Stanley Healthcare Center

F-F700, example #4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 555651

F-F756.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35346 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Some the facility failed to ensure the infection control practices were followed and implemented as evidenced by:

* Residents 2, 6, 9, 18, and 22's physicians were not notified when the residents' infections did not meet the McGeer's criteria.

* The facility failed to ensure Resident 627 had contact isolation precautions in place due to the clostridium difficile infection.

* The Infection & Control Surveillance Log of Infections for February 2025 was inaccurate. Resident 627's CAI infection was not included in the log.

* The blood pressure wrist machine used for the residents did not have a cleanable surface (Velcro with cloth material).

* The facility failed to ensure the hospice licensed staff practiced EBP when providing wound care treatment for Resident 20 who was on the EBP.

* CNA 3 did not wear gown when provided dressing and hygiene to Resident 7 who was on the EBP.

These failures posed the risk of transmitting infections and not accurately tracking the infections and appropriate antibiotic use.

Findings:

1. On 3/5/25 at 0923 hours, an interview, medical record review, and concurrent facility document review of

the facility's Infection Control Program was conducted with the DSD/IP.

a. Review of the facility's Infection Surveillance Monthly Report for January 2025 was conducted with the DSD/IP. The DSD/IP stated the report was used to track and report about the infections for January 2025.

The DSD/IP verified the report failed to show how many residents did not meet the McGeer's criteria. Further

review of the Infection Surveillance Monthly Report for January 2025 with the DSD/IP showed Residents 9, 18, and 22's physicians were not notified the residents' infections did not meet the McGeer's criteria.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 b. When asked about the total CAIs in the facility, the DSD/ IP stated there were a total of two CAIs. However, during review of the facility's Infection & Control Surveillance Log for February 2025 with the Level of Harm - Minimal harm or DSD/IP, the DSD/IP verified the log failed to include Resident 627's infection. Further review of Resident potential for actual harm 627's medical record with the DSD/IP showed Resident 627 was readmitted to the facility on [DATE REDACTED], with a diagnoses of clostridium difficile infection. The DSD/IP stated Resident 627 was to have contact isolation Residents Affected - Some precautions in place. The DSD/IP verified Resident 627 did not have a signage outside of her room to indicate the resident was on contact isolation precautions. Review of Resident 627's bowel elimination documentation with the DSD/IP showed Resident 627 had a total of 10 loose/diarrhea episodes in February 2025 and a total of five loose/diarrhea episodes in March 2025. The DSD/IP stated the CNAs were inaccurately documenting Resident 627's bowel movements. The DSD/IP acknowledged Resident 627's clostridium difficile infection should have been documented in the February 2025 Infection & Control Surveillance Log.

Further review of the February 2025 Infection & Control Surveillance Log with the DSD/IP showed Residents 2 and 6's physicians were not notified when the residents' infections did not meet the McGeer's criteria.

52251

2. Review of the facility's P&P titled Cleaning and Disinfection of Environmental Surfaces revised August 2019 showed all non-critical surfaces are to be disinfected with an EPA registered intermediate or low level hospital disinfectant according to the labels safety precautions and use directions.

Review of the Medline Micro-Kill Two germicidal wipes manufacturer guidelines showed the wipes are used

on hard, non-porous surfaces and equipment made of stainless steel, plastic, Formica (laminate material made of paper and synthetic resins) and glass.

On 3/4/25 at 0816 hours, a medication administration observation was conducted with LVN 1 for Resident 8. LVN 1 was observed using a wrist BP cuff with Velcro and cloth material closure to assess Resident 8's BP.

After obtaining the resident's BP reading, LVN 1 used the Micro-Kill wipes to disinfect the wrist BP cuff

before using it for the next resident.

On 3/4/25 at 0919 hours, a medication administration observation was conducted with LVN 2 for Resident 3. LVN 2 was observed using a wrist BP cuff with Velcro and cloth material closure to assess Resident 3's BP. LVN 2 then used the Micro-Kill wipes to disinfect the wrist BP cuff.

On 3/4/25 at 1015 hours, an interview was conducted with LVN 2. LVN 2 verified the Micro-Kill wipes was only for non-porous surfaces and it was inappropriate to use on the porous material of the wrist BP cuff.

On 3/4/25 at 1025 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified

the wrist BP cuff had a cloth fabric material. LVN 1 was informed and acknowledged the Micro-Kill wipes manufacturer's guideline showed to use the wipes for hard, non-porous surface. LVN 1 verified the disinfectant wipes were not appropriate to disinfect the Velcro/cloth material on the BP cuff. LVN 1 stated the facility had an electronic BP machine, manual BP cuffs, and stethoscopes for the facility staff to use, which had a cleanable surfaces and materials. LVN 1 acknowledged the equipments with non cleanable materials was an infection control issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 43119

Level of Harm - Minimal harm or 3. According to the CDC, enhanced barrier precautions (EBP) are an infection control intervention designed potential for actual harm to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for the residents known Residents Affected - Some to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition.

Review of the facility's signage for Enhanced Barrier Precautions showed everyone must clean their hands, including before entering and when leaving the room. It also showed the providers and facility staff must wear gloves and gown for the following high-contact resident care activities: dressing, bathing/ showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing.

Review of the facility's P&P titled Enhanced Barrier Precautions dated 8/2022 showed Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of MDROs to

the residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/ or indwelling medical devices regardless of MDRO colonization.

Medical record review for Resident 20 was initiated on 3/3/25. Resident 20 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 20's H&P examination dated 8/22/24, showed Resident 20 had the capacity to understand and make decisions.

Review of Resident 20's plan of care showed a care plan problem addressing Resident 20's enhanced barrier precautions due to bilateral lower extremity open wound. An intervention dated 2/20/25, included to utilize PPE (gown, gloves, face shield as indicated) during high contact resident care activities.

On 3/3/25 at 1209 hours, Resident 20's room was observed with an enhanced barrier precaution signage posted by the door. The Hospice LVN was observed standing by the foot of the bed of Resident 20 and rendering wound care treatment. The Hospice LVN was observed wearing gloves but not wearing a gown.

On 3/3/25 at 1211 hours, an interview was conducted with the Hospice LVN. The Hospice LVN verified the above findings. The Hospice LVN verified there was a signage by Resident 20's door showing Resident 20 was on the EBP. The Hospice LVN stated she missed the sign and should have worn a gown to prevent cross contamination.

On 3/3/25 at 1220 hours, LVN 1 was informed of the above findings and stated the EBP signage was used to identify any open wound and the hospice staff should have worn the proper PPE for infection control purposes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 On 3/6/25 at 1013 hours, an interview was conducted with the DSD/IP. The DSD/IP acknowledged the above findings and stated the EBP included donning of gown, gloves, and mask for high contact activities such as Level of Harm - Minimal harm or wound care treatment to protect the resident from any MDRO and other infections. potential for actual harm 32179 Residents Affected - Some 4. Medical record review of Resident 7 was initiated on 3/3/25. Resident 7 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 7's Order Summary Report dated 3/1/25, showed a physician's order dated 2/18/25, to place the resident on the EBP due to an indwelling urinary catheter.

On 3/3/25 at 0830 hours, CNA 3 was observed assisting Resident 7 and handing a wet towel to the resident to wipe the resident's forehead and face. CNA 3 was observed not wearing a gown. In front of the resident's room door, a signage was observed indicating EBP and for the facility staff to wear a gown and gloves when providing direct care to the resident.

On 3/4/25 at 0805 hours, CNA 3 was observed touching and repositioning Resident 7, and picking up Resident 7's urinary catheter bag, without wearing a gown.

On 3/4/25 at 0830 hours, an interview was conducted with CNA 3. CNA 3 was informed of the above

observations when she was providing care to Resident 7 without wearing a gown. CNA 3 stated she knew

she needed to wear a gown but forgot to because she was rushing to assist the resident. CNA 3 verified the findings.

On 3/4/25 at 0900 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above findings and stated CNA 3 should have worn a gown and gloves in accordance with the EBP. LVN 1 verified Resident 7 had the EBP due to the presence of indwelling urinary catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 52238 potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure the essential Residents Affected - Few equipment was maintained in safe operating condition.

* The facility failed to ensure the quality control record for February and March 2025 reflected on the glucometer with the serial number 1040-4333929. This failure had the potential for the residents requiring glucose checks to have inaccurate readings.

Findings:

On 3/4/25 at 1339 hours, a concurrent review of the Assure Platinum Blood Glucose Monitoring System: Quality Control Record for February and March 2025 and inspection of the glucometer with the serial number 1040-4333929 was conducted with LVN 1. The log showed the glucometer quality control was completed for February and March 2025. However, when the glucose quality control results documented on the log were compared to the glucometer device's saved results (memory), it showed the glucose quality control results documented for 2/1 through 2/4, 2/6, 2/8 through 2/13, 2/16 through 2/20, 2/23 through 2/27, and 3/3/25, were not observed on the glucometer device. For example, the documented normal control result of 96 mg/dl and the high control result of 256 mg/dl documented on the log on 2/1/25, were not observed on the glucometer device.

LVN 1 verified the above findings.

On 3/5/25 at 0815 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43119

Residents Affected - Few Based on observation, interview, medical record review, facility document review, and facility P&P review,

the facility failed to ensure the residents' entrapment assessments were accurately completed for four of 12 final sampled residents (Residents 1, 12, 13, and 20). This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death.

Findings:

According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space

in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards.

The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:

- Zone 1: within the rail;

- Zone 2: under the rail, between the rail supports or next to a single rail support;

- Zone 3: between the rail and the mattress;

- Zone 4: under the rail, at the ends of the rail;

- Zone 5: between split bed rails;

- Zone 6: between the end of the rail and the side edge of the head or foot board; and

- Zone 7: between the head or foot board and the mattress end.

Review of the facility's P&P titled Proper Use of Side Rails revised date 12/2016 showed an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's:

- Bed mobility;

- Ability to change positions, transfer to and from bed or chair, and to stand and toilet;

- Risk of entrapment from the use of side rails; and

- That the bed's dimensions are appropriate for the resident's size and weight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 0909 Review of the facility's Bed Inspection Measurements dated 1/6/25, showed the bed numbers 13, 18, 19, and 26 were measured; however, the measurements for the bedframe lengths, mattress lengths, mattress Level of Harm - Minimal harm or heights, and zones pass or fail assessments were inaccurate. potential for actual harm 1. On 3/3/25 at 0907 hours, during the initial tour of the facility, Resident 13 was asleep in bed with the Residents Affected - Few bilateral half side rails elevated at the head of the bed.

On 3/4/25 at 0836 hours, Resident 13 was observed lying in bed with the bilateral half side rails elevated.

Medical record review for Resident 13 was initiated on 3/3/25. Resident 13 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 13's plan of care showed a care plan intervention dated 12/16/24, to use the bilateral half side rails to maximize independence with turning and repositioning in bed.

Review of Resident 13's H&P examination dated 2/20/25, showed Resident 13 had a diagnosis of Alzheimer's disease and had the capacity to understand and make decisions.

Cross reference to

F-F909, example #4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52251

Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide

the pharmaceutical services to ensure the accurate administration of medications for one of three residents (final sampled resident, Resident 8) observed for medication administration when:

* LVN 1 failed to assess Resident 8's bowel status prior to administering a laxative (promotes bowel movements) medication as per the physician's order. This failure had the potential to negatively affect the resident's health conditions that could posed the risk for possible complications.

Findings:

Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with the prescriber orders.

On 3/4/25 at 0816 hours, a medication administration observation for Resident 8 was conducted with LVN 1. LVN 1 prepared and administered Resident 8's medications which included polyethylene glycol (laxative) powder 17 gm and Senna (laxative) 8.6 mg. LVN 1 administered the polyethylene glycol and Senna medications without assessing the resident's bowel status or checking the resident's medical record for her bowel elimination.

Medical record review for Resident 8 was initiated on 3/4/25. Resident 8 was readmitted to the facility on [DATE REDACTED].

Review of Resident 8's H&P examination dated 4/27/24, showed the resident could make her needs known but could not make medical decisions.

Review of Resident 8's Order Summary Report showed the following physician's orders:

- dated 10/17/24, to administer polyethylene glycol 3350 oral powder 17 gm/scoop by mouth one time a day for bowel management; and to hold for loose stool.

- dated 5/8/24, to administer Senna 8.6 mg one tablet by mouth two times a day for bowel management; and to hold for loose stool.

On 3/4/25 at 0852 hours, an interview and concurrent medical record review was conducted with LVN 1 for Resident 8. When asked if LVN 1 had assessed the resident's bowel status prior to administering the laxative medications, LVN 1 verified she did not assess Resident 8's bowel status or check the resident's medical

record for the resident's bowel elimination prior to administering the laxative medications. LVN 1 stated Resident 8 always wanted her laxatives and stool softeners.

On 3/5/25 at 0824 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) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52238

Residents Affected - Few Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's identified drug recommendations were addressed for two of 12 final sampled residents (Residents 1 and 17). This failure posed the risk for the residents to have adverse consequences related to their medications.

Findings:

Review of the facility's P&P titled Medication Regimen Review revised 5/19 showed:

- The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.

- The attending physician documents in the medical record that the irregularity has ben reviewed and what (if any) action was taken to address it.

1. Medical record review for Resident 17 was initiated on 3/5/25. Resident 17 was admitted to the facility on [DATE REDACTED].

a. Review of Resident 17's Order Summary Report showed a physician's order dated 9/6/24, to administer Preparation H (temporarily relieve swelling, burning, pain, and itching caused by hemorrhoids) 0.25 mg per rectal every six hours for hemorrhoids.

Review of Resident 17's Consultant Pharmacist's Medication Regimen Review dated 12/9/24, showed if clinically feasible, please provide a duration of therapy for the Preparation H rectal ointment.

b. Review of Resident 17's Order Summary Report showed a physician's order dated 12/12/24, to administer Benadryl (antihistamine) 25 mg one tablet by mouth at bedtime for allergy/itching.

Review Resident 17's Consultant Pharmacist's Medication Regimen Review dated 1/16/25, showed the resident currently had an order for Benadryl 25 mg at bedtime for allergy/itching. The MRR further showed first generation antihistamines, such as Benadryl, possessed more anticholinergic and sedative effects than

the new agents. Consult with the physician if a change to a less sedating agent, such as Zyrtec (antihistamine), Allegra (antihistamine), or Claritin (antihistamine) would be feasible for Resident 17.

Further review of Resident 17's medical record failed to show the facility had addressed the Pharmacy Consultant's recommendations for the Preparation H and Benadryl medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 On 3/5/25 at 1013 hours, an interview was conducted with the DON. When asked about the facility's process for reviewing and addressing the Pharmacy Consultant's MRR recommendations, the DON stated she Level of Harm - Minimal harm or handed the MRR binder directly to the licensed nurse who then followed through and notified the physician potential for actual harm with the specific recommendation. The licensed nurse would then write done next to the recommendation once the recommendation was addressed. The DON verified when the recommendation was addressed with Residents Affected - Few the physician, whether the physician approved the recommendations or not, the licensed should document in

the resident's progress notes.

On 3/6/25 at 0900 hours, a follow-up interview was conducted with the DON. The DON provided her progress note documentation dated 3/6/25 at 0827 hours, which showed the LVN called Resident 17's hospice regarding the Consultant's Pharmacist's recommendation for the Preparation H medication for December 2024.

On 3/6/25 at 0925 hours, a follow-up interview was conducted with the DON. The DON provided LVN 2's progress note dated 3/5/25 at 1903 hours, which showed the hospice company providing services to Resdient 17 acknowledging the pharmacy recommendation for the Benadryl medication for January 2025.

The DON verified the pharmacy recommendations were followed up after she was informed by the surveyor for the pharmacy recommendations for December 2024 and January 2025 were not done for Resident 17.

32179

2. Medical record review for Resident 1 was initiated on 3/3/25. Resident 1 was admitted to the facility on [DATE REDACTED].

Review of the Note to Attending Physician/Prescribers dated 2/8/25, showed the CMS guidelines released

on 11/2017 indicated PRN psychotropic medications were now limited to 14 days. If the PRN psychotropic order needed to be extended beyond 14 days, it must be justified by the physician. Please evaluate the following order for a stop date: lorazepam (antianxiety medication) 2 mg/ml, administer 0.5 ml every four hours as needed for anxiety.

Further review of Resident 1's medical record failed to show documented evidence the facility had addressed

the pharmacy recommendations for the resident's lorazepam medication.

On 3/5/25 at 1210 hours, an interview and concurrent medical record review was conducted with the DSD/IP.

The DSD/IP stated the facility had followed up with the physician regarding the pharmacist's drug regimen

review recommendation for Resident 1's lorazepam medication. However, the DSD/IP acknowledged there was no documented evidence the pharmacy recommendation was followed up but assured the licensed nurses would contact the physician. The DSD/IP verified the above findings.

On 3/5/25 at 1430 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 was asked if Resident 1 had experienced shortness of breath or episodes of anxiety. LVN 2 stated in the last two months, she had not observed the resident experiencing anxiety and had not administered the lorazepam during the day shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 52251 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents Affected - Few the medication error rate was below 5%. The facility's medication error rate was 11.11%. Two of two licensed nurses (LVNs 1 and 2) observed during the medication administration were found to have made an errors.

* LVN 1 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 8. LVN 1 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per

the physician's order.

* LVN 2 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 3. LVN 2 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per

the physician's order. In addition, LVN 2 failed to administer Resident 3's vitamin B12 (supplement) medication as ordered.

These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications or delay in interventions.

Findings:

Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with prescriber orders, including any required time frames.

1. On 3/4/25 at 0816 hours, a medication administration observation for Resident 8 was conducted with LVN 1. LVN 1 prepared and administered Resident 8's medications, which included the polyethylene glycol powder 17 gm. LVN 1 was observed reconstituting the polyethylene glycol powder medication with five oz of water and administered it to the resident. LVN 1 verified she mixed the polyethylene glycol powder medication in a plastic cup with five oz of water. The plastic cup showed five oz on the bottom of the cup.

Review of Resident 8's Order Summary Report showed a physician's order dated 10/17/24, to administer polyethylene glycol 3350 powder 17 gm/scoop by mouth one time a day for bowel management, to mix with eight oz of water.

On 3/4/25 at 0852 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she reconstituted the polyethylene glycol medication in five oz of water because that was the size of

the plastic cup. LVN 1 verified Resident 8's physician's order for the polyethylene glycol medication showed to mix the medication with eight oz of water.

2. On 3/4/25 at 0919 hours, a medication administration observation for Resident 3 was conducted with LVN 2. LVN 2 prepared and administered Resident 3's medications, which included the polyethylene glycol powder 17 gm. LVN 2 was observed reconstituting the polyethylene glycol powder medication in five oz of water and administered it to the resident. LVN 2 verified she mixed the polyethylene glycol medication in a plastic cup with five oz of water.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 Review of Resident 3's Order Summary Report showed the following physician's orders:

Level of Harm - Minimal harm or - dated 6/30/24, to administer polyethylene glycol 3350 powder 17 gm/scoop by mouth one time a day for potential for actual harm bowel management, to mix with eight oz of water.

Residents Affected - Few - dated 9/11/24, to administer vitamin B12 100 mcg one tablet by mouth one time a day for supplement.

Review of Resident 3's MAR for March 2025 showed the vitamin B12 medication was administered on 3/4/24 at 0900 hours, along with the other medications.

However, during the medication administration observation with LVN 2, LVN 2 was not observed preparing and administering the vitamin B12 to Resident 3.

On 3/4/25 at 1015 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified she did not administer the vitamin B12 medication to Resident 3 during the medication administration observation. LVN 2 verified she signed Resident 3's MAR for the vitamin B12 as administered

on 3/4/25, along with the medications she administered during the medication administration observation. LVN 2 stated the medication was not availiable in the medication cart. In addition, LVN 2 verified Resident 3's physician's order for the polyethylene glycol medication showed to mix the medication in eight oz of water.

On 3/5/25 at 0815 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43119

Residents Affected - Some Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure

the sanitary requirements were met in the kitchen as evidenced by:

* The facility failed to ensure the microwave utilized to warm up the food was maintained in sanitary condition and free of food residue.

* The facility failed to ensure the sanitary condition of the hood over the stove was maintained.

* The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition.

* The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue.

* The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface.

These failures had the potential for cross contamination and foodborne illnesses to the residents consuming

the foods prepared in the facility's kitchen.

Findings:

Review of the facility's Diet Type Report dated 3/3/25, showed 23 of 23 residents consumed the foods prepared in the kitchen.

1. Review of the facility's P&P titled Sanitation dated 2023 showed 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.

According to the USDA Food Code 2022 Section 4-101.11, Multiuse, Characteristics, materials that are used

in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.

On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The kitchen microwave on a countertop shelf was observed to be dirty with white crumbs on the glass plate inside the microwave. The [NAME] verified the findings.

2. Review of the facility's P&P titled Hoods, Filters, and Vents dated 2023 showed the hoods must be cleaned every two weeks and must be free of dust and grease.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the Level of Harm - Minimal harm or food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that potential for actual harm are subjected to such drippage are no longer clean.

Residents Affected - Some On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The kitchen hood over the stove had black, dirt residue. The [NAME] acknowledged the findings and stated the dietary staff cleaned the hood once a week on Wednesdays and

the hood was also cleaned by an outside company. The sticker on the hood showed it was last serviced on 10/2024.

3. Review of the facility's P&P titled Sanitation dated 2023 showed 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. Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining.

According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded.

According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.

On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The following was observed and verified by the Cook:

- Two slotted scoops with black handles partially melted.

- Two scoops with black handles partially melted.

- One rubber spatula with red handle had chipped and cracked edges.

- Two stainless steel spatulas with discolored and partially melted handles.

- One stainless steel slotted spoon discolored with fuzzy film.

- One stainless steel tong with black rubber handle partially melted and worn out.

- One basting brush for butter had frayed bristles and worn out.

- One white plastic cheese grater worn out with cracked, chipped, and broken edges.

- Four stainless steel whisk with chipped and cracked rubber handles.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 The [NAME] acknowledged the above findings and stated the above items should have been replaced for infection control purposes. Level of Harm - Minimal harm or potential for actual harm 4. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, Residents Affected - Some the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The following was observed and verified by the Cook:

- Two scoops with black handles had dry water spots.

- One scoop with cream handle had fuzzy film and dry white crusted residue.

- Two scoops with blue handles had dry crusted residue.

- One scoop with white handle use for food portioning had fuzzy film.

- One scoop with green handle use for food portioning had dry crusted residue and fuzzy film.

- One scoop with blue handle use for food portioning had dry crusted residue and fuzzy film.

- One mesh strainer had dry crusted residue.

The [NAME] verified the above findings and stated all the dirty utensils should have been washed to prevent cross contamination.

5. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces.

On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The light brown, green, red, and yellow cutting boards were observed fuzzy, heavily marred and had deep groves. The [NAME] verified the findings and stated the cutting boards should have been changed and the facility had new ones to replace them.

On 3/5/25 at 1614 hours, an interview was conducted with the Dietary Supervisor. The Dietary Supervisor acknowledged all the above findings and stated the following:

- All the dirty utensils should have been sanitized to prevent the growth of bacteria and for infection control purposes.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 - The microwave should have been cleaned for infection control purposes.

Level of Harm - Minimal harm or - The chipped spatula should not be used because particles could fall and mixed in to the food. potential for actual harm - The basting brush should have been replaced to prevent the bristles from getting mixed with the food. Residents Affected - Some - The cutting boards were changed every three months and should have been replaced to prevent bacteria growth when not properly washed.

- The mesh strainer should have been washed properly for infection control purposes.

- The cheese grater should have been discarded and not used.

- The whisk should have been replaced.

- The hood over the stove was cleaned every six months and it was important to keep it clean to prevent dirt and grease from getting mixed with the food.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32179

Residents Affected - Few Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 1 and 13) reviewed for hospice services received the necessary care and services.

* The facility failed to ensure the hospice visit calendar was available in Resident 1's medical record and provide accurate documentation of the hospice staff visits for Resident 1. The facility also failed to ensure the care plan were updated and available in the resident's medical record.

* The facility failed to ensure the hospice visit calendar was available in Resident 13's medical record. Additionally, the facility failed to ensure a care plan was initiated for the hospice services provided for Resident 13.

These failures posed a risk of delayed communication and the provision of hospice care between the hospice provider and the facility.

Findings:

Review of the facility's P&P titled Hospice Program dated 7/2017 showed the facility has designated the DON to coordinate care provided to the resident by our facility staff and the hospice staff. She is responsible for the following:

- Obtaining the following information from the hospice: the most recent hospice plan of care specific to each resident, hospice election form, physician certification and recertification of the terminal illness specific to each resident.

- Ensuring that the facility staff provided orientation on the policies and procedures of the facility including the resident rights, appropriate form and record keeping requirements, to hospice staff furnishing care to the residents.

The P&P also showed the coordinated care plans for the residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

1. Medical record review for Resident 1 was initiated on 3/3/25. Resident 1 was admitted to the facility on [DATE REDACTED].

Review of Resident 1's Order Summary Report dated 3/4/25, showed a physician's order dated 8/28/24, to admit Resident 1 to the facility under Hospice Provider A.

a. Review of Resident 1's hospice binder did not show a calendar to indicate when the hospice staff would visit the resident for January, February, and March 2025.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 On 3/4/25 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked about the licensed nurse, social worker, and HA visits for January, February, and March 2025. Level of Harm - Minimal harm or LVN 1 was unsure and verified the hospice visit calendar was not in Resident 1's medical record. potential for actual harm

On 3/5/25 at 1430 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN Residents Affected - Few 2 was also unsure about Resident 1's hospice visit frequencies for January, February, and March 2025. LVN 2 verified the above findings.

b. Review of Resident 1's Order Summary Report dated 3/4/25, showed a physician's order dated 8/28/24, to have the skilled nursing visits twice per week and three PRN visits for symptom management or condition changes. The HA visits were ordered twice per week for personal hygiene, ADL care, and ROM exercises.

Review of the facility document titled CHHA Communication Sheet for January and February 2025 did not show the

documented HA visit entries as ordered twice a week. Further review of the communication sheet showed documented entries on 1/30, 2/4, 2/26, and 2/28/25.

On 3/5/25 at 1400 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DSD/IP. The DSD/IP was asked about the CHHA Communication Sheet for January, February, and March 2025. The DSD/IP was unable to provide the documentation to show the HA documented visits. The DSD/IP stated the HA should have documented their visits twice per week. The DSD/IP verified the above findings and stated Hospice Provider A's plan of care was followed.

c. Review of Resident 1's hospice binder showed a physician's certification for hospice benefits covering the period from 10/1 to 11/29/24. The most recent plan of care for hospice was dated October 2024.

On 3/5/25 at 1400 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DSD/IP. The DSD/IP was asked to show the latest physician certification and plan of care for hospice for Resident 1. The DSD/IP stated the last physician certification for hospice was on 11/29/24, and

the plan of care from Hospice Provider A dated October 2024 was available in the resident's medical record. However, review of Resident 1's medical record and hospice binder did not show for an updated physician certification for December 2024 to March 2025 and there was no current hospice care plan. The DSD/IP stated the facility's care plan should have been updated to include the hospice visits from the skilled nursing hospice staff, social worker, HA, and other hospice staff. The DSD/IP verified the above findings.

43119

2. Medical record review for Resident 13 was initiated on 3/3/25. Resident 13 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 13's H&P examination dated 2/20/25, showed Resident 13 had a diagnosis of Alzheimer's disease and had the capacity to understand and make decisions.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 Review of Resident 13's Order Summary Report for March 2025 showed a physician's order dated 2/20/25, to admit the resident to Hospice Provider A on routine level of care with a primary diagnosis of Alzheimer's Level of Harm - Minimal harm or disease. potential for actual harm

Review of the Resident 13's hospice binder did not show a calendar for January February, and March 2025 Residents Affected - Few to show the schedule when the hospice staff were visiting Resident 13.

Review of Resident 13's plan of care failed to show a care plan problem addressing Resident 13's hospice care services (focuses on improving the quality of life for individuals with terminal illnesses and their families by providing comfort, pain management, and emotional and spiritual support, rather than focusing on curing

the disease).

On 3/6/25 at 1117 hours, an interview and concurrent medical record review was conducted with the DSD/IP.

The DSD/IP was informed and acknowledged the above findings. The DSD/IP stated there should be a care plan to ensure the facility staff were aware of Resident 13's plan of care while receiving hospice care services.

On 3/6/25 at 1529 hours, a follow-up interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP stated there should be a calendar in placed to ensure the facility staff were aware when

the hospice staff were scheduled to visit the resident and to provide the hospice staff an update of Resident 13's condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 555651 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555651 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 32179

Residents Affected - Few Based on interview, facility document review, and facility P&P review, the facility failed to ensure the QAPI committee developed and implemented action plans to include monitoring the effectiveness of those plans in achieving and sustaining the improvement for a repeated deficient practice cited at