Health inspection·July 8, 2025

F 0684 Further review of Resident 1's Progress Notes showed the following nursing entries: Level of Harm - Minimal harm or potential for actual harm - dated 7/5/25 at 1031 hours, documenting the 72-hour monitoring status post suspected victim of physical abuse. Residents Affected - Few - dated 7/6/25 at 0443 hours, documenting Resident 1 was received in bed with no distress noted. Resident 1 was on the monitoring for refusing medications, no episodes noted at this time, resting well, no complaints of pain or discomfort, all needs attended to. - dated 7/6/25 at 1504 hours, documenting Resident 1 was on monitoring for refusal of medications, and had no episodes observed at this time . Continued monitoring will be maintained. - dated 7/8/25 at 0347 hours, documention showed the resident was currently on monitoring for a skin tear on the left forearm with no active bleeding. Further review of Resident 1's Progress Notes failed to show the licensed nurse's entries documenting the monitoring of Resident 1 on 7/6/25 during the 1900 to 0700 hours shift, and on 7/7/25 during the 0700 to 1900 hours shift. Inaddition, review of Resident 1's medical record failed to show the change of condition assessment was initiated when Resident 1 made an allegation of abuse on 7/4/25. On 7/8/25 at 1130 hours, a phone interview was conducted with LVN 2. LVN 2 stated the change of condition assessment was initiated whenever there was a change from the baseline in the resident's condition. LVN 2 stated when there was a change of condition, the change of condition assessment should be completed to ensure the licensed nurses would follow up and monitor the resident every shift for 72hours. LVN 2 stated a resident's allegation of physical abuse was considered a change of condition for the resident. LVN 2 stated on 7/5/25, she was informed by CNA 2 of her concern of suspected abuse towards Resident 1. LVN 2 stated she did not complete the change of condition assessment for Resident 1 following the allegation of physical abuse and only documented in Resident 1's progress notes. LVN 2 stated the change of condition assessment should have been completed for the resident's allegation of physical abuse to ensure Resident 1 was monitored. On 7/8/25 at 1250 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked about the facility's protocol for an allegation of abuse. The DON stated for the allegation of abuse, the licensed nurse was responsible for completing the facility's internal incident report, the change in condition assessment, and developing a care plan. The DON stated for the abuse victim, a change of condition assessment should be completed, and the resident should be monitored for emotion distress by the licensed nurses, every shift for 72 hours. The DON reviewed Resident 1's medical record and verified the above findings. The DON stated a change of condition assessment for Resident 1's allegation of abuse by the CNA was not completed. On 7/8/25 at 1426 hours, a follow-up interview was conducted with the DON. The DON stated a change of condition was any situation outside of the resident's normal status or baseline. The DON stated when there was a change in condition for a resident, the facility's protocol was to assess the resident and inform the physician and resident's responsible party of the change in condition. The DON stated the documentation for a change in the resident's condition included completing a change of condition assessment. The DON stated the purpose of a change of condition assessment was to ensure the problem would be addressed. The DON further stated the change of condition assessment would initiate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555751 If continuation sheet Page 2 of 5 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 555751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newport Subacute Healthcare Center 2570 Newport Blvd Costa Mesa, CA 92627 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 the monitoring of the resident on every shift for 72 hours. The DON stated an allegation of abuse was considered a change in condition. On 7/8/25 at 1530 hours, the Administrator and DON were informed and acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555751 If continuation sheet Page 3 of 5 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 555751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newport Subacute Healthcare Center 2570 Newport Blvd Costa Mesa, CA 92627 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 one of three sampled residents (Resident 2) was free from the unnecessary medications. Residents Affected - Few * The facility failed to follow the physician's order to hold the midodrine (blood pressure support) medication when Residents 2's SBP was greater than 120 mmHg. This failure had the potential for Resident 2 to develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber's orders, including any required time frame. The following information is checked/verified for each resident prior to administering the medications: a. allergies to medications; and b. vital signs, if necessary. Medical record review for Resident 2 was initiated on 7/7/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's plan of care showed a care plan problem dated 5/13/25, addressing Resident 2's hypotension. The interventions showed to administer midodrine 10 mg as ordered. Review of Resident 2's Order Summary Report dated 7/8/25, showed a physician's order dated 5/12/25, to administer midodrine 10 mg by mouth every 12 hours for hypotension and hold the medication for the SBP greater than 120 mmHg. Review of Resident 2's MAR for 6/2025 and 7/2025 showed documentation Resident 2 was administered midodrine 10 mg on the following dates and times when Resident 2's SBP was greater than 120 mmHg: - On 6/1/25 at 0900 hours, when Resident 2's SBP was 121 mmHg. - On 6/11/25 at 2100 hours, when Resident 2's SBP was 122 mmHg. - On 6/18/25 at 0900 hours, when Resident 2's SBP was 122 mmHg. - On 6/28/25 at 0900 hours, when Resident 2's SBP was 121 mmHg. - On 7/4/25 at 0900 hours, when Resident 2's SBP was 122 mmHg. - On 7/5/25 at 2100 hours, when Resident 2's SBP was 132 mmHg. On 7/8/25 at 1130 hours, a telephone interview was conducted with LVN 2. LVN 2 stated for the administration of the BP medications to the residents, the licensed nurse would check the resident's BP prior to administering the BP medication. LVN 2 stated if the BP reading was within the parameters as ordered by the physician, LVN 2 would then administer the medication. LVN 2 stated if the BP reading was outside of the ordered parameters, the medication would be held. LVN 2 further stated after the administration of the medication, she would document in the MAR. When asked, LVN 2 stated a check (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555751 If continuation sheet Page 4 of 5 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 555751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newport Subacute Healthcare Center 2570 Newport Blvd Costa Mesa, CA 92627 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 0757 mark in the MAR indicated the medication was administered to the resident on the indicated date and time. Level of Harm - Minimal harm or potential for actual harm On 7/8/25 at 1324 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON stated for the administration of the BP medications, the licensed nurse should check the physician's order to determine if there were any BP parameters. The DON stated if there were ordered BP parameters, the licensed nurse was expected to obtain the resident's BP and administer the BP medication if the BP reading was within the ordered parameters. The DON further stated after the administration of the medication, the licensed nurse was expected to document the medication administration in the MAR. The DON stated the check marks in the MAR indicated the medication was administered to the resident. The DON reviewed Resident 2's medical record and stated Resident 2 was administered the midodrine medication for low BP. The DON reviewed Resident 2's MAR for 6/2025 and 7/2025 and verified the above findings. The DON stated the midodrine medication should have been held on the above dates and times for the documented SBP readings. Residents Affected - Few On 7/8/25 at 1530 hours, the Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555751 If continuation sheet Page 5 of 5