Health inspection·March 28, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/27/25 at 0804 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified Resident 24 had the order to be up in the chair for all meals including breakfast, lunch, and dinner. LVN 2 stated the resident should be up in the wheelchair as ordered by the physician and to help prevent aspiration. On 3/27/25 at 0840 hours, a concurrent interview and medical record review was conducted with the DOR. The DOR verified Resident 24's order and stated the ST documentation from 3/7/25, showed for the resident to be upright in the chair for all meals as the resident's head of bed could not be elevated to 90 degrees. On 3/28/25 at 0755 hours, an observation and concurrent interview was conducted with Resident 24 in her room. Resident 24 was observed eating breakfast in bed. When Resident 24 was asked if she wanted to be up in wheelchair while eating, Resident 24 nodded her head yes. On 3/28/25 at 0804 hours, an observation and concurrent interview was conducted with LVN 2 in Resident 24's room. LVN 2 verified the observation of Resident 24 eating breakfast in bed. LVN 2 stated Resident 24 should be up in the wheelchair to eat her meals, including breakfast. On 3/28/25 at 1336 hours, an interview with the Administrator and DON was conducted. The DON and Administrator acknowledged above findings. 2. Review of the facility's P&P titled Wander System Monitoring Program revised 12/2023 showed it is the policy of this facility that all new residents will be evaluated, a part of the initial assessment process, for being at risk for wandering. Any residents identified as a wandering risk will be reassessed quarterly and with change in behavior. All residents identified to be at risk for wandering will have a wandering-monitoring bracelet placed. Anytime a wander system alarm sounds all staff are to respond and verify all residents at risk for wandering are accounted for. - one wander-monitoring bracelet will be placed on either resident's wrist or approved alternate location, (i.e. ankle or nonmetal back of resident's wheelchair) - each monitoring wristband will be checked every shift for placement and function and replaced as per manufacturer's recommendation Medical record review for Resident 31 was initiated on 3/25/25. Resident 31 was admitted on [DATE], and readmitted on [DATE]. Review of Residents 31's MDS assessment dated [DATE], showed Resident 31's BIMS score of 8 (meaning cognitive impaired). On 3/27/25 at 0835 hours, an observation and concurrent interview was conducted with CNA 1. Resident 31 was observed lying in bed with the wander guard on her right ankle. CNA 1 stated Resident 31 had had her wander guard since her admission to the facility for elopement prevention. However, further review of Resident 31's medical record failed to show the physician's order was obtained and the care plan was developed for use of the wander-monitoring bracelet. On 3/27/25 at 0906 hours, an interview and concurrent record review was conducted with the DSD. Review of Resident 4's medical record failed to show documentation the facility had an order, informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 2 of 30 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 03/28/2025 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 consent, and care plan for the use of the wander guard. The DSD verified there was no current physician's order and care plan for the use of the wander guard. On 3/27/25 at 1042 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 3 of 30 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 03/28/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Nutrition revised 5/2019 showed it is the policy of the facility to ensure that all the residents maintain an acceptable parameters of the nutritional status, such as body weight and protein labels, unless the residents clinical condition demonstrates that this is not possible. Further review of the P&P showed any of the resident's weight that varies from the previous reporting period by 5% or 5 lbs. in 30 days, 7.5% in 90 days, and 10% in 180 days will be evaluated by the IDT to determine the cause of weight loss/gain and intervention required. Under the section clinical evaluation showed the following: Residents Affected - Few - The nurse will notify the physician, family, and/or resident of weight loss or gain with interventions. - Any resident meeting the criteria for weight loss and any resident at risks will be weighed weekly with the weight entered into POC/PCC. Weekly weight will be reviewed by the Registered Dietitian/designee. - The IDT will update and revise the care plan as appropriate. Medical record review for Resident 32 was initiated on 3/25/25. Resident 32 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 32 was cognitively intact. Review of Resident 32's Weights and Vitals Summary from 2/7/25 to 2/28/25, showed the following weight and comparison. - dated 2/7/25, 192 lbs; - dated 2/10/25, 181 lbs; - dated 2/18/25, 179 lbs; - dated 2/28/25, 176 lbs; a loss of 16 lbs /8.33% in 21 days compared to 2/7/25; - dated 3/6/25, 176 lbs; - dated 3/12/25, 179 lbs; and - dated 3/19/25, 180 lbs. a. Review of the Resident 32's Nutrition Evaluation and RDN Review dated 2/12/24, showed the following: - Resident 32's weight was 181 lbs. - Weight loss of 11 lbs (5.7%) in three days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 4 of 30 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 03/28/2025 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 0692 - BMI 28.3 in healthy range Level of Harm - Minimal harm or potential for actual harm - Ideal weight range 133-148-163 lbs. - Desirable body weight 176-186 lbs. Residents Affected - Few - Recommendation per registered dietician showed weekly weights. - Under the section for Nutritional Plan of Care showed to change GT feeding Jevity 1.5 (enteral formula) at 75 ml per hour for 20 hours (to provide 1500 ml/2250 calories/95.7 gm protein/1140 ml free water) in 24 hours; every four hours, to flush the tubing with 150 ml water (to provide 600 ml); and flush the GT with 20-30 ml of water pre and post medication administration. Review of Resident 32's Nutrition Interdisciplinary Team Update dated 2/17/25, showed Resident 32 had significant weight loss of 11 lbs in three days likely related to recent change to the enteral nutrition per Resident 32's family member and Resident 32 was not able to recall his usual body weight. The RD assessed the resident and received a new tube feeding order to better likely to meet estimated needs. The document further showed Jevity 1.5 formula at 75 ml per hour for 20 hours (to provide 1500 ml/ 2250 calories/95.7 gm protein/1140 ml free water) in 24 hours; every four hours, to flush the tubing with 150 ml water (to provide 600 ml); and flush the GT with 20-30 ml of water pre and post medication administration. Further review of Resident 32's medical records failed to show if the RD and IDT had evaluated and analyzed Resident 32's nutritional status when Resident 32 had the weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. On 3/27/25 at 1334 hours, an interview and concurrent medical record review for Resident 32 was conducted with the RD. The RD verified the above findings and stated he was responsible to monitor the resident's weight in the facility. The RD verified Resident 32 had a significant weight loss of 16 lbs/8.33 % in 21 days on 2/28/25. The RD stated he was not able to find documentation to show the RD evaluation and IDT meeting for the nutritional status were done for the Resident 32 when he had the significant weight loss on 2/28/25. b. Review of the Resident 32's medical record did not show if the physician and the resident/resident's representative were notified when Resident 32 had the weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. Review of the Resident 32's Care Plan revised 2/24/25, showed a care plan problem addressing Resident 32 being at risk for malnutrition. The intervention included to monitor and report to the MD as needed for any signs and symptoms of decreased appetite, nausea, vomiting, unexpected weight loss and to monitor, record, report to the MD as needed for signs and symptoms of malnutrition, emaciation, muscle wasting, and significant weight loss. On 3/27/25 at 0954 hours, an interview and concurrent medical record review for Resident 32 was conducted with LVN 3. LVN 3 stated the RD monitored the residents' weekly weights and notified the licensed nurses when there were significant weight changes, then the licensed nurse initiated the change in condition and notified the physician and the resident and/or their representative. LVN 3 verified Resident 32 had the weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. LVN 3 stated she was not able to find documented evidence if the physician and Resident 32 or the resident's representative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 5 of 30 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 03/28/2025 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 0692 were notified of the above weight loss for Resident 32. Level of Harm - Minimal harm or potential for actual harm c. Review of the Resident 32's Care Plan revised 2/24/25, showed a care plan problem addressing Resident 32 being at risk for malnutrition. The Care Plan further showed on 2/10/25, Resident 32 had 11 lbs weight loss in three days. Interventions included Jevity 1.5 formula at 75 ml per hour for 20 hours to provide 1500 ml/ 2250 calories/95.7 gm protein/1140 ml free water. Residents Affected - Few Further review of Resident 32's Care Plan did not address Resident 32's weight loss of 16 lbs./8.33 % in 21 days on 2/28/25. On 3/27/25 at 1613 hours, an interview and concurrent medical record review for Resident 32 was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated she and the RD were responsible to monitor the residents' weight in the facility. The DON stated when the resident had the significant weight changes, the RD should evaluate the resident, an IDT meeting should be conducted, the physician and resident should be notified, and the care plan should address the significant weight loss. The DON verified Resident 32 had a significant weight loss of 16 lbs/8.33 % in 21 days on 2/28/25. The DON verified there was no documented evidence if the RD evaluated Resident 32 for the above significant weight loss and the IDT meeting was conducted. The DON further verified she was not able to find documentation to show the physician and Resident 32 and/or the resident's representative were notified of the above significant weight loss of Resident 32 on 2/28/25. In addition, the DON verified the Care Plan for Resident 32 did not address the above weight loss on 2/28/25. 3. Review of the facility's P&P titled Charting and Documentation dated 4/2008 showed all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. Review of the facility's P&P titled Nursing Administration dated 5/2019 showed to provide care and services including: defining and implementing the interventions for maintaining or improving the nutritional status that are consistent with the resident needs, goals, and recognized the standards of practice or explaining adequately in the medical record why the facility could not or should not do so and monitoring and evaluating the resident's response or lack of response to the interventions; and revising or discontinuing the approaches as appropriate, or justifying the continuation of the current approaches. Each resident is to be weighed upon admission, weekly weights for four weeks and monthly thereafter. The weight will be entered directly into POC/PCC. Review of the facility's P&P titled Care Plans - Comprehensive dated 5/2019 showed each of the resident's comprehensive care plan is designed to: a. Incorporate the identified problem areas; b. Incorporate the risks factors associated with the identified problems; c. Build on resident's strengths; d. Reflect the resident's expressed wishes regarding treatment and goals; e. Reflect the treatment and goals, timetables and objectives in measurable outcomes; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 6 of 30 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 03/28/2025 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 0692 f. Identify the professional services that are responsible for each element of care; Level of Harm - Minimal harm or potential for actual harm g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Residents Affected - Few i. Reflect currently recognized standards of practice for the problem areas and conditions. Medical record review for Resident 41 was initiated on 3/25/25. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's Care Plan Report initiated on 2/14/25, showed a care plan problem addressing Resident 41's nutritional problem or potential nutritional problem related to acute chronic systolic CHF, cellulitis of the right lower/limb, cellulitis of left lower limb, Type 2 diabetes mellitus complications, weakness, and CKD Stage 3. The interventions included an 1800 ml/day fluid restriction and to monitor and report to the MD as needed for any signs and symptoms of decreased appetite, nausea, vomiting, unexpected weight loss, stomach pain , etc. Review of Resident 41's Weight and Vitals Summary showed Resident 41's recorded weight was 193 lbs which was documented based from the acute care hospital admission on [DATE], and 181 lbs on 2/18/25. Review of Resident 41's Amount Eaten record showed the Resident 41 refused his meal on the following mealtimes and dates: - breakfast on 3/15/25, - lunch on 3/15, 3/21, 3/22, and 3/24/25, and - dinner on 2/26-2/27/25, and 3/6, 3/11-3/13, and 3/20/25. Review of Resident 41's Amount Eaten record from 2/26/25 to 3/26/25, showed a missing documentation on the following mealtimes and dates: - breakfast on 3/16 and 3/21/25; - lunch on 3/6-3/7, and 3/12/25; and - dinner on 2/28/25, and 3/7, 3/9, 3/16, 3/21, and 3/24/25. Review of Resident 41's Fluid Intake from 2/26/25/25 to 3/27/25, showed the missing documentation on the following shifts and dates: - morning shift on 3/7, 3/10, 3/12, and 3/21/25; - evening shift on 2/28/25, and 3/7, 3/9-3/10, 3/16, 3/21, and 3/24/25, and - night shift on 3/13-3/14, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 7 of 30 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 03/28/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 41's care plan showed no documented evidence of Resident 41's care plan problem regarding the refusal of the meals. On 3/27/25 at 0842 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified all of the above missing documentation and acknowledged no care plan was initiated on Resident 41's refusal of the meals. 03/27/25 at 1002 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 41's care plan problem to address the refusal of meals was not initiated. On 3/28/25 at 1520 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 41's recorded weight from admission date 2/14/25, was based from the acute care hospital record. The DON acknowledged the facility staff should have recorded Resident 41's weight at the time of admission. The DON verified all of the above findings. Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for three of three final sampled resident (Residents 4, 31, and 32) reviewed for weight loss. * The facility failed to ensure the RD's recommendations on 3/14/25, were followed up with the physician and addressed in the Nutrition IDT when Resident 4 had a severe weight loss of 15 lbs in seven days. This failure had the potential for Resident 4 not to receive the necessary intervention to prevent further weight loss. * The facility failed to ensure the RD and IDT analyzed and implemented the necessary interventions to address Resident 32's unplanned severe weight loss of 16 lbs which was equivalent to 8.33% in 21 days. In addition, the physician and resident and/or their representative were not notified of Resident 32's unplanned significant weight loss of 16 lbs, 8.33% between 2/7/25 and 2/28/25. Resident 32's resident-centered plan of care was not revised to address Resident 32's severe weight losses 8.33% between 2/7/25 and 2/28/25. * The facility failed to ensure a care plan problem was developed for Resident 41's refusal of meals, the accuracy of the documentation on Resident 41's weight upon admission, and amount of food intake and fluid intakes were completed for Resident 41. These failures posed the risk for the residents' weight loss to not be managed timely. Findings: Review of the facility's P&P titled Nutrition revised dated 5/2019 showed it is the policy of this facility to ensure that all the residents maintain acceptable parameters of nutritional status, such as the body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. The P&P also showed the following: - any resident's weight that varies from the previous reporting period by 5% or 5 lbs in 30 days, 7.5% in 90 days and 10 % in 180 days will be evaluated by the IDT to determine the cause of weight loss/gain and the intervention required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 8 of 30 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 03/28/2025 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 0692 - the nurse will notify the physician, family and/or resident of the weight loss/gain with interventions. Level of Harm - Minimal harm or potential for actual harm 1. Medical record review for Resident 4 was initiated on 3/25/25. Resident 4 was admitted to the facility on [DATE]. Residents Affected - Few Review of Residents 4's MDS assessment dated [DATE], showed Resident 4's BIMS score was 9 (moderate cognitive impairment). Review of Resident 4's Weight Summary showed the following dates and weights: - on 2/9/25, 117 lbs; - on 2/10/25, 113 lbs; a weight loss of 4 lbs from 2/9/25; - on 2/28/25, 113 lbs; - on 3/6/25, 98 lbs, a weight loss of 15 lbs from 2/28/25; and - on 3/23/25, 102 lbs, a weight loss of 14.2 lbs from 2/9/25. Review of Resident 4's Order Summary report showed a physician's order dated 2/9/25, for a regular diet, regular texture with thin liquid. Review of Resident 4's Nutrition Evaluation note dated 2/10/25, showed Resident 4's goals was to maintain the weight of 112-122 lbs. On 3/28/25 at 0929 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked what the facility's plan was to address Resident 4's weight loss. Review of Resident 4's Nutrition IDT note dated 3/14/25, showed a recommendation to fortify Resident 4's diet. The RD failed to show documentation if the recommendations of the RD on 3/14/25, was communicated to the resident's physician. On 3/28/25 at 1501 hours, an interview and concurrent medical record review was conducted with the DON. Review of Resident 4's medical record failed to show documentation the facility had communicated and followed up with the resident's physician regarding Resident 4's weight loss. The DON verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 9 of 30 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 03/28/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 GT placement check was performed prior to starting the resident's enteral feeding for one of one final sample resident reviewed for tube feeding (Resident 32). This failure had the potential for the residents to develop complications related to the GT care and management, including tube dislodgement. Findings: Review of the facility's P&P titled Enteral Feedings-Safety Precautions revised 12/2011 showed the section for Preventing Aspiration showing to check enteral tube placement prior to each feeding and administration of medication. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 12/2011 showed the section for Steps in the Procedure showing to verify placement of the tube as follows: - Observe for a change in the external tube length marked at the time of the initial insertion X-ray. - Observe for signs of respiratory distress (if applicable). - Auscultate: attach 60 ml syringe containing approximately 10 ml air. Auscultate the abdomen (approximately three inches below the sternum) while injecting the air from the syringe into the tubing. Listen for whooshing sound to check the placement of the tube in the stomach. - Check pH of aspirate, if feeding has been interrupted for a few hours, aspirate a small amount from the stomach, observe the aspirate and then measure the pH (using pH strips). A pH of five or less suggests that the tube is placed in the stomach. However, pH of six or greater is not definitive of placement outside of the stomach. Further review of the P&P showed if any of the above suggests improper tube positioning, do not administer the feeding or medication; and to notify the charge nurse or physician. Medical record review for Resident 32 was initiated on 3/25/25. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's Order Summary Report showed the following physician's orders: - dated 2/7/25, to check the tube placement/patency before and after giving medications and before starting the tube feeding. - dated 3/25/25, for continuous Glucerna 1.5 (enteral feeding) at 75 ml/hr for 20 hours (to turn off at 0900 hours, and to start at 1300 hours). On 3/25/25 at 1517 hours, Resident 32 was observed lying in bed with enteral feeding connected; however, the enteral feeding was observed to be turned off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 10 of 30 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 03/28/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few On 3/25/25 at 1523 hours, RN 2 was observed coming into Resident 32's bedside. RN 2 then proceeded to start Resident 32's enteral feeding. RN 2 was then observed priming and connecting the enteral feeding tube to the resident's GT and starting the enteral feeding. RN 2 was not observed checking for the GT placement. On 3/25/25 at 1539 hours, an interview was conducted with RN 2. RN 2 verified the above findings and stated he was notified regarding the problem with the feeding tube for Resident 32. RN 2 stated the resident's enteral feeding was initially started by a LVN; however, he should have verified the proper placement and patency of the feeding tube for Resident 32 before he started the enteral feeding for Resident 32. RN 2 further stated prior to starting an enteral feeding, he should verify the GT placement by injecting approximately 10 ml of air bolus into the tubing while using a stethoscope to auscultate and verify the placement. On 3/27/25 at 1613 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 11 of 30 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 03/28/2025 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** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for two of two sampled residents (final sample resident, Residents 356 and nonsampled resident, Resident 705) reviewed for respiratory care. Residents Affected - Few * The facility failed to ensure the oxygen was administered as ordered by the physician to Resident 356. * The facility failed to ensure the nasal cannula tubing was dated and a storage bag was provided for Resident 705. These failures had the potential for these residents to not receive the appropriate respiratory care or developed respiratory infection which may negatively affect the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of the procedure is to provide guidelines for safe oxygen administration. Further review of the P&P showed to verify that there is a physician order for the procedure and to review the physician's order or facility protocol for oxygen administration. Medical record review for Resident 356 was initiated on 3/25/25. Resident 356 was admitted to the facility on [DATE]. Review of Resident 356's Order Summary Report showed a physician's order dated 3/19/25, to administer the oxygen at two liters per minutes via nasal cannula continuously to keep the oxygen saturation level above 90%. Review of Resident 356's Care Plan dated 3/19/25, showed a care plan problem addressing the ADL self-care performance deficit. The interventions showed Resident 356 required staff assistance for bed mobility and transfers. Review of Resident 356's H&P examination dated 3/20/25, showed Resident 356 had no capacity to understand and make decisions. On 3/25/25 at 1232 hours, Resident 356 was observed lying in the bed. The oxygen was observed to be on at 3.5 liters per minutes and was not connected to the nasal cannula tubing. The nasal cannula tubing was observed on the bed, not on Resident 356 and was not connected to the oxygen machine. On 3/25/25 at 1234 hours, LVN 6 was called into the room of Resident 356. LVN 6 verified the above observation and stated Resident 356 required a continuous oxygen administration. LVN 6 further stated the nasal cannula should be on Resident 356's nose and connected to the oxygen machine. LVN 6 was observed checking Resident 356's oxygen saturation level using a pulse oximeter which showed 86% (normal range 95 -100 %). LVN 6 was then observed placing the nasal cannula on Resident 356 's nose and connected the tubing to the oxygen machine and started the oxygen at 2 liters per minute. LVN 6 again checked for the resident's oxygen saturation level which showed 93% with 2 liters per minute of the oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 12 of 30 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 03/28/2025 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 On 3/27/25 at 1613 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. 2. Review of the facility's P&P titled Oxygen Use of revised 5/2021 showed the oxygen cannula or mask will be changed at least every seven days, as well as the disposable humidifier. The tubing, masks, humidifiers and other disposables used for oxygen administration will be dated in an identifiable fashion. Medical record review for Resident 705 was initiated on 3/25/25. Resident 705 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 705's H&P examination dated 3/21/25, showed Resident 705 had a diagnosis of acute respiratory failure with hypoxia. Review of Resident 705's Order Summary Report dated 3/21/25, showed a physician's order dated 3/22/25, for oxygen at a rate of 2 liters per minute via nasal cannula to keep the oxygen saturation levels above 90%. On 3/25/25 at 1252 hours, during the initial tour of the facility, an observation was conducted for Resident 705. Resident 705 was observed lying in bed with oxygen at a rate of 2 liters per minute via nasal cannula The nasal cannula was observed undated and without a storage bag to keep the nasal cannula tubing when the tubing was not in use. On 3/25/25 at 1300 hours, an observation and concurrent interview was conducted with LVN 1 regarding Resident 705. LVN 1 was asked if Resident 705's nasal cannula was dated when it was changed and had a storage bag. LVN 1 stated there was a missing date on the nasal cannula when it was changed and the storage bag was not placed in the room for Resident 705. LVN 1 stated Resident 705 should have had a dated nasal cannula and a dated storage bag next to the oxygen machine. On 3/28/25 at 1117 hours, the DON and Administrator was made aware and acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 13 of 30 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 03/28/2025 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%. Residents Affected - Few * LVN 1 did not administer Resident 34's metformin HCL (medication to lower the blood sugar) with meal or food as ordered. * LVN 1 administered Advil (pain reliver) 200 mg two tablets for Resident 44's pain level of 8 which was not a prescribed pain level for this pain medication. These failures had the potential to negatively impact the residents' health outcomes. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medication shall be administered in a safe and timely manner, and as prescribed. The medications must be administered in accordance with the orders, including any required time frame. 1. On 3/26/25 at 0827 hours, a medication administration observation for Resident 34 was conducted with LVN 1. Resident 34 had no breakfast tray on the overbed table. LVN 1 prepared the following medications for Resident 34: - one tablet of allopurinol (prevent or lower high uric acid levels in the blood) 100 mg - one tablet of eliquis (blood thinner) 5 mg - one tablet of digoxin (used to treat heart failure and irregular heartbeat) 250 mcg - two tablet of gabapentin (anticonvulsant) 100 mg - one tablet of furosemide (diuretic) 20 mg - one tablet of metformin 500 mg with meals - one tablet of metoprolol (beta blocker) 50 mg hold if systolic blood pressure below 100 mmHg or pulse below 60 beats per minute. Medical record review for Resident 34 was initiated on 3/25/25. Resident 34 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Residents 34's MDS dated [DATE], showed Resident 34's BIMS score of 13 (meaning cognitively intact). Review of Resident 34's Order Summary Report showed the following active physician's order: - dated 1/10/25, to administer metformin Hcl 500 mg one tablet by mouth two times a day for diabetes mellitus and to take with meals (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 14 of 30 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 03/28/2025 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 Residents Affected - Few On 3/26/25 at 1223 hours, an interview was conducted with LVN 1. LVN 1 verified the metformin medication was not given with meals nor food. 2. On 3/26/25/ at 0842 hours, a medication administration observation for Resident 44 was conducted with LVN 1. Resident 44 complained of pain and the pain level was at 8 (using the 0-10 pain scale with 0 = no pain and 10 = worst pain). LVN 1 prepared and administered the following medications: - two tablet of vitamin D3 (supplement) 25 mcg/1000 IU - two tablet of sodium chloride (supplement) tablet 1 gm - one syringe of enoxaparin (anticoagulant) 40 mg/4 ml - two tablet of ibuprofen (pain reliver, generic name for Advil) 200 mg Medical record review for Resident 44 was initiated on 3/25/25. Resident 44 was admitted to the facility on [DATE]. Review of Residents 44's MDS dated [DATE], showed Resident 44's BIMS score of 15 (meaning cognitively intact). However, review of Resident 44's Order Summary Report showed a physician's order dated 3/11/25, for Advil tablet 200 mg two tablets by mouth every six hours as needed for mild/moderate pain (pain level of 4-6), not for the pain level of 8. On 3/26/25 at 1032 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the Advil medication was given to Resident 44 with the pain level of 8. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 15 of 30 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 03/28/2025 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. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications. * The facility failed to ensure Medication Cart A was maintained in a clean and sanitary manner. * The facility failed to ensure Medication Cart B was maintained in a clean and sanitary manner and the expired medication in the medication cart was disposed. * The facility failed to dispose of the expired medications in the Medication Storage Room. * The facility failed to store the oral and external medications separately in the Medication Storage Room. These failures had the potential to negatively impact the residents' well-being, for the medications to lose the stability and effectiveness, and medication errors. Findings: Review of the facility's P&P titled Drug Storage and Labeling (undated) showed the drugs and biologicals will be stored in a safe, secure and orderly fashion, and will be accessible only to the licensed nursing or pharmacy personnel. Oral medications will be stored separately from the ointments, creams, lotions, liquids and for external use. The eye medications will be kept separate from the ear medications. 1. On 3/26/25 at 0951 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 4. The following was observed: - the first drawer compartment was not clean and had dried up light brown residue, and - the upper rim compartment where the tongue depressors were stored had a dark brown residue. LVN 4 verified the above findings. 2. On 3/26/25 at 1028 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 3. The following was observed: - a bottle of Pro-stat concentrated liquid protein (protein supplement) had a sticky medication residue on the top part of the bottle, - the bottom drawer compartment was not clean and had a dried up yellow brown residue, and - a bottle of Glucosamine Chondroitin Complex (joint supplement) had an expiration date of 2/2025. LVN 3 verified the above findings. LVN 3 acknowledged the bottle of Glucosamine Chondroitin Complex (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 16 of 30 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 03/28/2025 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 should have been disposed. Level of Harm - Minimal harm or potential for actual harm 3. On 3/26/25 at 1128 hours, an inspection of the Medication Storage Room and concurrent interview was conducted with RN 1. The Medication Storage Room was observed with four expired bottles of docusate sodium (stool softener). The two bottles had an expiration date of 6/2024 and the other two bottles had an expiration date of 1/2025. RN 1 verified the four expired bottles of docusate sodium should have been disposed properly. Residents Affected - Few On 3/28/25 at 1050 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings. 4. On 3/26/25 at 1142 hours, an inspection of the Medication Storage Room and concurrent interview was conducted with RN 1. The following medications were observed stored side by side in the second shelf of Medication Storage Room cabinet: - one box of bisacodyl suppository (medication to relieve constipation), - one box of Salonpas (pain relieving patch), and - four bottles of Geri-tussin-DM (medication to relieve cough). RN 1 acknowledged the rectal suppository, pain relieving patch, and bottles of oral medications were stored together. On 3/26/25 at 1332 hours, an interview was conducted with the DON. The DON acknowledged the above findings, and stated the medications to be taken by mouth and suppository should not be stored together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 17 of 30 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 03/28/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the egg rolls and cream of rice during the puree preparation. * Residents 7, 706, 707, 756, and 758 (nonsampled residents) were not served a regular textured diet as ordered by the physician. * Resident 706 (nonsampled resident) was not served the appropriate serving portion as ordered by the physician * [NAME] 1 failed to use the correct scoop size to serve rice for Resident 33 (final sample resident). These failures had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the kitchen. Review of the facility's P&P titled Menu Planning dated 2023 showed the menus are planned to meet nutritional needs of resident in accordance with established national guidelines, physician's orders, and to the extent medically possible, in accordance with the most recent recommended dietary allowance of the Food and Nutrition Board of National Research Council National academy of sciences. - Procedures: The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. Review of the facility's Week 3 cycle menu showed two #8 scoops for Beef and Broccoli stir fry; #8 scoop for steamed rice; and one egg roll each for a regular diet. Review of the facility's Week 3 cycle menu showed two #8 scoop for Beef and Broccoli stir fry; #16 scoop for steamed rice; and one egg roll each for Small Portion Diet. Review of the facility's Week 3 cycle menu showed #6 scoop for Beef and Broccoli stir fry; #16 scoop for egg roll; and four oz cream of rice for Puree Diet. Review of the facility's pureed recipe for Steamed Rice, Cycle 1, 2025 Winter for Purees: Stovetop Method: Add oil and salt to water, bring to a boil, stir in the rice, reduce heat to low; cover and simmer 20 minutes or until rice is tender, and most of the water has been absorbed, remove from heat and let stand (covered) for five minutes; transfer to the service line and serve with a #8 scoop; and prepare the rice according to regular recipe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 18 of 30 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 03/28/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's pureed recipe for Egg Roll (Vegetable) 1-1/2, Cycle 1, 2025 Winter for Dysphagia/Puree: Place portions needed into a food processor, process to a fine texture, prepare a slurry with hot liquid and thickener, mix well with a wire whip, add 1/2 (half) of the slurry to the egg rolls, and process for one minute. 1. On 3/26/25 at 1025 hours, an observation and concurrent interview was conducted with [NAME] 1 during the puree preparation process. [NAME] 1 was observed placing 10 egg rolls in the Robot Coupe and added ¾ (three forth) cup of slurry mixture and processed the egg rolls and the slurry together for a pureed texture. On 3/26/25 at 1042 hours, an observation of the Cream of [NAME] preparation was conducted with [NAME] 1. [NAME] 1 poured two cups of water in a deep metal pan over the stove top and without measuring poured the mixture of Cream of [NAME] into the pan while stirring with a spoon. On 3/26/25 at 1050 hours an interview and concurrent recipe review of Egg Rolls and Cream of [NAME] was conducted with [NAME] 1. [NAME] 1 was asked about the proper preparation of the egg rolls. [NAME] 1 verified the egg rolls should have been placed in the food processor and blended before adding the slurry mixture; however, they were processed together. [NAME] 1 was also asked about the preparation of the Cream of Rice. [NAME] 1 verified he did not follow the recipe and poured the cream of rice directly from the box into the pan instead of measuring. [NAME] 1 stated he was confused when preparing the meal. 2. On 3/26/25 at 1245 hours, an observation and concurrent interview was conducted in the kitchen with Cooks 1, 2, and the Dietary Resource. [NAME] 1 was observed preparing all lunch trays for the residents and stated he did not have enough regular textured Beef and Broccoli stir fry to serve the remaining five residents (Residents 7, 706, 707, 756, and 758) as ordered by the physician. When [NAME] 1 was asked how he would proceed with the serving of the meals for the five residents identified, he stated all he had left was chopped textured Beef and Broccoli for Residents 7, 706, 707, 756, and 758. [NAME] 1 was asked if the chopped texture diet followed the physician's orders, and he verified it did not. Dietary Resource also verified there was not enough food prepared to make sure Residents 7, 706, 707, 756, and 758 received the proper diet texture as ordered by the physician. a. Medical recorded review for Resident 7 was initiated on 3/26/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report dated 3/27/25, showed a physician's order dated 2/12/25, for no added salt diet, regular texture, thin liquids consistency. b. Medical record review for Resident 706 was initiated on 3/26/25. Resident 706 was admitted to the facility on [DATE]. Review of Resident 706's Order Summary Report dated 3/27/25, showed a physician's order dated 3/12/25, for Regular diet, regular texture, thin liquids consistency. c. Medical record review for Resident 707 was initiated on 3/26/25. Resident 707 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of 707's Order Summary Report dated 3/27/25, showed a physician's order dated 3/24/25, for Regular diet, soft and bite sized- level 6 texture, thin liquids consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 19 of 30 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 03/28/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm d. Medical record review for Resident 756 was initiated on 3/26/25. Resident 756 was admitted to the facility on [DATE]. Review of 756's Order Summary Report dated 3/27/25, showed a physician's order dated 3/13/25, for Regular diet, regular texture, thin liquids consistency. Residents Affected - Few e. Medical record review for Resident 758 was initiated on 3/26/25. Resident 758 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of 758's Order Summary Report dated 3/27/25, showed a physician's order dated 3/21/25, for constant carbohydrate diet, regular- level 7 texture, thin liquids consistency. 3. On 3/26/25 at 1251 hours, an observation and concurrent interview was conducted with [NAME] 1 and the RD regarding Resident 706. Resident 706 was observed receiving 1.25 scoops of Beef and Broccoli, stir fry. [NAME] 1 was asked why Resident 706 was receiving 1.25 scoops of Beef and Broccoli while the other residents received two full scoops for the regular diet ordered. [NAME] 1 verified he had ran out of food and did not have the correct portion size for Resident 706. When [NAME] 1 and the RD were asked how they would ensure to have enough food for the residents, the RD and [NAME] 1 stated they referred to the census of the facility. Medical record review for Resident 706 was initiated on 3/26/25. Resident 706 was admitted to the facility on [DATE]. Review of Resident 706's Order Summary Report dated 3/27/25, showed a physician's order dated 3/12/25, for regular diet, regular texture, thin liquids consistency. 4. On 3/26/25 at 1257 hours, an observation and concurrent interview was conducted with Cooks 1 and 2 in the kitchen. [NAME] 1 was observed using a #8 scoop for Resident 33's rice. Cooks 1 and 2 were asked if the right scoop size was used to serve rice for Resident 33 who had a meal ticket showing a small portion in blue writing. [NAME] 1 verified he did not use scoop size #16 to serve Resident 33's rice. [NAME] 2 verified it was the responsibility of both cooks to verify the meal cards upon serving the residents in the facility. Medical record review of Resident 33 was initiated on 3/25/25. Resident 33 was admitted on [DATE]. Review of Resident 33's Order Summary Report dated 3/27/25 showed a physician's order dated 3/14/25, for easy to chew- Level 7 texture, thin liquids consistency, small portion. On 3/28/25 at 1117 hours, the DON and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 20 of 30 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 03/28/2025 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 food safety and sanitation guidelines were followed when: Residents Affected - Some * The facility failed to ensure the food items were properly stored and maintained. * The facility failed to ensure the food items were dated and labeled. * The facility failed to ensure the kitchen equipment was maintained in a sanitary condition and/or cleaned properly. These failures had the potential to result in foodborne illnesses for 57 of 59 residents receiving the dietary services in the facility's kitchen. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the facility's kitchen. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Labeling and Dating of Foods dated 2023 showed the following: Policy: All food items in the storage room, refrigerator, and freezer need to be labeled and dated. Procedure: -Food delivered to the facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date for the product. -Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines within the this section- specifically the Dry Goods Storage Guidelines. 1. On 3/25/25 at 1115 hours, during the initial tour of the kitchen, a concurrent observation and interview with [NAME] 1 and the RD were conducted. The following was observed: - Five pumpkin pies with a label date of 2/23/25, and without the expiration dates; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 21 of 30 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 03/28/2025 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 - One box of the tater tots removed from the freezer by [NAME] 1, placed directly on the floor, and put back into the freezer; Level of Harm - Minimal harm or potential for actual harm - One buttermilk ranch bottle used, without the opened date and expiration date; Residents Affected - Some - One bread knife with a melted handle; - One missing tile on the drain next to the ice maker machine - Grey web-like formation on the vent above the stove - Two bags of the wheat toast with best by dates of 3/19 and 3/22/25; and - Two bags of the bagels with an opened date of 3/14/25, and without an expiration date Cook 1 verified the above findings and stated the damaged items needed to be discarded and the expired bread needed to be discarded. The RD stated the food items should have been dated to ensure the kitchen staff were aware of how long the food items had been opened. The RD also verified the box of tater tots removed from the freezer and placed directly on the floor and returned to the freezer could contaminate the remaining items in the freezer and spread infection. [NAME] 1 stated he did not know the tile on the drain near the ice machine was missing. [NAME] 1 further stated the vent above the stove was cleaned on 3/19/25; however, he did not see the web-like formation. The RD and [NAME] 1 verified all the findings. 2. Review of the facility's P&P title Dishwashing dated 2023 showed all dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean ad in good working order. - Gross food particles shall be removed by carefully scraping and pre-rinsing in running water. On 3/25/25 at 1132 hours, a concurrent observation and interview was conducted with [NAME] 1 and the RD. The following was observed: - Three 7-inch pans with blue handles with brown sticky residue and dark brown stains; - One large deep rectangular pan with brown and black discoloration on the exterior surface; - Two large draining pans with brown and white flaky residue around the rim of each pan; - One can opener with brown residue covering the spinning wheel of the device; and - [NAME] sticky residue stains on the floor, in between the coffee machine table and juice machine table. Cook 1 and the RD verified the findings and stated the kitchen equipment needed to be cleaned properly. 3. On 3/26/25 at 1104 hours, a concurrent observation and interview was conducted with the Dietary Resource. Below the dish drying table, a melted grey, white, and brown substance covering the right side of the pole was observed. The Dietary Resource verified the pole underneath the dish drying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 22 of 30 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 03/28/2025 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 table had rust and brown discoloration. The Dietary Resource also stated the pole needed to be re-welded. Level of Harm - Minimal harm or potential for actual harm On 3/28/25 at 1117 hours, the DON and Administrator were informed and acknowledged the above findings. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 23 of 30 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 03/28/2025 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 33 was initiated on 3/26/25. Resident 33 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 33's Order Summary Report showed a physician's order dated 3/23/25, for vancomycin HCl Intravenous Solution (antibiotics) 750 mg intravenously every day shift for 10 days for wound infection. Review of Resident 33's IV MAR for March 2025 did not show documented evidence Resident 33's peripheral IV site was monitored for the complicated reactions during the IV infusion and for the signs and symptoms of infiltration. On 3/26/25 at 1214 hours, an observation and concurrent interview was conducted with Resident 33. Resident 33 was observed to have a peripheral IV site on her right forearm covered with a light brown dressing. Resident 33 was asked since when the resident had the peripheral IV site and what it was for, Resident 33 stated she could not recall when it was inserted, and it was intended for an infection. On 3/26/25 at 1233 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified there was no documented evidence Resident 33's peripheral IV site was monitored for the complicated reactions during the IV infusion and for the signs and symptoms of infiltration. On 3/28/25 at 1330 hours, an interview was conducted with the DON. The DON was made aware and verified the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for two of 15 final sampled residents (Residents 4 and 33). * Resident 4's POLST failed to show documentation as to whether Resident 4 had formulated the advanced directive. * The facility failed to ensure Resident 33's peripheral IV catheter care was documented. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete. Findings: 1. Review of the facility's P&P titled Advance Directive revised 11/2019 showed once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to the members of the care plan team. The facility will also notify the attending physician of the advance directives so that, if necessary, the appropriate orders can be documented in the resident's medical record and plan of care. Medical record review for Resident 4 was initiated on 3/25/25. Resident 4 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 24 of 30 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 03/28/2025 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 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Residents 4's MDS assessment dated [DATE], showed Resident 4's BIMS score was 9 (moderately cognitive impaired). Residents Affected - Few On 3/26/25 at 1326 hours, a review of Resident 4's POLST dated 1/8/25, was conducted. Section D of the POLST for Information and Signatures showed Resident 4 had no advance directive. However, the POLST failed to show documentation as to whether it was discussed with Resident 4 or the legally recognized decision maker. The form further showed the physician had signed the POLST on 1/9/25. On 3/27/25 at 0952 hours, an interview and concurrent medical record review was conducted with the SSD. A follow-up review of Resident 4's POLST dated 1/8/25, showed Section D for Information and Signatures showing Resident 4 had an advance directive dated 9/17 which was discussed with the Legally Recognized Decisionmaker and the box for No Advanced Directive indicated error. The form showed the physician had signed the POLST on 1/9/25. The SSD verified she just updated Resident 4's POLST. The SSD verified there was no documentation to show the SSD had updated Resident 4's POLST and communicated to the resident's physician prior to making the POLST modification. On 3/27/25 at 1206 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 25 of 30 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 03/28/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the hospice and facility staff worked collaboratively together in the plan of care for one of one hospice resident (final sampled resident, Resident 1) as per the hospice contract agreement. This failure had the potential of Residents 1 to not receive hospice care as per the hospice contract agreement and P&P. Findings: Review of the facility's P&P titled Hospice Program revised 12/2011 showed when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions. Review of Hospice A's Services Agreement: Exhibit B (undated) showed for Nursing Services, a registered nurse will be assigned to coordinate and supervise care and services for residents and families. Registered nurses responsibilities include the participation in interdisciplinary team, utilization review, discharge planning, and meetings. Medical record review for Resident 1 was initiated on 3/25/25. Resident 1 was admitted to the facility on [DATE], and readmitted back to the facility on 2/7/25. Review of Resident 1's Physician's Orders for March 2025 showed an order dated 3/4/25, to admit the resident to the facility under Hospice A. Review of Resident 1's Significant Change MDS assessment dated [DATE], showed Resident 1 with the BIMS score of 9 which meant the resident was cognitively moderately impaired. Review of Resident 1's Change of Condition Review IDT dated 3/7/25, showed no documented evidence a hospice representative was included in the IDT meeting. On 3/282/5 at 0953 hours, a concurrent interview and medical record review was conducted with the IP. The IP verified Resident 1 was under Hospice A services. Review of Resident 1's medical record showed no documented evidence the hospice care team had participated in the IDT meeting conducted on 3/7/25. The IP stated the hospice care team was also providing care to the hospice resident, therefore, the hospice staff should also be included in the IDT meeting to ensure for the continuation of care between the facility's nursing staff and hospice staff. On 3/28/25 at 1336 hours, an interview with the Administrator and DON was conducted. The DON and Administrator acknowledged above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 26 of 30 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 03/28/2025 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** 3. Medical record review for Resident 24 was initiated on 3/25/25. Resident 24 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 24's Physician's Orders for March 2025 showed an order dated 2/28/25, for continuous oxygen at one liter per minute via nasal cannula/mask to keep the oxygen saturation level above 90% every shift. Review of Resident 24's H&P examination dated 3/3/25, showed Resident 24 had impaired memory. On 3/25/25 at 1614 hours, during an observation, LVN 7 was observed in Resident 24's room wearing gloves and assisting Resident 24's roommate with her oxygen. LVN 7 was observed placing the nasal cannula on Resident 24's roommate and turning on the oxygen concentrator. LVN 7 was then observed going to Resident 24 to provide assistance to the resident with her oxygen and touched Resident 24's nasal cannula. LVN 7 was not observed performing hand hygiene between residents contact and did not change the gloves when working between Resident 24 and her roommate. On 3/25/25 at 1618 hours, an interview with LVN 7 was conducted outside of Resident 24's room. LVN 7 verified the above findings. LVN 7 stated she should have changed her gloves and perform hand hygiene between residents contact to ensure infection control and to prevent the spread of bacteria. On 3/28/25 at 1336 hours, an interview with the Administrator and DON was conducted. The DON and Administrator acknowledged above findings. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed as evidenced by: * The OTA failed to perform hand hygiene before and after assisting Resident 4 to the bathroom. * LVN 1 failed to perform hand hygiene before and after taking the resident's blood pressure, during the medication preparation and administration, and in between the medication administration for Residents 3 and 34. * LVN 7 failed to perform hand hygiene after removing her gloves and in between contacts with Resident 24's roommate and Resident 24. These failures posed the risk for the transmission of the communicable diseases to other residents in the facility. Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene dated 12/2012 showed the facility considers hand hygiene the primary means to prevent the spread of infection. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: - before and after direct resident contact (for which hand hygiene is indicated by acceptable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 27 of 30 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 03/28/2025 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 professional practice) Level of Harm - Minimal harm or potential for actual harm - upon and after coming in contact with resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident). Residents Affected - Few Review of the facility's P&P titled Administering Medication dated 12/2012 showed the staff follow establish facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medication, as applicable. 1. On 3/25/24 at 1135 hours, during the initial tour of the facility, an observation was conducted with the OTA with Resident 4. The OTA was observed taking Resident 4 to the bathroom with her gloved hands, and left Resident 4 in the bathroom. The OTA removed her gloves, did not wash her hands, took a clean towel on the hallway, and donned a new pair of gloves without hand washing. On 3/25/25 at 1155 hours, an interview was conducted with the OTA. The OTA acknowledged the findings and stated she should have washed her hands after removing her gloves. 2. On 3/26/25 at 0815 hours, a medication administration observation for Resident 3 was conducted with LVN 1. LVN 1 took Resident 3's blood pressure and prepared and administered Resident 3's medications. However, LVN 1 did not perform hand hygiene before and after taking Resident 3's blood pressure and during the medication preparation and administration. On 3/26/25 at 0827 hours, a medication administration observation for Resident 34 was conducted with LVN 1. LVN 1 took Resident 34's blood pressure and prepared and administered Resident 34's medications. However, LVN 1 did not perform hand hygiene before and after taking Resident 34's blood pressure and during the medication preparation and administration. Furthermore, LVN 1 was not observed performing hand hygiene in between the medication administration for Residents 3 and 34. On 3/26/25 at 1032 hours an interview was conducted with LVN 1. LVN 1 verified the above findings and stated she needed to wash her hands before and after taking the blood pressure and the medication administrations. On 3/28/25 at 1050 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 28 of 30 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 03/28/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the kitchen's essential equipment in a clean and safe operating condition when: Residents Affected - Few * The ice machine was not cleaned as per the manufacturer's guidelines for cleaning and sanitizing. * The low temperature dishwasher handles were missing covers and had brown discoloration. * The low temperature dishwasher machine was not operating as per the manufacturer's instructions. * The residents' dining room refrigerator temperature log was not monitored as per the facility's policy. There failures had the potential for the essential equipment to not function in the way it was intended, and exposed the residents to unsafe practices, which could lead to food borne illnesses for the residents. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the kitchen. Review of the facility's P&P titled Sanitation dated 2023 showed the following: Policy: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. - All the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 1. On 3/25/25 at 1132 hours, during the initial tour of the kitchen with the RD and [NAME] 1, an inspection of the ice machine was conducted. The ice machine contained white flaky residue/build-up on the outside panel of the ice bin. The RD and [NAME] 1 verified the findings. On 3/27/25 at 1316 hours, a follow-up inspection of the ice machine and concurrent interview with the Maintenance Director was conducted. The top front cover of the ice machine was removed. The ice machine was observed with white and brown buildup on the base in between the left panel of the ice machine and the left side of ice maker door. The Maintenance Director was asked when the ice machine cleaning was last completed. The Maintenance Director stated the ice machine was cleaned and descaled once a month and the last cleaning was completed on 3/5/25. When the Maintenance Director was asked if he was aware of the white and brown buildup as identified during the ice machine inspection, the Maintenance Director stated his focus was on the inside of the ice maker door. When the Maintenance Director was asked if he was aware of the white flaky residue/build-up on the outside panel of the ice machine, he stated he was not aware of it. 2. On 3/26/25 at 1104 hours, an observation of the low temperature dishwasher and concurrent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 29 of 30 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 03/28/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview was conducted with the Dietary Resource. The low temperature dishwasher handles on the right and left of the machine showed brown discolored handles and were missing covers on each side of the handles. The Dietary Resource verified the findings. 3. Review of the reference range posted outside the low temperature dishwasher panel showed the reference range for chlorine level was 50-100 PPM. On 3/26/25 at 1105 hours, a concurrent observation, interview, and record review was conducted with Dietary Staff 1 regarding the low temperature dishwasher, with the presence of the Dietary Resource. Dietary Staff 1 was asked about the reference range for the chlorine levels for the dishwasher. Dietary Staff 1 stated the proper chlorine levels for the dishwashing machine were 50 to 100 PPM. Dietary Staff 1 was asked to conduct Ecolab Chlorine Paper Test which showed results of 200 PPM and displayed a near black color on the test strip. The Ecolab Chlorine Paper Test was conducted three more times. All the results showed the chlorine levels greater than 200 PPM and displayed a near black color on the test strip. Dietary Staff 1 was asked what the near black color on the test strip meant and he stated too much chemical chlorine was being dispensed when the dishwasher was running. The Dietary Resource stated the facility would use the two-sink compartment to wash the dishes. Review of the form titled Dishmachine Temperature and Sanitizing Agent Log dated March 2025 showed the result of the PPM levels for the breakfast, lunch, and dinner from 3/1 through 3/26/25 was 100 PPM. Dietary Staff 1 was asked for the possible reasons as to why the levels of the PPM were higher today compared to the documented results on March 2025 log. Dietary Staff 1 stated the Ecolab technician came on 3/26/25, and must have adjusted the setting which might have affected the chlorine levels. Dietary Staff 1 was asked what needed to be done when the chlorine levels were out of the acceptable range. Dietary Staff 1 stated he needed to contact the Ecolab technician to come back to fix the machine. 4. Review of the facility's P&P titled Cold Storage Temperature Monitoring and Record Keeping dated 2023 showed the following: - Food & Nutrition Services staff shall review and record temperatures of all the refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. - Food & Nutrition Services staff will record and initial the temperatures on the Healthcare Menu Direct, LLC.'s Clod storage Temperature log at the beginning of the AM and PM shifts. On 3/27/25 at 0835 hours, an interview and concurrent facility document review was conducted with [NAME] 1 and the RD. [NAME] 1 was asked when the temperatures for the resident dining room refrigerator were recorded. [NAME] 1 stated the temperatures were recorded in the morning. Review of the form titled Resident Dining Room Refrigerator Temperature Log for March 2025 failed to show a recorded temperature for the dining refrigerator for 3/27/25. The RD and [NAME] 1 verified the findings. Review of the form titled Resident Dining Room Refrigerator Temperature Log dated February and March 2025 failed to show a recorded temperature for the PM shift. The RD and [NAME] 1 were asked where the PM shift temperatures were being recorded. The RD verified the staff have not been recording the temperatures on the temperature log for the evening shift. On 3/28/25 at 1117 hours, the DON and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555027 If continuation sheet Page 30 of 30