Health inspection·January 9, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 7 was initiated on 12/27/23. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's History and Physical examination dated 2/6/23, showed Resident 7 had the capacity to understand and make decisions. Residents Affected - Few Review of Resident 7's MDS dated [DATE], showed Resident 7 was cognitively intact and Resident 7 required maximum assistance for her toileting needs. b. On 12/7/23 at 1438 hours, a concurrent observation and interview was conducted with the Resident 8. Resident 8 was observed lying in the bed. Resident 8 stated the facility staff took more than an hour to respond to her call light. Resident 8 stated that happened most of the time when she called. Medical record review for Resident 8 was initiated on 12/27/23. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 was cognitively intact and Resident 8 had impairment to both sidesof her upper and lower extremity. Further review of the MDS showed Resident 8 required moderate assistance for her activities of daily living. c. On 12/28/23 at 1000 hours, a concurrent observation and interview was conducted with Resident 3. Resident 3 was observed standing by the bedside. Resident 3 stated sometimes during the night shift, she pressed the call light for assistance for water, ice, or medication. Resident 3 stated she was feeling upset because they came in and turned off the call light without attending to her needs. Resident 3 stated she had witnessed her roommate using the call light to be changed after having a bowel movement, but the staff did not come for a long time. Resident 3 stated she would have to walk outside to find the nurse. Medical record review for Resident 3 was initiated on 12/28/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's History and Physical examination dated 4/15/23, showed Resident 3 had capacity to understand and make decisions. d. On 12/28/23 at 0930 hours, a concurrent observation and interview was conducted with Resident 9. Resident 9 was observed sitting up in bed with head of bed elevated 60 degrees. Resident 9 stated sometimes at night shift, she had waited about one hour after pressing the call light and the nurse came in and turned the call light off before attending her needs. Resident 9 felt upset about it and stated she needed assistance to be changed and cleaned after a bowel movement. Medical record review for Resident 9 was initiated on 12/28/24. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE] showed for toileting hygiene, Resident 9 was dependent. Helper did all the effort and Resident 9 did none of effort to complete the activity. e. On 1/3/24 at 1400 hours, a concurrent observation and interview was conducted with Resident A. Resident A was observed sitting upright in the bed with both heels elevated with the pillow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 2 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St 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 0558 Level of Harm - Minimal harm or potential for actual harm Resident A stated when they called the nurse for assistance, Resident A would have to wait more than an hour during the night shift to be changed because the nurse was busy taking care of another resident. Medical record review for Resident A was initiated on 1/3/24. Resident A was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident A's MDS dated [DATE] showed for toileting hygiene, Resident A needed substantial or maximal assistance. The helper did more than half the effort. f. On 1/3/24 at 1500 hours, a concurrent observation and interview was conducted with Resident B. Resident B was sitting up in the wheelchair in front of the room. Resident B stated once a while, she turned on the call light because she needed help to change diaper in bed or assistance to go to the bathroom and would need to wait 30 minutes or more for assistance. Medical record review for Resident B was initiated on 1/3/24. Resident B was admitted to the facility on [DATE]. Review of Resident B's care plan dated 4/16/21 showed a care plan problem addressing at risk for bowel/bladder incontinence related to disease process, impaired mobility, and advance age. The intervention included to encourage fluids during the day, to promote prompted voiding responses, and ensure an unobstructed path to the bathroom. g. On 1/3/24 at 0930 hours, a concurrent observation and interview was conducted with Resident C and Resident C's family member. Resident C was observed lying on her back in bed and had a suprapubic catheter. Resident C and Resident C's family member stated during the night shift, Resident C needed help getting their diaper changed or the catheter emptied but sometimes waited 30 minutes to one hour. Resident C stated feeling sad about it because the nurse was so busy with other residents. Medical record review for Resident C was initiated on 1/3/24. Resident C was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident C's care plan dated 11/30/23 showed the resident's risk for bowel/bladder incontinence related to activity intolerance, confusion, dementia, impaired mobility, medication side effects, and benign prostate hyperplasia (enlargement of prostate gland). The intervention included the use of disposable briefs; change every 2hrs and as needed; check as required for incontinence; and wash, rinse and dry perineum. On 1/4/24 at 1515 hours, an interview was conducted with LVN 10. LVN 10 stated during the night shift on the weekend, sometimes the facility was short of CNAs because they called in sick or the registry CNA did not come. LVN 10 acknowledged if multiple residents pressed their call lights at the same time, it could be overwhelming for the CNA to attend to all the resident needs. There was a time when a CNA spend long time with one resident who needed total assistance. On 1/4/24 at 1530 hours, an interview was conducted with CNA 3. CNA 3 stated there were a couple times when they were short at night because the registry CNA did not come in. There was a challenging time when one resident called for medicine, another resident called for a diaper change, and another resident needed other assistance at same time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 3 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On 1/5/24 at 0954 hours, a concurrent observation and interview was conducted with Resident 2. Resident 2's call light was observed hanging on the wall towards the head of the bed. When asked if Resident 2 could reach the call light, Resident 2 was observed attempting to reach the call light. Resident 2 then stated he was not able to reach the call light. Resident 2 further stated he had a concern with the facility's call light response time. He stated the facility staff took 20 minutes to 2 hours to respond to the call light. When asked how Resident 2 knew the time, Resident 2 stated he looked at the clock on the wall to check the time. Resident 2 stated he needed staff assistance for his activities of daily living and felt frustrated when the staff did not answer the call light timely. On 1/5/24 at 1004 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 verified the above observation and stated Resident 2's call light was not within reach of Resident 2. LVN 2 stated Resident 2 required staff assistance for his activities of daily living so the call light should have been within reach. Review of Resident 2's medical record was initiated on 1/5/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's History and Physical examination dated 12/8/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact and required moderate to maximum assistance for his activities of daily living. On 1/5/24 at 1203 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 4 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual activity needs for one of 14 sampled residents (Resident 2). This failure posed the risk of not providing individualized activities to the residents. Findings: Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed it isthe policy of the facility that the IDTshall develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Under the procedure section showed the care plan is developed by the IDT which included but not limited to following professionals: a. Attending physician; b. Registered nurse responsible for resident; c. Dietary supervisor/dietitian; d. Social services staff member responsible for the resident; e. Activity staff member responsible for the resident; f. Rehabilitation specialist physical occupational, and/or speech therapist as indicated; g. Consultants (as appropriate); h. Director of Nursing services; i. Nursing assistant responsible for resident care; and, j. Others as necessary or indicated. On 1/5/24 at 0954 hours, a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed lying in bed with the television on. Resident 2 stated he was bored watching television the whole day and almost every day. Resident 2 stated he did not want to go to the group activities and was not provided the activities he could do in his room other than watching television. Medical record review for Resident 2 was initiated on 1/5/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact and required moderate to maximum assistance for his activities of daily living. The MDS further showed it was very important for Resident 2 to participate in his favorite activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 5 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 2's Care Plan showed no documented evidence of a care plan problemto address the activity needs of Resident 2. On 1/5/24 at 1049 hours, a concurrent interview and medical record review of Resident 2 was conducted with the Activity Director. The Activity Director verified a care plan problemaddressing activity needs of Resident 2 was not initiated. The Activity Director stated she did the activity needs assessment for Resident 2; however, she did not get chance to initiate the care plan. The Activity Director stated a personalized care plan addressing the activity needs for Resident 2 should have been initiated. On 1/5/24 at 1203 hours, a concurrent interview and medical record review for Resident 2 was conducted with the DON. The DON verified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 6 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of 14 sampled residents (Resident 9). Residents Affected - Few * The facility failed to ensure Resident 9 received the protein supplement as ordered by the physician two times a day. This had potential for not providing necessary care and services to meet the care needs for this resident and medical complication. Findings: Review of the facility's P&P titled Medication Administration, undated, showed if a dose of a regularly scheduled medication is held, refused, or given at a time other than the prescribed time, that particular dose on the medication sheet is to be circled, and an explanation is to be offered on the back of the medication sheet. If doses of any medication are refused for more than three (3) consecutive days, or if the refusal of one dose could cause or has caused further deterioration in the resident's clinical condition, the attending physician is to be notified. Medical record review for Resident 9 was initiated on 12/28/24. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Physician Order Summary Report dated 11/6/23, showed to give Prostat (protein supplement) 30 ml with med pass as part of fluid restriction two times a day. Review of Resident 9's MAR for November 2023 showed Resident 9 did not receive Prostat on 11/6, 11/8, 11/10, 11/13, 11/15, 11/17, 11/22, 11/23, 11/24, and 11/30/23 at 1700 hours. Review of Resident 9's MAR for December 2023 showed Resident 9 did not receive Prostat on 12/4, 12/6, 12/8, 12/11, 12/13, 12/15, 12/18, 12/22, 12/24, and12/27/23 at 1700 hours. Review of Resident 9's care plan problem dated 10/28/23, showed the resident'snutritional problem or potential nutritional problem related to on a therapeutic diet, admitted with multiple wounds and pressure injury, edema, infection, on dialysis and increase needs (Kilocalories/Protein) related to end stage renal disease or hemodialysis, risk of alternate skin integrity. The intervention included to administer the medications as ordered. On 12/28/23 at 0930 hours, an interview was conducted with Resident 9. Resident 9 stated sometimes she was getting the protein supplement one time a day but knew she should get two times a day. She could not recall what day she was getting once a day. On 1/9/23 at 1330 hours, a concurrent medical record review and interview with the DON was conducted. The DON was asked if the Prostat was given for those dates at 1700 hours. TheDON stated the resident went out to dialysis and the supplement was heldor not administered. The DON was asked if the nurse informed the physician if they hadbeen held or not administered the supplement due to the resident out to dialysis. The DON was unable to provide the documentation and verified the finding. On 1/9/23 at 1400 hours, a concurrent medical record review and interview was conducted with LVN 4. LVN 4 was asked if Resident 9 received the Prostat on dialysis days at 1700 hours. LVN 4 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 7 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St Huntington Beach, CA 92648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete sometimes Resident 9 came back from the dialysis center around 1900 hours, and LVN 4 had already been off work. LVN 4 stated the medication was being held or not administered because not within the range of one hour after 1700 hours. LVN 4 stated if Resident 9 came back fromdialysis around 1800 hours, she would administerthe Prostat. LVN 4 was asked if the physician had been informed Resident 9 might miss the dose scheduled at 1700 hours due to dialysis. LVN 4 stated she was not sure about it. LVN 4 verified the finding. Event ID: Facility ID: 555249 If continuation sheet Page 8 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the RNA services to seven of 14 sampled residents (Residents 2, 9, 10, 11, 12, 13,and 14) as ordered by the physician. This failure had the potential for the resident's decline in ROM functions and deterioration in their ability to perform ADL care. Findings. Review of the facility's P&P titled ROM (range of motion) and Contracture Prevention revised 5/2019 showed the facility is to ensure that resident receive services, care, and equipment to assure that every resident maintains, and/or improves to his/her highest level of range of motion and mobility, unless reduction is clinically unavoidable. Under the procedure section showed an interdisciplinary care plan is developed to maintain or increase joint mobility, the implementation of the program was carried out by the appropriate personnel in skilled rehab, routine therapy, restorative nursing, or CNA staff. 1. Medical record review for Resident 2 was initiated on 1/5/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident 2 had impairment to one side of upper extremity (shoulder, elbow, wrist, and hand). Review of Resident 2's Physician Order Summary showed an order dated 12/6/23, for RNA to perform the AROM and AAROM exercisesto the BUE/LUE three times a week as tolerated. Review of Resident 2's Care Plan dated 12/6/23, showed a care plan problem addressing Resident 2's limited physical mobility. The interventions included for the RNAs to perform the AROM/AAROM exercises three times a week as tolerated. Review of Resident 2's Documentation Survey Report from 12/22/23 to 1/5/24, for RNA services showed Resident 2 received RNA services on 12/22, 12/27,and 1/5/24. Further review of the document showed Resident 2 did not receive the RNA services on 12/25, 12/29/23, and 1/1/24. On 1/5/24 at 1128 hours, an interview with RNA 4 was conducted. RNA 4 stated some days, the facility was short of RNAs and sometimes, they got reassigned to be CNAs to care for the residents. RNA 4 stated when the facility was short of RNAs, she could not provide the RNA services to the residents in the facility. On 1/5/24 at 1203 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above findings and stated Resident 2 had missed three RNA services from 12/22/23 to 1/5/24. 2. On 12/28/24 at 0930 hours, Resident 9 was observed sitting up in bed. Resident 9 stated she did not get the exercise all the time and they had been missing her exercise. Medical record review for Resident 9 was initiated on 12/28/24. Resident 9 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 9 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St 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 0688 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 9's Physician Order Summary Report showed an order dated 11/4/23, showed the RNAs to assist the resident with the AROM exercises to the BUE and BLE three times per week as tolerated. Residents Affected - Few Review of Resident 9's Documentation Survey Report for December 2023 and January 2024 for RNA services showed Resident 9 did not receive the RNA services on 12/7,12/16, 12/23, 12/30/23 and 1/2/24. Review of Resident 9's Care Plan dated 10/28/23, showed a care plan problem addressing Resident 9's ADL self-care performance deficits related to impaired mobility, disease process, bilateral hand deformities. The interventions included the RNAs to assist the resident with the AROM BUE/BLE exercises three times per week as tolerated. 3. Medical record review for Resident 10 was initiated on 12/28/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Documentation survey Report for December 2023 and January 2024 for RNA services showed Resident 10 did not receive the RNA services on 12/30/23 and 1/2/24. Review of Resident 10's Order Summary Report showed an order dated 12/27/23, for the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times a week as tolerated. Review of Resident 10's care plan dated 11/22/23 showed a care plan problem addressing Resident 10's ADL self-care performance deficits related to impaired mobility, infection, disease process. The intervention included the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times a week as tolerated. On 1/2/23 at 1130 hours, Resident 10 was observed sitting upright in bed on the air loss mattress. Resident 10 verbalized his concerns regarding exercises. He was aware he would not get the physical therapy services due to his insurance. He would like to receive the exercises routinely. He did not get exercises regularly and did not know what his schedule for the exercises was. 4. Medical record review for Resident was initiated on 1/3/24. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 11's Physician Order Summary Report showed an order dated 11/16/23, for the RNAs to assist the resident with ambulation three times per week as tolerated with the Pivot Front Walker. Review of Resident 11's Documentation Survey Report for December 2023 and January 2024 for the RNA services showed Resident 11 did not receive the RNA services on 12/17, 12/24, 12/31/23, and 1/2/24. On 1/4/24 at 1015 hours, Resident 11 was sitting upright in bed. Resident 11 had verbalized the concerns regarding his RNA services. Resident 11 stated they had been missing coupled times last month and did not do it because the staff told him that they were understaff. 5. Medical record review for Resident 12 was initiated on 1/3/24. Resident 12 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 10 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 12's Documentation survey Report for December 2023 and January 2024 for the RNA services showed Resident 12 did not receive the RNA services on 12/12, 12/17, 12/24, 12/31/23, and 1/2/24. Review of Resident 12's Physician Order summary report showed an order dated 6/10/23, for the RNAs to assist the resident with ambulation with a front wheel walker three times per week as tolerated. Review of Resident 12's care plan showed a care plan problem addressing Resident 12's ADL self-care performance deficits related to disease process, impaired mobility, impaired cognition, weakness. The intervention included the RNAs to assist the resident with ambulation with a front wheeled walker three times per week as tolerated. 6. Medical record review for Resident 13 was initiated on 1/3/24. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's Documentation Survey Report for December 2023 and January 2024 for the RNA services showed Resident 13 did not receive the RNA services on 12/17, 12/24, 12/31/23 and 1/2/24. Review of Resident 13's Physician Order Summary report showed an order dated 1/4/24, for the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times per week as tolerated. Review of Resident 13's care plan dated 11/9/23, showed a care plan problem addressing ADL self-care performance deficits related to impaired mobility, infection, disease process. The intervention included the RNAs to assist the resident with the AAROM exercises to the BUE/BLE three times per week as tolerated. 7. Medical record review for Resident 14 was initiated on 1/3/24. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Documentation Survey Report December 2023 and January 2024 for the RNA services showed Resident 14 did not receive the RNA services on 12/16, 12/30/23 and 1/2/24. Review of Resident 14's Physician order summary report showed an order dated 2/8/23, for the RNAs to assist the resident with the PROM exercises to the BUE/BLE three times per week as tolerated. Review of Resident 14's MDS dated [DATE], showed Resident 14 had impairment to the BUE and BLE. Review of Resident 14's care plan dated 2/8/23 showed a care plan problem addressing ADL self-care performance deficits related to medical condition. The intervention included the RNAs to assist the resident with the PROM exercises to the BUE/BLE three times per week as tolerated. An interview and concurrent medical record review was conducted with RNA 3 on 1/3/23 at 0900 hours. RNA 3 stated on Monday 1/1/23, RNA 3 knew there were no RNAs. RNA 3 stated they only had one RNA, but they pulled her to work on the floor as a CNA. RNA 3 stated there were no RNAs on 12/30 and 12/31/23. RNA 3 was asked if they provided the RNA services for those dates for Residents 9, 10, 11, 12, 13, and 14. RNA 3 acknowledged there were no RNA services on those dates and verified the findings. An interview was conducted with RNA 1 on 1/3/24 at 1530 hours. RNA 1 stated on 1/2/23, RNA 1 was only one RNA on the floor for 46 residents. RNA 1 stated she was trying to catch up for doing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555249 If continuation sheet Page 11 of 12 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 555249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Cliff Healthcare Center 18811 Florida St 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete weekly or monthly weights and the PT helped her with the residents needing the RNA services for ambulation. RNA 1 stated there was not enough time to do the RNA services for all scheduled residents. RNA 1 stated they worked eight hours shifts and must provide the RNA services to 46 residents, each service needing 10 to 15 minutes for each exercise. An interview and concurrent medical record was conducted with RNA 2 on 1/4/24 at 1250 hours. RNA 2 stated they did not have RNAs on 12/5, 12/30, 12/31/23, 1/1, and 1/2/24. RNA 2 also stated there were no RNAs on 12/16, 12/17, 12/24, and 12/25/23. RNA 2 was asked regarding the missing entries for the RNA services for Residents 9, 10, 11, 12, 13, and 14. RNA 2 acknowledged RNA services was not provided. If the residents refused, they should have documented it. RNA 2 verified the findings. Event ID: Facility ID: 555249 If continuation sheet Page 12 of 12