduced or discontinued entirely; and when a medication is being prescribed to treat, or in anticipation of, an adverse consequence of another prescribed drug. Medical record review for Resident 9 was initiated on 10/2/23. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's H&P examination dated 12/24/22, showed Resident 9 had the capacity to understand and make decisions. Review of Resident 9's Order Summary Report dated 10/3/23, showed a physician's order dated 8/24/23, for fluoxetine HCL (antidepressant) capsule 20 mg one capsule by mouth one time a day for verbalization of feeling depressed; and a physician's order dated 12/20/22, for amitriptyline HCL (antidepressant and nerve pain medication) tablet 50 mg one tablet by mouth at bedtime for neuropathy (weakness, numbness, and pain from nerve damage). Review of the Note to Attending Physician/Prescriber dated 8/6/23, showed a recommendation from the Pharmacy Consultant to consider reevaluating the continued use or a dose reduction of fluoxetine and amitriptyline. Review of the Behavior Management Follow-up dated 9/25/23, did not show documentation regarding the fluoxetine and amitriptyline medications, identified/target behaviors, and progress/updates/side effects. On 10/5/23 at 1454 hours, an interview and concurrent medical record review was conducted with the SSD and DON. The SSD stated she met with the Psychiatrist and DON once a month, and the Psychiatrist reviewed the medications and assessed the need for a dosage increase and/or decrease. When asked the DON about medication regimen review (MRR) process, she stated the Pharmacist came every month and reviewed the medications, and the pharmacy recommendations were sent via email and completed as soon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 25 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete as possible. When asked the DON about gradual dose reduction (GDR) process, she stated the facility met with the Psychiatric Nurse Practitioner every month to discuss medications, how often undesirable expression of distress occurred, review monthly summary, or tally of behaviors; and assessed if gradual dose reduction was appropriate. The DON verified the above findings and stated the GDR for fluoxetine and amitriptyline were not attempted and the above medications should have been included in the Behavior Management Follow-up form. The DON stated the pharmacy recommendation should have been followed up with the physician and she did not know why the above medications were not included in the Behavior Management Follow-up form. Event ID: Facility ID: 555027 If continuation sheet Page 26 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 10 was initiated on 10/3/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Telephone Order Sheets showed the following orders: -A physician's order dated 9/14/22, to administer Xanax (medication to treat anxiety) oral tablet 0.5 mg (Alprazolam) one tablet by mouth every 8 hours PRN for anxiety for 14 days manifested by verbalizations of feeling anxious; -A physician's order dated 9/14/22, to administer lorazepam (medication to treat anxiety) Intensol Oral Concentrate 2 mg/ml 0.25 ml by mouth every 6 hours PRN for anxiety and agitation manifested by restlessness for 14 days. a. Review of Resident 10's MAR for September 2023 showed a physician's order dated 8/17/23, for non-pharmacologic interventions- (AA)-Intervention Codes: 1=one on one; 2= activity; 3= adjust room temperature; 4= back rub; 5= change position; 6= give fluids; 7= give food; 8= re-direct; 9= refer to nurses notes; 10= remove resident from environment; 11= return to room; 12= toilet; and 13= other as needed related to anxiety. Review of Resident 10's MAR for September 2023 showed lorazepam medication was given on the following dates and times:: - 9/15/23 at 0455 hours - 9/16/23 at 0345 hours - 9/20/23 at 0010 and 0610 hours - 9/26/23 at 0414 hours However, Resident 10's MAR failed to show documentation non-pharmacological interventions were provided to Resident 10 prior to the administration of lorazepam medication. On 10/5/23 at 1112 hours, an interview and concurrent medical record review was conducted with LVN 2. When asked if the non-pharmacological interventions were provided to Resident 10 for anxiety and prior to the administration of lorazepam, LVN 2 stated there were no documentation of non-pharmacological interventions provided for Resident 10's anxiety. b. Review of Resident 10's Telephone Order Sheet dated 9/29/23, showed a physician's order for Xanax 0.5 mg one tablet PO PRN Q 8 hours for anxiety m/b verbalizations of feeling anxious; and continue lorazepam 0.25 ml (0.5 mg) PO/SL PRN Q 6 hours for anxiety/SOB. The physician's order for Xanax and lorazepam failed to include a stop date of 14 days. Review of Resident 10's medical record failed to show the physician's documentation to extend the PRN Xanax and lorazepam use beyond 14 days. The facility was unable to provide the physician's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 27 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0758 documentation. Level of Harm - Minimal harm or potential for actual harm On 10/5/23 at 1450 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated there should be a physician's documentation to extend any psychotropic medication after 14 days of PRN use. LVN 1 verified the Xanax and lorazepam medications were reordered on 9/29/23, but there was no physician's documentation to extend Resident 10's Xanax and Lorazepam after 14 days of PRN use. Residents Affected - Few c. Review of Resident 10's Telephone Order Sheet dated 9/29/23, showed a physician's order for Xanax 0.5 mg one tablet PO PRN Q 8 hours for anxiety m/b verbalizations of feeling anxious; and continue lorazepam 0.25 ml (0.5 mg) PO/SL PRN Q 6 hours for anxiety/SOB. Review of Resident 10's MAR for September and October 2023 showed the behavior monitored for anxiety was episodes of restlessness. On 10/5/23 at 1540 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated Resident 10's episodes of behavior for the use of Xanax should have been accurately documented in the MAR. LVN 5 verified there was no documented evidence of monitoring for verbalization of feeling anxious as ordered for the use of Xanax. Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 23 final sampled residents (Residents 10 and 543) were free from the unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure Resident 543's episodes of behaviors for the use of duloxetine (medication used to treat depression) and Trazadone (medication used to treat depression and aid with sleep) were consistent with the physician's orders. * The facility failed to provide the non-pharmacological interventions to Resident 10's anxiety to minimize the Xanax and lorazepam use; failed to provide the physician's documentation to extend Resident 10's Xanax and lorazepam medications (psychotropic medications) after 14 days of PRN use; and failed to ensure Resident 10's episodes of behavior for the use of Xanax (antianxiety medication) were accurately monitored and documented in the MAR. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the facility's P&P titled Psychoactive Drug Management dated 12/98, showed it is the policy of this this facility that each resident's drug regimen is free from unnecessary drugs. Unnecessary drugs are drugs used in excessive dose, for excessive duration, without adequate monitoring, without adequate indication for use and/or in the presence of adverse consequences which indicate the dose should be reduced or the drug discontinued. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to facility on 9/20/23. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23 to monitor episodes of anxiety AEB verbalization of feeling nervous (specify medication). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 28 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0758 Level of Harm - Minimal harm or potential for actual harm * However, the order did not specify the name of medication for Resident 543. In addition, the Order Summary Report did not show Resident 543 had an order for medications to treat anxiety. Review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/20/23, to monitor episodes of depression AEB inability to sleep (trazodone). Residents Affected - Few * However, the Order Summary Report failed to show the number of hours of sleep for Resident 543 was being monitored. Review of Resident 543's plan of care showed a care plan problem initiated on 9/21/23, for antidepressant medication. Interventions included to monitor/document/report to MD PRN for ongoing sign and symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and constant reassurance. Further review of Resident 543's Order Summary Report dated 10/3/23, showed a physician's order dated 9/29/23, for duloxetine HCL oral capsule Delayed Release Particles 30 mg one capsule by mouth in the morning for depression m/b verbalization of feeling sad; and a physician's order dated 9/29/23, for trazodone HCL oral tablet 50 mg one tablet by mouth as needed for depression m/b inability to sleep Q HS for 14 days. Review of Resident 543's MAR for September and October 2023 showed the monitored behaviors were anxiety m/b verbalization of feeling nervous; and depression m/b inability to sleep. * However, the MAR did not show Resident 543 was monitored for hours of sleep. Review of Resident 543's Behavior Management Follow-Up dated 9/25/25, showed trazodone 50 mg one tablet PRN for depression m/b inability to sleep Q HS and duloxetine 30 mg one tablet PO Q AM for depression m/b verbalization of depressed mood. On 10/3/23 at 1432 hours, an interview and concurrent medical record review for Resident 543 was conducted with the SSD and the DON. The DON stated she was in charge of the drug regimen review for the residents. The DON acknowledged behavior monitoring for trazadone did not show monitoring hours of sleep to determine if Resident 543 was having difficulty sleeping. The DON acknowledged the sleep hours should be tallied and recorded into the resident's record. In addition, the DON verified there was no monitoring of depression m/b verbalization of feeling sad for the use of duloxetine as ordered by the physician for Resident 54. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 29 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **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 the medication error rate was below 5%. The facility's medication error rate was 7.41%. Two of two licensed nurses (LVNs 2 and 4) were found to have made errors during the medication administration observations. Residents Affected - Few * Resident 10 had a physician's order to apply 2 grams of 1% Voltaren (pain relief gel); however, the LVN failed to utilize the dosing card to determine the dose of Voltaren administered to Resident 10. * Resident A had a physician's order for Pulmicort inhalation (corticosteroid medication) for hypoxia which was scheduled to be administered at 0900 hours; however, the LVN did not administer Resident A's Pulmicort until approximately 5 hours after the mediation was ordered to be administered. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be administered in accordance with the orders, including any required time frames. The medications must be administered within one hour of their prescribed time, unless otherwise specified. 1. On 10/4/23 at 0816 hours, a medication administration observation for Resident 10 was conducted with LVN 2. LVN 2 prepared and administered Resident 10's medications which included 1% Voltaren external topical gel 2 grams for pain. LVN 2 was observed squeezing the 1% Voltaren gel from a medicine tube into a plastic medicine cup (without having utilized the dosing card). LVN 2 then administered the 1% Voltaren topical gel to Resident 10. Medical record review for Resident 10 was initiated on 10/2/23. Resident 10 was admitted to the facility on [DATE]. Review of the physician's order dated 9/28/23, showed to apply 2 grams of 1% Voltaren external gel topically to bilateral knees two times a day for pain. At the conclusion of the medication administration observation for Resident 10, LVN 2 was asked how she determined she administered the ordered dose (2 grams) of 1% Voltaren topical gel to Resident 10. LVN 2 stated the 1% Voltaren topical gel came with a dosing card used to ensure accurate dosing of the medication. LVN 2 stated she should have utilized the dosing card, which showed 2.25 inches of 1% Voltaren topical gel, when applied to the dosing card, equated to 2 grams of the medication. 2. On 10/5/23 at 0809 hours, a medication administration observation for Resident A was conducted with LVN 3. LVN 3 prepared and administered Resident A's medications. On 10/5/23 at 1010 hours, after having administered Resident A's scheduled medications, a medical record review was conducted with LVN 3. Review of Resident A's physician's order dated 9/26/23, showed an order for Pulmicort inhalation suspension 0.5 mg/2 ml one vial two times a day (at 0900 hours and 1700 hours) for hypoxia. LVN 3 verified she failed to administer Resident A's Pulmicort inhalation suspension 0.5 mg/2 ml as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 30 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0759 Level of Harm - Minimal harm or potential for actual harm On 10/5/23 at 1425 hours, an interview was conducted with LVN 3. LVN 3 was asked if Resident A had received his morning dose (0900 hours) of Pulmicort suspension 0.5 mg/2 ml one vial inhalation. LVN 3 stated she had not administered Resident A's Pulmicort 0.5 mg/2 ml one vial via inhalation (scheduled for 0900 hours). LVN 3 then went to Resident A's room and administered Resident A's Pulmicort suspension 0.5 mg/2 ml one vial via inhalation at 1420 hours (which was scheduled to be administered at 0900 hours). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 31 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 3. On 10/5/23 at 0844 hours, and inspection of the facility's treatment cart was conducted with the treatment nurse. The top drawer of the treatment cart was observed with several unpackaged gauze pads lying on top of a pair of scissors. Additionally, a plastic cup was observed with an ointment inside of the plastic cup, and located within the plastic cup was the end of an application stick. The top drawer of the treatment cart also contained vinyl exam gloves, tape, and plastic bags. The Treatment Nurse verified the findings. The Treatment Nurse stated the ointment in the plastic cup was Calmoseptine ointment (skin barrier ointment). The Treatment Nurse stated she prepared the Calmoseptine ointment yesterday and planned to apply the ointment to a resident; however, the resident was unavailable. The Treatment Nurse stated she should have thrown the Calmoseptine ointment (inside of the plastic cup) and the unpackaged gauze into the trash. The Treatment Nurse stated storing clean gauze unpackaged and Calmoseptine ointment in a plastic cup (within the residents' treatment cart) was not in accordance with the facility's infection control practices. The Treatment Nurse stated clean gauze was to be stored in a clean package and Calmoseptine ointment not in use was to remain in the original package (tube). 2. On 10/4/23 at 0930 hours, Medication Cart A was observed parked in the hallway in front of Room A. Medication Cart A was facing the hallway, unlocked, and unattended. On 10/4/23 at 0956 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Medication Cart A was unlocked and unattended . LVN 2 stated she forgot to lock Medication Cart A when she moved to another cart. LVN 2 further stated the medication cart should be locked at all times when not attended. Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly two of four medication carts and failed to store resident biologicals and treatment supplies in a safe manner for one of one treatment cart. *The facility failed to ensure two medication carts (Medication Carts A & B) were kept locked when unattended by staff. * The facility failed to ensure medications were not left unattended on top of Medication Cart B. * The facility's treatment cart was observed with several unpackaged gauze pads lying on top of a pair of scissors and Calmoseptine ointment stored inside of a plastic cup. These failures posed the risk of unauthorized persons having access to the medications and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2007 showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 32 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's P&P titled Administering Medication, revised 12/2012 showed medications shall be administered in a safe and timely manner, and as prescribed. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward all other sides closed. No medications are kept on top of the cart. The care must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Review of the facility's P&P titled Security of Medication Cart revised 4/07 showed medication carts must be securely locked at all times when out of the nurse's view. 1. On 10/3/23 at 1117 hours, LVN 3 was observed leaving Medication Cart B unattended and out of sight, parked across Resident 543's room facing the hallway. Plastic cups contained medications were observed on top of the cart. LVN 3 came out of Resident 543's room after a couple of minutes. LVN 3 verified Medication Cart B had medications left on top of the cart and the medications belonged to Resident 443. LVN 3 stated the medication cups contained medications including: Vancomycin (antibiotic), Losartan (medication to treat high blood pressure), Lasix (medication to treat fluid retention), Metformin (medication to treat high blood sugar), Potassium Chloride (medication to treat and prevent low potassium), Probiotic (medication to maintain good bacteria in the body), Docusate Sodium (stool softener), doxazosin (medication to treat high blood pressure and urinary retention), and cephalexin (antibiotic). LVN 3 verified the findings and stated she should not have left the medications unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 33 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **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 ensure the physician was notified regarding laboratory services were not performed as ordered and abnormal laboratory test results were reported for two of 23 final sampled residents (Residents 344 and 543). * The facility failed to ensure the physician was notified of laboratory test not performed as ordered for Resident 344. * The facility failed to ensure the physician was notified of the abnormal lab results and documented in Resident 543's medical record. These failures had the potential to adversely affect the residents' physical health. Findings: Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed it is the policy of the facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant, or Nurse Practitioner. Laboratory and radiology services will be arranged as ordered. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be reported to the resident's attending Physician, Physician Assistant or Nurse Practitioner. 1. Medical record review for Resident 344 was initiated on 10/2/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated 9/25/23, showed Resident 344 was alert and oriented times three (oriented to time, place, and person) and able to follow commands. Review of Resident 344's Order Summary Report for September 2023 showed a physician's order dated 9/25/23, for Resident 344 to have laboratory testing completed for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), and UA with C and S (Urinalysis with Culture and Sensitivity) for 9/26/23. Review of Resident 344's MAR for September 2023 showed a physician's order dated 9/25/23, for Resident 344 to have laboratory testing completed for CBC, Comprehensive Metabolic Panel, and Urinalysis with Culture and Sensitivity for 9/26/23. Review of Resident 344's Skilled Nursing Facility Laboratory Test Request draw date 9/26/23, showed CBC with differential, CMP, Urinalysis, and Urinalysis with reflex to microscopic and culture if indicated were checked. Further review of the clinical record showed no documented evidence of the above laboratory testing results. Review of Resident 344's Nurses Progress Notes for September 2023 showed no documented evidence the laboratory testing were not drawn on 9/26/23, or the physician was notified of the laboratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 34 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0773 testing not performed as ordered for Resident 344. Level of Harm - Minimal harm or potential for actual harm On 10/4/23 at 1005 hours, an interview, concurrent medical record review, and facility document review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 verified there was no laboratory test results in Resident 344's electronic and paper medical record. LVN 1 verified there was no documentation to show laboratory test results were received or reported to the physician. LVN 1 showed the Skilled Nursing Facility Laboratory Request form that Resident 344 laboratory test samples were drawn. LVN 1 stated he would call the laboratory to request for the results of the laboratory test performed on 9/26/23. Residents Affected - Few On 10/4/23 at 1014 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON verified there was no documented evidence to show Resident 344's laboratory results were received and reported to the physician in the electronic or paper medical record. The DON stated the laboratory result form might be in the overflow in the Medical Records room. The DON was asked if the laboratory results should be readily available in the resident's medical record and she stated, yes. On 10/4/23 at 1041 hours, the DON stated she could not find the laboratory test results for Resident 344. The DON stated LVN 1 called the laboratory and found out the laboratory testing for Resident 344 were not drawn on 9/26/23, due to Resident 344 was not available at the time when the samples should be collected. The DON stated the nurses should have a documentation showing Resident 344 was not available for the blood draw or urine sample collection. The DON further stated the physician reordered the laboratory testing. 2. Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed results of laboratory, radiology, and diagnostic tests outside the clinical references ranges shall be reported to the resident's attending physician, PA, and NP. Medical record review for Resident 543 was initiated on 10/2/23. Resident 543 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 543's laboratory report dated 9/22/23, showed the following results outside of the clinical reference range: For CBC with differential test result: - Red blood cells 2.87 (L) (reference range: 4.80-11.00 K/uL) - Hemoglobin 9.2 (L) (reference range: 12.0-16.0 g/dL) - Hematocrit 29.2 (L) (reference range: 36.0-48.0 %) - MCV: 101.7 (H) (reference range: 80.0-100.0 fL) - MCH: 32.1 (H) (reference range: 37.0-31.0 pg) - MCHC: 31.5 (L) (reference range: 32.0-37.0 g/dL) - % Neutrophils 81.1 (H) (reference range: 36.0-75.0 %) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 35 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0773 - Absolute Lymphocytes 0.81 (L) (reference range: 1.50-4.00 K/uL) Level of Harm - Minimal harm or potential for actual harm For BMP test result: - Sodium (Na) 134 (L) (reference range: 135-145 mmo/L) Residents Affected - Few - Chloride (Cl) 96 (L) (reference range: 100-110 mmo/L) - Carbon Dioxide (CO2) 33 (H) (reference range: 24-32 mmo/L) - BUN (Blood Urea Nitrogen) 24 (H) (reference range: 7-17 mg/dL) Review of the laboratory results showed a handwritten note the NP was notified. However, there was no documentation of the name of reporting staff, the time when the NP was notified, or if there were any new orders for the abnormal lab results. On 10/03/23 at 1432 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no documentation in the Resident 543's medical record or progress notes showing the NP was notified, any new orders, or if any interventions were implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 36 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 23 final sampled residents (Resident 343) was provided a prescribed therapeutic diet. This failure posed the risk of Resident 343's nutrition needs not being met. Findings: Review of the facility's P&P titled Nutrition Care: Diet Orders for New Admission, Diet Changes, Nothing by Mouth (NPO), or Hold Meals (undated) showed all residents/patients will have a written diet order on admission which has been prescribed by the physician. Verbal telephone orders may be received and recorded by a registered dietitian and will be signed by the prescriber. On 10/2/23 at 1229 hours, during the dining observation, Resident 343 stated she had a thyroid surgery in the past. Resident 343 stated she did not eat most of her protein in her plate because it was harder for her to swallow, or the food got stuck in her throat. Resident 343's meal card ticket showed a regular soft diet and bite-sized texture with thin liquids. Medical record review for Resident 343 was initiated on 10/2/23. Resident 343 was admitted to the facility on [DATE]. Review of Resident 343's H&P examination dated 9/28/23, showed Resident 343 had the capacity to understand and make decisions. Review of Resident 343's Order Summary Report for September and October 2023 did not show a physician's order for Resident 343's diet. Review of Resident 343's MAR for September and October 2023 did not show a physician's order for Resident 343's diet. Review of Resident 343's Nursing Progress Notes for September 2023 did not show an admission note or documented evidence Resident 343 had a therapeutic diet order that was verified by the physician. Review of Resident 343's Speech Therapy Evaluation and Plan of Treatment dated 9/27/23, showed Resident 343 had history of thyroidectomy (a surgical removal of all or part of the thyroid gland). Resident 343 reported diet texture for approximately four to five years now after the surgery. Resident 343 was on a regular diet, soft, and bite size texture, thin liquids consistency, and aspiration precautions. Review of Resident 343's diet slip dated 9/27/23, showed a regular diet, mechanical soft texture, and thin liquids. On 10/2/23 at 1230 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified there was no physician's diet order in the resident's electronic or paper medical record. LVN 5 showed a yellow diet slip of Resident 343 which showed a regular diet, mechanical soft texture, and thin liquids in Resident 343's paper medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 37 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/2/23 at 1236 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated there should be a physician's diet order in place for the residents. On 10/2/23 at 1250 hours, an interview was conducted with ST 1. ST 1 stated Resident 343 had an order for ST evaluation to determine, assess, and perform swallowing trials for the appropriate and least restrictive diet for the resident. ST 1 stated Resident 343's diet was her baseline due to Resident 343's history of thyroidectomy. ST 1 stated she determined the resident's diet by looking into resident's electronic medical record or in the green admission binder. On 10/2/23 at 1301 hours, an interview and medical record review was conducted with LVN 1. LVN 1 verified there was no admission report document for Resident 343 in the green admission binder. On 10/2/23 at 1501 hours, a follow-up interview and concurrent medical record review was conducted with the DON. The DON showed the ST's Evaluation and Plan of Treatment documentation dated 9/27/23, and stated Resident 343's diet was listed in the document and the physician signed the document. However, the DON also verified the diet order should still be in a written physician's order. The DON also verified there was no admission note or any documented evidence in the nursing progress note to show Resident 343's diet order was verified by the physician. On 10/3/23 at 0846 hours, an interview was conducted with the RD. The RD stated she got the resident's physician's diet order electronically or by the diet slip turned in the kitchen by the licensed nurses upon admission. The RD further stated she did not verify the residents' diet orders with the physician, and the licensed nurse was to verify the residents' diet orders with the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 38 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: Residents Affected - Some * The facility failed to ensure the blenders used for puree preparation were air dried prior to storing. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to offer and provide hand hygiene to the residents before and after meals. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility on 10/3/23, showed 54 of 57 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. During the initial kitchen tour on 10/2/23 at 0842 hours, a concurrent observation and interview was conducted with the DSS. The heavy-duty blender, robot coupe blender, and standard blender were observed stored on the counter shelves and still wet and with visible water inside. The DSS verified the above findings and stated it should have been air dried because moisture caused bacteria. 2. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. During the initial kitchen tour on 10/2/23 at 0845 hours, a concurrent observation and interview was conducted with the DSS. A yellow, red, brown, green, and white cutting boards were observed with deep groves, heavily marred, discolored, and fuzzy. The DSS acknowledged the above findings and stated it should have been changed when it started to get bad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 39 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During the initial kitchen tour on 10/2/23 at 0840 hours, a concurrent observation and interview was conducted with the DSS. Three white spatulas with red handles and one white plastic spatula were cracked, chipped, discolored, appeared to be partially melted and worn off. The DSS verified the findings and stated the spatulas were used for puree preparation, it was not safe to use because small pieces from the spatulas could chipped and mixed with the food. 4. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. During the initial kitchen tour on 10/2/23 at 0847 hours, a concurrent observation and interview was conducted with Dietary Aide 1. Black dirt residue was observed on the kitchen hood. Dietary Aide 1 verified the findings and stated the kitchen staff were supposed to clean the hood weekly, and the hood was to be cleaned every six months by an outside company. 5. During dining observation of the facility on 10/2/23 at 1233 and 1301 hours, CNA 3 was observed not offering and providing hand hygiene to Residents 31 and 36 before and after meals. On 10/2/23 at 1301 hours, a concurrent observation and interviewed with Residents 31 and 36 was conducted. Resident 31 was observed sitting in the wheelchair. Resident 31 stated she needed assistance going to the restroom. Resident 31 stated she was not offered hand hygiene before and after her meal. Resident 36 was observed sitting on her bed with her head elevated at 90 degrees. Resident 31 stated she needed assistance getting out of the bed. Resident 36 stated she was not offered hand hygiene prior and after her meal. On 10/2/23 at 1310 hours, an interview was conducted with CNA 3. CNA 3 stated she needed to offer hand wipes, hand washing, or wash cloth to the residents before and after they ate. CNA 3 stated that she forgot to offer hand hygiene to Residents 31 and 36 before they ate. CNA 3 stated she offered a wash cloth to Residents 31 and 36 after they ate. On 10/2/23 at 1317 hours, an interview was conducted to Residents 31 and 36. Both residents denied they were offered a wash cloth by CNA 3 after they ate. On 10/5/23 at 1354 hours, an interview was conducted with the IP. The IP stated the facility's protocol was for the staff to offer and provide hand hygiene to the residents before and after meals. The IP stated the facility did not use a specific handwipes and the staff could just offer a wash cloth for the hand hygiene. The IP stated if hand hygiene was not provided to the residents, there could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 40 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0812 be a potential introduction of germs or bacteria to their mouth if their hands were dirty and an infection could develop and lead to hospitalization. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 41 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **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 provide the rehabilitation services for one of 23 final sampled residents (Resident 345). Residents Affected - Few * The facility failed to ensure Resident 345 was provided RNA services for AROM exercises to bilateral upper and lower extremities as per the physician's orders. This failure had the potential for Resident 345 to decline in the ROM functions and mobility. Findings: Review of the facility's P&P titled Quality of Care: RNA, Restorative Nursing, and Documentation revised 2/2022 showed it is the policy of the facility that Restorative Nursing shall be provided to a resident upon recommendation by the rehabilitation department to meet the resident restorative nursing care need. Physician's orders are to be obtained when a resident is to participate in the facility's restorative nursing program for ambulation or range of motion (ROM). The staff providing the program shall document that the RNA program is provided by documenting on the Restorative Record of Care under RNA or PCC-POC point click care record, or nursing assistant's notes. When a treatment is refused or withheld, the reason shall be documented and that the charge nurse was notified. Weekly progress notes are to be written by the staff providing the program. The content is to include the following: therapy program provided, equipment or apparatus used, and resident's response and comparison from the previous weeks. During the initial tour of the facility on 10/2/23 at 0824 hours, an interview was conducted with Resident 345. Resident 345 had not started rehabilitation therapy, wished to do rehabilitation therapy exercises and had been in the facility for two weeks. On 10/3/23 at 1029 hours, and 10/5/23 at 0743 hours, a concurrent observation and interview with Resident 345 was conducted. Resident 345 was observed in bed with head of the bed elevated watching television. Resident 345 stated there were no staff assisting her to perform the exercises. Resident 345 was asked if she refused any services offered to her such as restorative nursing services for exercises of her range of motion, and Resident 345 stated she had not refused any offered exercises. Resident 345 stated she moved her extremities on her own. Resident 345 further stated she had not seen the DOR since she had been admitted to the facility. Medical record review for Resident 345 was initiated on 10/2/23. Resident 345 was admitted to the facility on [DATE]. Review of Resident 345's H&P examination dated 9/18/23, showed Resident 345 was oriented to place, person, time, and followed commands. Review of Resident 345's MDS dated [DATE], showed the following: - Section C, Resident 345 was cognitively intact. - Section G, Resident 345 required extensive assistance from two staff for bed mobility, and had one impairment to her lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 42 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0825 - Section O, Resident 345 was under hospice care. Level of Harm - Minimal harm or potential for actual harm Review of Resident 345's Joint Mobility assessment dated [DATE], showed Resident 345 had limited ROM of BLEs. Residents Affected - Few Review of Resident 345's Order Summary Review for September 2023 showed the following physician's orders: - dated 9/25/23, RNA to begin on 9/26/23, 5x/week as tolerated for BUE AROM exercises to prevent contracture; - dated 9/25/23, RNA to begin 9/26/23, 5x/week as tolerated for BLE AROM exercises to prevent contracture; and - dated 10/3/23, the RNA services was discontinued. Review of Resident 345's CNA Tasks for September and October 2023 showed No Data Found under Nursing Rehab: Active ROM to BUE and AROM exercises to BLE to prevent further contracture. Review of Resident 345's Therapy Notes dated 10/3/23, showed per the resident and RNA, Resident 345 stated she did not want to get into the chair or any ROM exercises to the upper/lower extremities at this time. The risks and benefits were explained to Resident 345. Further medical record review for Resident 345 showed no documented evidence Resident 345 was provided, offered, or refused RNA services. On 10/5/23 at 0808 hours, an interview and concurrent medical record review was conducted with RNA 1. RNA 1 stated when the residents completed their physical or occupational therapy, the therapy department would recommend RNA services. RNA 1 stated she and the DSD each got a copy of the RNA orders. RNA 1 stated she documented electronically in the Point Click Care system (PCC) under the CNA task tab where it showed the recommended RNA services specific for the resident. RNA 1 stated when a resident refused the RNA services, she would notify the charge nurse and document the refusal. RNA 1 stated there should be a check under the Resident Refused in the CNA task tab under the RNA question. RNA 1 further stated she was involved in the weekly RNA meeting that included the DOR, DON, and DSD to discuss the residents' response to the RNA services. RNA 1 stated Resident 345 refused her RNA services for AROM to BUE and BLE when she offered in the morning and afternoon. RNA 1 confirmed there was no documentation when Resident 345 was offered or refused RNA services for AROM to BUE and BLE. RNA 1 further stated she only documented for RNA services electronically. On 10/5/23 at 0817 hours, an interview and concurrent medical record review was conducted with the Medical Records Director. The Medical Records Director verified there was No Data Found in the CNA task tab under RNA services. On 10/5/23 at 0825 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD stated she was part of the weekly RNA services meeting. The DSD stated she was the one responsible in the documentation of the report in the nurses progress notes for any updates of the resident's response to their RNA services. The DSD verified there was no documented evidence for Resident 345 regarding if RNA services were offered, performed, or refused. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 43 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/5/23 at 0852 hours, an interview was conducted with the DOR. The DOR stated the rehabilitation department performed a Joint Mobility Assessment prior to the recommendation of RNA services to determined if residents would benefit and to prevent further ROM decline. The DOR stated the facility offered RNA services if there was a need even if the resident was on hospice. The DOR was asked what Resident 345's cognition was, and the DOR stated she did not assess for Resident 345's cognition but Resident 345 was able to converse. The DOR stated Resident 345 did not want to do RNA services that was why the RNA services discontinued. Event ID: Facility ID: 555027 If continuation sheet Page 44 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 - Minimal harm or potential for actual harm 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** 2. Medical record review for Resident 10 was initiated on [DATE]. Resident 10 was admitted to the facility on [DATE]. Residents Affected - Few On [DATE] at 0816 hours, an interview and concurrent medical record review was conducted with LVN 2. Review of Resident 10's Order Summary Report dated [DATE], showed a physician's order dated [DATE], for Pilocarpine 1% ophthalmic solution instill 1 drop in both eyes three times a day for glaucoma and to instill 1 drop into both eyes two times a day for glaucoma. LVN 2 verified the conflicting of administration frequency in the order and stated she would clarify the order with Resident 10's physician, specific to the frequency in which to administer the Pilocarpine 1% ophthalmic solution. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 23 final sampled residents (Residents 10, 31, 344, and 543) were complete and accurate. * The facility failed to ensure the indwelling urinary catheter care was recorded for Resident 344. * Resident 10's physician's order for Pilocarpine 1% ophthalmic solution contained a conflicting administration frequency. * The facility failed to record the edema assessment for Resident 31. * Resident 31's medical record contained a physician's order for another resident (Resident 44). * The facility failed to ensure Resident 543's POLST form was accurate and signed by the physician. * The facility failed to ensure Resident 543's wound treatments were documented in the TAR. These failures had the potential to not providing necessary care and services to these residents as their medical information was inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation revised 4/2008 showed all observations, medications administered, services performed, etc., must be documented in the resident's medical records. 1. Medical record review for Resident 344 was initiated on [DATE]. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's H&P examination dated [DATE], showed Resident 344 was alert and oriented times three and able to follow commands. Review of Resident 344's Order Summary Report for [DATE] showed a physician's order dated [DATE], to perform an indwelling urinary catheter (a catheter inserted through the urethra into the bladder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 45 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 to drain urine) care every shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident 344's TAR for [DATE] showed an indwelling urinary catheter care every shift was not recorded on 9/26-[DATE] for PM shift, and on 9/29-[DATE] for NOC shift. Residents Affected - Few On [DATE] at 0930 hours, an interview and concurrent medical record review was conducted with the Treatment Nurse. The Treatment Nurse verified the above finding. The Treatment Nurse stated after she provided the indwelling urinary catheter care for Resident 344, she would document in the TAR to show the care was provided and completed. On [DATE] at 0944 hours, the DON verified and acknowledged the above finding. 3. During an initial tour of the facility on [DATE] at 0856 hours, Resident 31 was observed sitting in her wheelchair. Resident 31 was observed with edema on her bilateral upper arms. Resident 31 stated she had it before admission to the facility. Resident 31 also stated she had swelling on her left leg. Medical record review for Resident 31 was initiated on [DATE]. Resident 10 was admitted to the facility on [DATE]. The H&P examination dated [DATE], showed Resident 10 had the capacity to make decisions. Review of Resident 31's Order Summary dated [DATE] at 1150 hours, showed an order to monitor BUE nonpitting edema for skin breakdown every shift for 21 days and monitor LLE +2 edema for skin breakdown every shift for 21 days. Review of Resident 31's eMAR for [DATE] showed missing documentation for BUE and LLE edema monitoring on the following days: - 9/11, 9/12, 9/13, 9/14, 9/18, 9/19, 9./20, 9/21, 9/26, 9/27, [DATE], for PM shift. - 9/19, 9/20, 9/21, and [DATE], for NOC shift On [DATE] at 1434 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified the order for edema monitoring for Resident 31. LVN 1 verified edema monitoring should be reflected in the eMAR as ordered. LVN 1 acknowledged and verified the above findings. 4. On [DATE] at 1145 hours, review of Resident 31's medical record was initiated. However, Resident 44's Order Summary dated [DATE] at 1157 hours, was found in Resident 31's medical record under the physician's order tab. On [DATE] at 1153 hours, a concurrent interview and Resident 31's medical record review was conducted with the Treatment Nurse. The Treatment Nurse verified the physician's order was for Resident 44 and it was her signature on Resident 44's physician order. The Treatment Nurse stated she must have mistakenly filed it in Resident 31's medical record. 4. Medical record review for Resident 543 was initiated on [DATE]. Resident was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. a. Review of Resident 543's Physician's Order for Life-Sustaining Treatment (POLST) form dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 46 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 [DATE], showed the following items were selected: Level of Harm - Minimal harm or potential for actual harm - Section A: Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B) Residents Affected - Few - Section B: Selective Treatment-goal of treating medical conditions while avoiding burdensome measures. In addition, Section D of the POLST form did not show a physician's signature. Review of the POLST form under the section for Directions for Health Care Provider showed the following: - To be valid a POLST form must be signed by a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law. - Any incomplete section of the POLST form implies full treatment for that section. On [DATE] at 1432 hours, an interview and concurrent medical record review was conducted with the SSD and DON. The DON stated the licensed nurses looked at the POLST; however, the physician needed to verify the information on the document. The DON also verified Resident 543's POLST was inaccurate when Section B was checked for Selective Treatment, instead of Full Treatment. When asked when the POLST needed to be signed by the physician when Resident 543 was admitted on [DATE], the DON stated the physician was required to sign within 72 hours of admission. b. Medical record review for Resident 543 was initiated on [DATE]. Resident 543 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 543's Order Summary Report dated [DATE], showed the physician's orders dated [DATE], for the following: - to cleanse the right buttock Stage 2 pressure ulcer with NS (normal saline), pat dry, apply calmoseptine, and cover with foam and dry dressing every day shift - to cleanse groin MASD with NS, pat dry, and apply calmoseptine every shift for 21 days - to cleanse bilateral buttocks MASD with NS, pat dry, and apply calmoseptine every shift for 21 days Review of Resident 543's TAR for [DATE] showed no documentation of wound care performed on the PM shifts on 9/23, 9/28, 9/29, and [DATE], for the following wound care: - to cleanse groin MASD with NS, pat dry apply calmoseptine every shift for 21 days - to cleanse the bilateral buttocks MASD with NS, pat dry apply calmoseptine every shift for 21 days [DATE] at 1405 hours, an interview and concurrent medical record review of Resident 543 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 47 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 - Minimal harm or potential for actual harm conducted with the Treatment Nurse. The Treatment Nurse verified the missing documentation for the dates identified. When asked if the treatment was performed on the above shifts where no documentation shown, the Treatment Nurse stated she would not know if it was not documented. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 48 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and prevent the transmission of diseases and infections to all residents; and fail to implement safe and sanitary infection control practices for one of 23 final sampled residents (Resident 393). Residents Affected - Few * The facility failed to ensure the personal items were not on the clean sorting table in the laundry. * The facility failed to ensure Resident 393's urinary drainage bag and urine meter drainage container (used to measure and drain urine when emptying) were not touching the floor. These failures posed the risk for transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Laundry revised 2/2022 showed it is the policy of the facility that careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious disease to other staff members, residents, and visitors. The supervisor of laundry services will work closely with the infection control team to establish and maintain consistent high standards. On 10/4/23 at 1341 hours, an inspection of the laundry area and concurrent interview with the Maintenance Director was conducted. The following was observed on top of the clean sorting table: - a bottle water, - a coffee cup, - a cellphone, and - an identification badge. The Maintenance Director verified the above findings. The Maintenance Director stated there should not be any personal items on top of the clean sorting table area. 2. Review of the facility's P&P titled Catheter Care, Urinary revised 10/2010 showed the purpose of the procedure is to prevent catheter-associated urinary tract infections. Further review of the facility's P&P showed to be sure the catheter tubing and drainage bag are kept off the floor Medical record review for Resident 393 was initiated on 10/04/23. Resident 393 was admitted to the facility on [DATE]. On 10/02/23 at 1208, 1215, and 1230 hours, Resident 393 was observed in bed with an indwelling urinary catheter attached to a urinary drainage bag with a clear meter drainage plastic container. The bed was observed at the lowest position and close to the floor. The urinary drainage bag with attached clear meter drainage container were observed lying directly on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 49 of 50 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 555027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Nursing Center 7781 Garfield Avenue Huntington Beach, CA 92648 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/02/23 at 1233 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the bed was at the lowest position and the urinary drainage bag attached to the clear meter drainage container were lying directly on the floor. On 10/03/23 at 1037 hours, an interview was conducted with the IP. The IP stated the indwelling catheter bag should not be touching the floor and it could have a potential point of entry for the bacteria; and it should not be touching the floor even if there was a dignity bag covering it. Event ID: Facility ID: 555027 If continuation sheet Page 50 of 50