Inspection visit

InspectionMay 5, 2023

Q: What happened during the May 5, 2023 survey of STANLEY HEALTHCARE CENTER?

This was a inspection survey of STANLEY HEALTHCARE CENTER on May 5, 2023. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at STANLEY HEALTHCARE CENTER on May 5, 2023?

Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

STANLEY HEALTHCARE CENTERCMS #55565130 citations on this visit

30 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 30 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to one of 14 final sampled residents (Resident 729) and one nonsampled resident (Resident 25). Residents Affected - Few * Resident 729 had the Biofreeze gel (cooling menthol used to provide temporary pain relief) and Cool n' Heat roll on (topical liquid to help relieve minor aches and pains) at the bedside. Resident 729 did not have a physician's order to keep these medications at the bedside. * Resident 25 had the TheraHoney wound gel (healing gel used to speed up the healing of burns and wounds) at the bedside. Resident 25 did not have a physician's order to keep the medication at the bedside. These failures had the potential to negatively impact Residents 729 and 25's physiological well-being. Findings: Review of the facility's P&P titled Self-Administration of Medications revised February 2021 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy also showed self-administered medications are stored in a safe and secure place, which is not accessible by other residents. a. On 5/2/23 at 0812 hours, an observation and concurrent interview was conducted with Resident 729. Resident 729 was observed with the Biofreeze gel tube and Cool n' Heat roll on bottle at bedside. Resident 729 stated she applied the gel and roll on to her neck, shoulders, and hips for pain. Resident 729 stated the facility staff also helped her apply the gel and roll on to her back for pain. Resident 729 stated she had been self-administering the medications over a week and the nurses were aware. On 5/3/23 at 0746 hours, an observation and concurrent interview was conducted with Resident 729. Resident 729 was observed with the Biofreeze gel tube and Cool n' Heat roll on bottle at bedside. Resident 729 stated the physical therapist helped her applying them to her back for pain after her therapy sessions. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 61 Event ID: 555651 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0554 Level of Harm - Minimal harm or potential for actual harm Review of Resident 729's H&P examination dated 4/11/23, showed Resident 729 had the capacity to understand and make decisions. Review of the Self-Administration of Medications assessment dated [DATE], showed Resident 729 did not have evidence of cognitive and/or functional ability to safely self-administer medications. Residents Affected - Few Review of Resident 729's physician's orders failed to show the orders for the Biofreeze gel, Cool n' Heat roll on and self-administration of these medications. Review of Resident 729's plan of care failed to show a care plan problem was initiated or developed to address the resident's self-administration of the medications. On 5/3/23 at 0800 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 729 had the Biofreeze gel tube and Cool n' Heat roll on bottle at the bedside. LVN 1 stated she was not aware Resident 729 had the Biofreeze gel and Cool n' Heat roll on at bedside. LVN 1 stated Resident 729 could not have the medications at bedside. On 5/3/23 at 1154 hours, an interview was conducted with the CQA/IP. The CQA/IP verified Resident 729 did not have the physician's orders for the Biofreeze gel, Cool n' Heat roll, on and self-administering the medications. The CQA/IP verified Resident 729 did not have a care plan for self-administration of the medications. The CQA/IP stated Resident 729 should not have kept the medications at the bedside. On 5/4/23 at 0842 hours, an interview was conducted with the PTA. The PTA stated she applied the Biofreeze gel and Cool n' Heat roll on to Resident 729's back before and after the resident's therapy session when Resident 729 requested for it. The PTA stated she did not inform the nurses because the Biofreeze and Cool n' Heat roll on were over the counter items and she did not consider them as medications. On 5/5/23 at 1139 hours, an interview was conducted with the Pharmacist. The Pharmacist stated the Biofreeze gel and Cool n' Heat roll on contained menthol, which considered as a medication. On 5/4/23 at 1325 hours, an interview was conducted with the DON. The DON verified Residents 729 did not have the physician's order and care plan problem addressing the self-administration of the medications. b. On 5/2/23 at 0833 hours, an observation and concurrent interview was conducted with Resident 25. Resident 25 was observed with the TheraHoney wound gel at the bedside. Resident 25 stated the facility staff helped her apply the wound gel to her legs. On 5/3/23 at 0755 hours, an observation was conducted with Resident 25. Resident 25 was observed with the TheraHoney wound gel at the bedside. Medical record review for Resident 25 was initiated on 5/2/23. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 3/11/23, showed Resident 25 had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 2 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0554 Level of Harm - Minimal harm or potential for actual harm Review of the Self-Administration of Medications assessment dated [DATE], showed the resident did not have evidence of cognitive and/or functional ability to safely self-administer medications. Review of Resident 25's physician's orders failed to show an order for the TheraHoney wound gel and self-administration of the medication. Residents Affected - Few Review of Resident 25's plan of care failed to show a care plan problem was initiated or developed for the resident's self-administrations of medications. On 5/3/23 at 0816 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified Resident 25 had the TheraHoney wound gel at the bedside. The DSD/IP stated the TheraHoney wound gel was considered a medication and should not be at the bedside. The DSD/IP was observed removing the TheraHoney wound gel from Resident 25's bedside. On 5/3/23 at 1135 hours, a follow-up interview was conducted with the DSD/IP. The DSD/IP verified Resident 25 did not have a physician's orders for TheraHoney wound gel and self-administer the medication. The DSD/IP verified Resident 25 did not have a care plan for self-administration of the medications and Resident 25's Self-Administration of Medications Assessment showed she did not have the ability to safely self-administer medications. On 5/4/23 at 1325 hours, an interview was conducted with the DON. The DON verified Residents 25 did not have the physician's order and care plan problem addressing the self-administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 3 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 5's POLST signed on 2/22/23, showed Resident 5 had no advanced directive. On 5/2/23 at 1341 hours, an interview and concurrent medical record review was conducted with the SSD. When asked about the process for the resident's advanced directives, the SSD stated she provided the residents with the advanced directive literature and Advanced Directive Acknowledgement Form. The SSD further stated the advanced directive was discussed with the resident every care plan meeting. When asked if Resident 5 had an advanced directive, she stated Resident 5 did not had an advanced directive or Advanced Directive Acknowledgment Form. On 5/3/23 at 1600 hours, a follow-up interview was conducted with the SSD. When asked if she had any documentation to show she provided the advanced directive literature to Resident 5 or his responsible party, the SSD stated she did not have documentation regarding Resident 5's advanced directive. 5. Medical record review for Resident 21 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 21's POLST prepared on 11/21/22, showed Resident 21 did not have an advanced directive. On 5/2/23 at 1341 hours, an interview and concurrent medical record review was conducted with the SSD. When asked about the process for advanced directives, the SSD stated she provided the residents with the advanced directive literature and Advanced Directive Acknowledgement Form. The SSD further stated the advanced directive was discussed with the resident every care plan meeting. When asked if Resident 21 had an advanced directive, the SSD stated Resident 21 did not had an advanced directive or Advanced Directive Acknowledgment Form. On 5/3/23 at 1600 hours, a follow-up interview was conducted with the SSD. When asked if she had any documentation to show she provided advanced directive literature to Resident 21 or resident's responsible party, the SSD stated she did not have documentation regarding Resident 21's advanced directive. On 5/5/23 at 1500 hours, the Administrator, DON, CQA/IP Nurse, and SSD were informed and acknowledged the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to provide information regarding the rights to formulate the advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) to four of 14 final sampled residents (Residents 5, 21, 24, and 729) and one nonsampled resident (Resident 25). This failure had the potential for the residents' wishes related to the provision of medical treatment and services to not be followed if the residents were unable to make medical decisions for themselves. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 4 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's P&P titled Advance Directives dated December 2016 showed the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so upon admission. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1. Medical record review for Resident 25 was conducted on 5/2/23. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 3/11/23, showed Resident 25 had the capacity to understand and make decisions. Review of the POLST dated 3/13/23, under Section D, showed Resident 25 had no advance directive. The POLST did not show the advance directive was offered and discussed with Resident 25. Further review of Resident 25's medical record did not show the information was provided to Resident 25 for the formulation of advance directive. On 5/3/23 at 1405 hours, a concurrent interview and record review was conducted with the SSD. The SSD verified there was no documentation to show information on the formulation of advance directive was offered to Resident 25. The SSD stated the advance directive information should have been offered to Resident 25 and the discussion should have been documented in Resident 25's medical records. 2. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. Review of Resident 729's H&P examination dated 4/11/23, showed Resident 729 had the capacity to understand and make decisions. Review of the POLST dated 4/11/23, under Section D, showed Resident 729 had no advance directive. The POLST did not show the advance directive was offered and discussed with Resident 729. Further review of Resident 729's medical record did not show the information was provided to Resident 729 for the formulation of advance directive. On 5/3/23 at 1401 hours, a concurrent interview and record review was conducted with the SSD. The SSD was made aware and verified the above findings. The SSD stated the advance directive information should have been offered to Resident 729 and the discussion should have been documented in Resident 729's medical records. 3. Medical record review for Resident 24 was initiated on 5/2/23. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's H&P examination dated 2/5/23, showed Resident 24 could make needs known but could not make medical decisions. Review of the POLST dated 2/3/23, under Section D, showed Resident 24 had no advance directive. The POLST did not show the advance directive was offered and discussed with Resident 24 and/or his responsible party. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 5 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident 24's IDT Conference Note dated 2/6/23, showed Resident 24 did not have an advance directive. The note did not show information was provided to Resident 24 or his responsible party for the formulation of advance directive. On 5/3/23 at 1035 hours, an interview was conducted with Resident 24. Resident 24 stated he was aware what an advance directive was, however, he did not remember whether he was offered information to formulate an advance directive at the facility. Event ID: Facility ID: 555651 If continuation sheet Page 6 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0580 Level of Harm - Potential for minimal harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure facility staff identified and notified the physician and family or responsible party of Resident 15's change of condition related to low blood pressure. This failure had the potential for Resident 15 to not receive the appropriate care and services to treat medical conditions. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the facility will promptly notify the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition. Medical record review of Resident 15 was initiated on 6/15/23. Resident 15 was admitted to the facility on [DATE]. Resident 15 had diagnoses which included hypertension (high blood pressure). Review of Resident 15's Care Plan dated 1/13/23 showed a care plan problem addressing hypertension. One of hte care plan interventions was to check the blood pressures prior to the medication administration and notify the physician of any significant results. Review of Resident 15's untitled document showed on 5/22/23 at 2111 hours, the resident's blood pressure reading was 71/49 mmHg (normal blood pressure: 128/50 mmHg). Review of Resident 15 's Progress Notes for May 2023 showed no documented evidence Resident 1's change of condition was identified. Further review of progress notes did not show the physician and responsible party, or family member were notified of Resident 1's low blood pressure reading. Review of the facility document titled In-Service Sign in Sheet dated 5/11/23, with the subject titled Change of Condition did not show the signature of LVN 3. On 6/15/23 at 1455 hours, a concurrent interview and record review was conducted with the DON. The DON verified the above findings. The DON stated blood pressure reading of 71/49 mmHg was a change of condition for Resident 15. The DON stated LVN 3 should have rechecked the resident's blood pressure to confirm, notified the physician, the resident's responsible party, and called 911 if appropriate. The DON stated facility provided the in-service to all licensed staff regarding resident change of condition on 5/11/23, however; the DON was not able to provide documented evidence if LVN 3 had received the in-service. On 6/16/23 at 1720 hours, the Administrator, DON, and QA/IP were informed and acknowledged the above findings FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 7 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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 exercise reasonable care for the protection property from loss for one of 14 final sampled residents (Resident 729). Resident 729's two shirts were lost in the facility. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Personal Property revised September 2012 showed the facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. Review of the facility's P&P titled Grievances/Complaints, Recording and Investigating dated April 2017 showed all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances. On 5/2/23 at 0812 hours, an interview was conducted with Resident 729. Resident 729 stated three shirts were brought to the facility's laundry by a staff member; however, only one shirt was brought back to her room after it was laundered. Resident 729 further stated she had lost two shirts and the facility staff were aware. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. Review of Resident 729's H&P examination dated 4/11/23, showed Resident 729 had the capacity to understand and make decisions. Review of Resident 719's Inventory of Personal Effects dated 4/12/23, showed Resident 729 had four shirts/blouses upon admission to the facility. On 5/3/23 at 1132 hours, an interview was conducted with the DSD/IP. When asked about the facility's protocol regarding the residents' complaint of lost items, the DSD/IP stated the facility should look for the missing items and if the missing items were not found, the complaint should be reported to the SSD as a theft and loss. On 5/3/23 at 1425 hours, an interview was conducted with the SSD. The SSD verified Resident 729's Inventory of Personal Effects form included four shirts/blouses. The SSD stated she was not aware of Resident 729's missing shirts and the facility staff did not report to her about Resident 729's missing shirts. On 5/4/23 0932 hours, a follow-up interview was conducted with Resident 729. Resident 729 stated she lost one black and one white shirt. Resident 729 further stated the other shirts had thin straps. Resident 729 stated she could not remember the staff who she had complained to about her lost shirts. Resident 729 further stated the facility never found her two shirts and never replaced them. On 5/4/23 at 0942 hours, an interview was conducted with CNA 3. CNA 3 stated she recalled Resident 729 had complained about losing three shirts; however, CNA 3 could not recall when it occurred. CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 8 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 3 stated one shirt was found in the laundry room and Resident 729's family member confirmed the shirt was Resident 729's missing shirt. CNA 3 further stated she informed the DSD about the two other missing shirts. On 5/4/23 at 0946 hours, a follow-up interview was conducted with the DSD/IP. The DSD/IP stated she recalled CNA 3 reporting to her about Resident 729's two missing shirts; however, the DSD/IP did not file a grievance or report the complaint to the SSD because she thought all three missing shirts were found. The DSD/IP further stated she was not aware that only one of the shirts was found. The DSD/IP stated she did not follow-up with Resident 729 to verify whether her complaint was resolved. Event ID: Facility ID: 555651 If continuation sheet Page 9 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident-centered care plan for one of 14 final sampled residents (Resident 1) was revised to reflect the resident's poor oral intake and insidious weight loss (gradual, unintended, progressive weight loss over time) of - 4 lbs, (3%) from 12/2/2022 to 1/4/2023, - 10 lbs (7%) from 10/3/2022 to 1/4/2023, and - 12 lbs (8%) from 8/5/2022 to 1/4/2022. This failure caused Resident 1 to not receive the necessary care needed to maintain acceptable parameters of nutritional status. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed in part, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or the resident's legal surrogate. 2. Individualized care plans will address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Timeframes and parameters for monitoring and reassessment. On 5/3/23 at 1539 hours, a review of Resident 1's electronic medical record and concurrent interview was conducted with the DON. The DON stated the nursing staff was responsible for the resident's care plans. The DON confirmed Resident 1's poor intake in December and insidious weight loss from 8/5/22 to 1/4/23, had not been added to Resident 1's care plan but should have been added. On 5/4/23 at 1321 hours, an interview was conducted with the RDN. The RDN stated she was not involved in resident care planning. Cross reference to F802, example #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 10 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 15) were provided quality care when: Residents Affected - Few * The facility did not notify the physician or the resident's responsible party about Resident 1's change of condition regarding the resident's low blood pressure. This failure had the potential to cause harm to Resident 1. * Resident 15 had a permanent pacemaker (implanted electronic device in the chest to help control the heartbeat) with a pacemaker transmitter (allows information from the implanted device to be sent to the doctor) at the bedside. The facility failed to ensure the information related to Resident 15's pacemaker was documented in the medical record. The pulse for Resident 15's pacemaker was not monitored and recorded. Resident 15's pacemaker transmitter was not monitored routinely. This had the potential for Resident 15 to not receive the appropriate care and services to treat her medical conditions. Findings: 1. Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the nurse will notify the resident's physician when there has been a significant change in the condition of a resident, which includes any status that does not resolve itself without intervention by staff. Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1 had the diagnosis of hypertension (high blood pressure) and history of falls. Review of Resident 1's physician's orders showed the following two orders for metoprolol (antihypertensive) medication: - metoprolol tartrate 50 mg one tablet by mouth twice a day for hypertension; hold if systolic blood pressure less than 110 mmHg, heart rate less than 60 beats per minute, to be taken with food; and this order was started on 4/13/23 and discontinued on 5/3/23. - metoprolol tartrate 50 mg one tablet by mouth twice a day for hypertension; hold if systolic blood pressure less than 110 mmHg, heart rate less than 60 beats per minute; and this order was started on 4/21/23 and discontinued on 5/2/23. Review of Resident 1's MAR for April and May 2023 showed Resident 1 received metoprolol tartrate 50 mg on the following dates and times: - At 0700 hours from 4/14 to 5/3/23 - At 0900 hours from 4/1 to 4/7, 4/9, 4/11 to 4/17, 4/20 to 4/23, and 4/25 to 5/2/23 - At 1700 hours from 4/1 to 4/18, 4/20 to 4/27, and 4/29 to 5/2/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 11 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0684 Further review of Resident 1's MAR for April 2023 showed the following blood pressure readings: Level of Harm - Minimal harm or potential for actual harm - On 4/19/23, 81/63 mmHg - On 4/24/23, 96/56 mmHg Residents Affected - Few - On 4/28/23, 73/67 mmHg Review of Resident 1's Progress Notes for April 2023 showed no documented evidence Resident 1's physician and responsible party or family member were notified of Resident 1's low blood pressure readings. On 5/4/23 at 0907 hours, an interview was conducted with the DSD/IP. When asked about the facility's change of condition policy, she stated a change of condition was defined when something happens to a resident that was not within the resident's baseline. She further stated if a change of condition occurred, the charge nurse should contact the resident's provider and family member. When asked where a change in condition would be documented, she stated the nurse should document the resident's status and blood pressure in the progress notes. On 5/4/23 at 1333 hours, an interview was conducted with LVN 1. When asked what the process was if a resident had a low blood pressure reading, LVN 1 stated she would review the resident's ordered medications, provide interventions, and recheck the blood pressure. When asked about Resident 1's blood pressure reading of 96/56 mmHg on 4/24/23, she stated she elevated Resident 1's legs, which resolved the blood pressure after 30 minutes. When asked if she documented a change of condition for the resident, she stated she did not document a change of condition since Resident 1's blood pressure improved after 30 minutes. On 5/4/23 at 1425 hours, an interview and concurrent medical record review was conducted with the DON. When asked what the protocol was for a resident with low blood pressure, the DON stated she expected her staff to notify the physician and monitor the resident more frequently. Upon review of the blood pressure readings of 81/63 mmHg (4/19/23), 96/56 mmHg (4/24/23), and 73/67 mmHg (4/28/23), she stated those readings would be considered a change of condition for the resident. She would expect the nurse to notify the physician, monitor the resident, and document their interventions in the progress notes. On 5/5/23 at 1530 hours, the Administrator, DON, and CQA/IP were informed and acknowledged the above findings. Cross reference to F760. 2. Review of the facility's P&P titled Pacemaker, Care of a Resident revised December 2015 showed to monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia (an abnormally slow resting heart rate). Under the section for Documentation, the policy showed for each resident with a pacemaker, to document the following in the medical record and on a pacemaker identification card upon admission: - The name, address, and telephone number of the cardiologist; - Type of pacemaker; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 12 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0684 - Type of leads; Level of Harm - Minimal harm or potential for actual harm - Manufacturer and model; - Serial number; Residents Affected - Few - date of implant; and - Paced rate. Review of the manufacturer's instruction titled First Steps: How Do I Use the CardioMessenger showed to check the pacemaker transmitter once a day whether the transmitter is powered on and ready for use, which is indicated by a OK icon displayed on the screen. Medical record review for Resident 15 was initiated on 5/2/23. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 1/15/23, showed Resident 15 was able to make needs known but could not make medical decisions. The document showed Resident 15 had ASCVD with a permanent pacemaker and hypertension. Review of Resident 15's plan of care showed a care plan problem titled Risk for pacemaker malfunction dated 1/19/23. The interventions included to monitor and notify Resident 15's physician when the resident's pulse was below 60 beats per minute and/or when the resident became symptomatic (shortness of breath, chest pain, dizziness, altered level of consciousness, or hypotension). Review of Resident 15's Order Summary Report failed to show the physician's orders to monitor Resident 15's pulse and symptoms of pacemaker malfunction. Further review of Resident 15's medical record did not show information related to Resident 15's pacemaker or pacemaker transmitter. On 5/4/23 at 0951 hours, a concurrent interview and record review was conducted with the DSD/IP. The DSD/IP stated she was aware Resident 15 had a pacemaker and a pacemaker transmitter. The DSD/IP stated a copy of Resident 15's pacemaker card was in the medical record; however, Resident 15's pacemaker information was not documented in the medical records. The DSD/IP verified Resident 15 did not have the physician's orders to monitor her pulse. The DSD/IP stated Resident 15's pulse should be monitored and documented. On 5/4/23 at 1002 hours, an observation and concurrent follow-up interview was conducted with the DSD/IP. Resident 15's CardioMessenger Smart Transmitter (pacemaker transmitter) was observed on top of the overhead light with its charger cord plugged into the wall outlet. The DSD/IP was observed moving the pacemaker transmitter to Resident 15's bedside table. The pacemaker transmitter was observed with an OK icon displayed on the screen. The DSD/IP stated the pacemaker transmitter should be checked every shift by the licensed nurse to ensure an OK icon displayed on the screen and was ready for use. When asked how the licensed nurses were aware to check the pacemaker transmitter, the DSD/IP stated a physician's order should be in Resident 15's medical record to ensure the licensed nurses checked the pacemaker transmitter. The DSD/IP verified Resident 15 did not have a physician's order to monitor the pacemaker transmitter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 13 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/5/23 at 1104 hours, an interview was conducted with LVN 2. LVN 2 stated she was aware Resident 15 had a pacemaker; however, LVN 2 stated she was not aware Resident 15 had a pacemaker transmitter. When asked how LVN 2 checked if Resident 15's pacemaker was functioning properly, LVN 2 stated she checked Resident 15's apical pulse during the administration of her blood pressure medication. LVN 2 stated she documented Resident 15's pulse in the electronic MAR, under the monitoring section for Resident 15's blood pressure medication. LVN 2 stated she did not know how the pacemaker transmitter functioned and what she needed to do with the pacemaker transmitter. LVN 2 stated she had not been provided education or in-services about Resident 15's pacemaker transmitter. On 5/4/23 at 1321 hours, a concurrent interview and record review was conducted with the DON. The DON verified Resident 15 had the pacemaker and pacemaker transmitter. The DON stated a copy of Resident 15's pacemaker card was in the medical record; however, the information was not documented in Resident 15's medical record. The DON verified Resident 15 did not have physician's orders to monitor her pulse and to monitor the pacemaker transmitter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 14 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 1) received the appropriate services needed to maintain acceptable parameters of nutritional status when: Residents Affected - Few 1. The facility failed to implement the interventions to maintain Resident 1's nutritional status when Resident 1 experienced the following insidious weight loss (gradual, unintended, progressive weight loss over time): - 4 lbs, (3%) from 12/2/22 to 1/4/23, - 10 lbs (7%) from 10/3/22 to 1/4/23, and - 12 lbs (8%) from 8/5/22 to 1/4/22. 2. The facility failed to ensure the nutrition evaluations were performed by a qualified Registered Dietitian. 3. The facility failed to revise the resident-centered plan of care for Resident 1 to reflect the insidious weight loss from 8/5/22 to 1/4/23, and poor PO intake. These failures caused Resident 1 to experience severe weight loss of 11 pounds, 7.9% from 11/1/22 to 2/1/23; and severe weight loss of 16 pounds, 11% from 8/5/22 to 2/1/23. Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, showed, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ A professional reference review of BSN (Balance Senior Nutrition) Solutions, titled, Weight Loss in the Elderly: When Should You Be Concerned? dated March 19, 2018, showed, According to the Centers for Medicaid and Medicare services (CMS), weight can be a useful indicator of nutritional status when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. https://www.bsnsolutions.net/weight-loss-in-the-elderly-when-should-you-be-concerned-clone#:~:text=%E2%80%9CInsidio (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 15 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 Level of Harm - Actual harm Residents Affected - Few A professional reference review of Dietetics in Healthcare Communities, a dietetic practice group of the American Dietetic Association titled Unintended Weight Loss in Older Adults: ADA Evidence Based Practice Guidelines dated 2011 showed, Most reference tables do not include elderly individuals in their subject pool, and thus these tables are not age adjusted. Standard height and weight tables and BMI tables are therefore not valid for use in older adults. https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-5647e0d15658/UploadedImages 1. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant, unplanned and undesired weight loss will be based on the follow criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100: a. one month - 5% weight loss is significant; greater than 5% is severe, b. three months - 7.5% weight loss is significant; great than 7.5% is severe, c. six months - 10% weight loss is significant; greater than 10% is severe . Analysis 2. The Physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk for weight loss . Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was readmitted to the facility on [DATE], with diagnoses including Non-ST elevation myocardial infarction (NSTEMI), a type of heart attack and muscle weakness. Review of Resident 1's Annual History and Physical Examination dated 4/11/23, showed Resident 1 could make needs known but could not make medical decisions. Review of Resident 1's Physician's Order dated 12/1/22 to 1/31/22, showed the orders dated 4/16/21, for Regular No Added Salt diet and multivitamin one tablet PO QD for supplement. Review of the facility's document titled Vital Signs Grid from 4/16/21 through 5/3/23, showed the following weights and comparisons for Resident 1: * On 12/2/22 = 136 lbs, -7 lbs, a 4.9% insidious weight loss in three months [comparison weight on 9/1/22, 143 lbs], * On 1/4/23 = 132 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 12/2/22, 136 lbs]; -10 lbs, a 7% insidious weight loss in three months [comparison weight on 10/3/22, 142 lbs]; and -11 lbs, a 7.7% insidious weight loss in six months [comparison weight on 7/5/22, 143 lbs]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 16 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 Level of Harm - Actual harm Residents Affected - Few * On 2/1/23 = 128 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 1/4/23, 132 lbs]; -11 lbs, an 8% severe weight loss in three months [comparison weight on 11/1/22, 139 lbs]; -16 lbs, a 11% severe weight loss in six months [comparison weight on 8/5/22, 144 lbs]. Review of the facility's document titled Resident Care Details dated 11/1/22 to 4/30/23, showed Resident 1's PO intake for the following months: * For the month of November 2022, 48% of the 89 meals recorded, the intake was less than or equal to 50% intake. * For the month of December 2022, 38% of the 90 meals recorded, the intake was less than or equal to 50% intake. * For the month of January 2023, 35% of the 88 meals recorded, the intake was less than or equal to 50% intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 8/24/22, showed Resident 1's weight on 8/19/22 was 144 lbs. The resident had no weight gain or loss, was not at risk for weight loss and dehydration, and was on a Regular NAS (No Added Salt) diet. The document also showed no recommendations at this time, no concerns, and continue to monitor monthly weights. The Nutrition Evaluation form did not include Resident 1's PO intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 12/1/22, showed Resident 1's weight on 11/1/22, was 139 lbs. The resident had no weight gain or loss, was at risk for weight loss and dehydration, and was on a Regular NAS diet. The document showed N/A for nutrition interventions/recommendations and to continue to monitor monthly weight and po intake. The Nutrition Evaluation form did not include Resident 1's PO intake. Review of the facility's document titled Departmental Notes- Dietary completed by the RDN on 12/14/22, showed the RD notes were for a follow up on the resident's PO intake. The note showed the following: weight: 136 lbs, BMI (body mass index) 22.6, and normal status. Resident 1 had three lbs weight loss for one month, seven lbs weight loss for three months, and six lbs weight loss for six months. Resident 1 had been showing variable, low PO intake. Resident 1 had variable PO intake with an average of 20-40-50-70% of all meals. Per the Certified Dietary Manager, Resident 1 refused to eat, notifying the nursing staff that she was not hungry. Dietary offered nutritional supplements, but the resident refused. The note showed a recommendation for appetite stimulant to improve PO intake; and would continue to monitor weights, labs, and PO intake. Review of the facility's document titled Nutritional Screening and Assessment - annual completed by the Certified Dietary Manager and RDN on 2/28/23, showed the current weight 128 lbs; IBWR (ideal body weight range) 121#--125#-138#; recent weight change: loss of 4 lbs in one month, loss of 11 lbs (8%) in three months, and loss of 16 lbs (11%) in six months. The document showed estimated calories needs for weight maintenance based on actual body weight 25-30 calories/kg (kilogram) 1450-1740 calories; and recommendation for four-ounce HPN (High Protein Nourishment) BID (twice a day) at lunch and dinner. Review of the facility's document titled Nursing Summary completed by LVN 4 on 12/14/22 at 2240 hours, showed the resident's weight was 136 lbs on 12/2/22, with excellent appetite and no changes in condition. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by RN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 17 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 Level of Harm - Actual harm Residents Affected - Few on 12/18/22 at 1028 hours, showed Resident 1 was on monitoring for poor PO intake, consumed 75% breakfast, and given fluid as tolerated. The note showed snacks offered in between meals .will continue to monitor. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/18/22 at 0807 hours, showed Resident 1 had an episode of poor PO intake during dinner, consumed 30% of dinner. The note showed alternate offered and refused .will continue to monitor. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 6 on 12/18/22 at 0724 hours, showed for Resident 1 to continue monitoring for low appetite. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 5 on 12/19/22 at 1230 hours, showed in part, decreased appetite, ate 20% of breakfast and 30% of lunch, and when encouraged to eat, the resident became agitated and began to ramble and say things not pertaining to meal. When redirected, the resident stated, I don't want to eat or I can't eat or I don't like this food. When asked what meal she preferred or what other food she would like to eat, the resident said nothing or yelled to leave her alone. Provided food that the family said she liked, but the resident also refused the meals. The note showed encouraged supplements and fluids as the resident could tolerate. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/19/22 at 2257 hours, showed no episode of poor PO intake during dinner and consumed 100% of dinner. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DSD/IP on 12/20/22 at 1103 hours, showed in part, the physician ordered CBC (complete blood count), CMP (complete metabolic panel), UA (urinalysis)/c+s (culture plus sensitivity). Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/20/22 at 1939 hours, showed the resident consumed 50% of dinner, alternate was offered and refused, and fluids were encouraged and offered as tolerated. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DON on 2/3/23 at 2217 hours, showed Resident 1's weight was reviewed and the resident 's weight loss for six months. Resident 1 had a declining appetite. Physician 1 was made aware of the IDT recommendations for weekly weights, RD consult, fortify diet, and four-ounce HPN BID between meals; and agreed. Review of the facility's document titled Weight Variance Committee for Resident 1 dated 2/3/23, showed the following IDT members were present: the Certified Dietary Manager, DON, and SSD. The RDN was not present. The note showed the resident's average meal intake for breakfast, lunch, and dinner was 25-50%. The current weight was 128 lbs and BMI <22, and the identified weight trend was documented as -16 lbs x 6 months, with the known or suspected cause of decreased appetite. The current interventions was documented as none, and the physician and responsible party were notified on 2/3/23. Review of Resident 1's Physician Progress Notes dated 10/7/22, showed Resident 1's weight was 143 lbs, and to continue with the current orders. Review of Resident 1's Physician Progress Note dated 11/7/22, showed Resident 1 was doing fair and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 18 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 ate ok, and to continue with the current treatment. Level of Harm - Actual harm Review of Resident 1's Physician Progress Note dated 12/9/22, showed Resident 1 was alert, and to continue with the current medications. Residents Affected - Few Review of Resident 1's Physician Progress Note dated 1/20/23, showed Resident 1 was awake but confused on and off, and to continue with the present plan. Review of Resident 1's Physician Progress Note dated 2/5/23, showed Resident 1 was doing fair, except more forgetful. The document showed oral intake fair, weight 128 lbs, and to continue with the current treatment. During the lunch meal dining observation on 5/02/23 at 1208 hours, Resident 1 was observed sitting in the resident dining room with two other residents at the table. Resident 1 appeared thin, confused, and was not eating her lunch. Resident 1 was asked why she was not eating, she replied, I have too much at home. The DSD then asked Resident 1 if she wanted something else to eat but Resident 1 refused a meal alternative. Resident 1 consumed four ounces of juice and four ounces of HPN. On 5/2/23 at 1513 hours, Resident 1 was observed in the hallway sitting in her wheelchair drinking four ounces of HPN. On 5/02/23 at 1400 hours, an interview was conducted with the RDN. The RDN was asked to explain the resident weight loss protocol for the facility. The RDN stated significant weight loss of 5% in a month, 7.5% in three months, and 10% in six months were reviewed. The RDN talked to the DON but was not part of the IDT weight variance meeting. The RDN stated she was not involved in creating or revising the resident's care plans. On 5/3/23 at 1539 hours, an electronic medical review of Resident 1 and concurrent interview was conducted with the DON. The DON was asked to explain the resident's weight loss protocol for the facility. The DON explained the residents with significant weight loss of 5% in a month, 7.5% in three months, and 10% weight loss in six months were followed in the IDT weight variance committee. The nurses were responsible to notify the physician and resident's responsible party of any significant weight change. The DON stated the IDT weight variance committee included herself, the Certified Dietary Manager, and social service. The RDN was not part of the IDT weight variance committee, but the RDN asked the Certified Dietary Manager or DON about any residents with changes. The DON stated the RDN completed a report after each visit with recommendations. The DON and nursing received a copy of the RDN weekly report and recommendations. The charge nurse was responsible to notify the physician of the RDN's recommendations and write an order. If the physician did not agree with the RDN's recommendation, the charge nurse should document such in the resident's medical record. The DON was asked how the facility handled the residents with insidious weight loss. The DON stated if the residents experienced insidious weight loss, the IDT would intervene with the same protocol as significant weight loss. The DON was asked about Resident 1's weight loss. The DON stated Resident 1 was currently being followed in the IDT weight variance committee. The DON confirmed Resident 1 was first reviewed by the IDT weight variance committee on 2/3/23, due to a significant weight loss of 16 lbs in six months. The DON was asked who was responsible for weight change calculations. The DON stated the RDN calculated weight changes, but she could also run a report. Resident 1's weight report was reviewed with the DON. The DON confirmed Resident 1 had insidious weight loss of four lbs (3%) from 12/2/22 to 1/4/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 19 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 Level of Harm - Actual harm Residents Affected - Few 10 lbs (7%) from 10/3/22 to 1/4/23, and 12 lbs (8%) from 8/5/22 to 1/4/22. The DON confirmed Resident 1's insidious weight loss between 1/4/23 and 8/5/23 was not discussed in the IDT weight variance committee. When asked what the facility's criteria to follow a resident with insidious weight loss was, the DON stated if the resident became underweight. The DON was asked if a resident with poor PO intake would be followed in the IDT weight variance committee. The DON confirmed if a resident had poor PO intake that would be addressed in the IDT weight variance committee. The DON was asked to review Resident 1`s medical record during the month of December when Resident 1 experienced insidious weight loss and poor PO intake. The DON stated on 12/14/22, the RDN wrote a note that addressed Resident 1's insidious weight loss and poor PO intake. The DON acknowledged on 12/14/22, the RDN recommended an appetite stimulant for Resident 1. The DON confirmed there was no note from nursing showing the physician was contacted regarding the RDN's recommendation for an appetite stimulant. The DON confirmed the RDN recommendations should be completed within 72 hours of receiving the recommendations. The DON was asked how she was notified of the RDN recommendations. The DON stated she received a paper copy of the RDN's report and recommendations. The DON was asked how she ensured the RDN recommendations were completed. The DON stated the nursing usually put the completed RDN recommendations under the door of her office, but the DON had discarded the completed RDN recommendations. The DON stated she only kept the original RDN recommendation reports. The DON was not able to confirm she received any RDN recommendation reports from December 2022. The DON stated she did not remember seeing the RDN in December 2022 and thought the RDN had worked virtually. The DON stated on 12/18/22, Resident 1 was on a change of condition (COC) monitoring due to poor intake. The DON stated the facility's procedure for a COC did not include a change of condition form, and the nursing staff was only required to monitor the resident for 72 hours. The DON stated the nursing staff was responsible to notify the physician and resident responsible party of any change of condition. The DON confirmed there was no note showing the physician or Resident 1's responsible party were notified of Resident 1's poor intake. The DON stated on 12/20/22, the physician ordered a lab work for Resident 1, therefore, the nursing staff must have notified the physician of Resident 1's poor po intake. The DON was asked if any other interventions such as weekly weight monitoring were implemented for Resident 1 in December 2022. The DON confirmed no interventions to mitigate Resident 1's weight loss or poor intake was added for Resident 1 in December 2022. The DON confirmed Resident 1 was discussed in the IDT meeting on 2/3/23, related to a severe weight loss of 16 lbs, 11% since 8/5/22, due to declining appetite. The IDT recommended weekly weights, RD consult, fortify diet, four-ounce HPN (high protein nourishment) twice a day between meals. The DON acknowledged waiting until 2/3/23, to address Resident 1's weight loss with the IDT was not timely. The DON confirmed the RDN did not re-evaluate Resident 1 since 12/14/22. The DON confirmed the next RDN evaluation was completed on 2/28/23. The DON acknowledged waiting until 2/28/23, more than two months after Resident 1 began losing weight and since the previous RD evaluation on 12/14/22, was not considered timely. On 5/4/23 at 1321 hours, a telephone interview was conducted with the RDN. The RDN was asked the facility process with monthly weights. The RDN stated she obtained a paper copy of the monthly weights from the weight book. The RDN calculated significant weight changes of 5% in a month, 7.5% in three months, and 10% in six months. She stated she only addressed significant weight change. The RDN wrote her recommendations on a paper form and gave a copy to the DON. When asked if only residents with weight loss were discussed in the weight variance committee, the RDN stated she was not sure what residents were discussed since she did not attend the weight variance committee meeting. The RDN was asked how she ensured her recommendations were completed. The RDN stated if the resident came back on her radar, she would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 20 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 Level of Harm - Actual harm follow up on her recommendations. The RDN confirmed she had no system to ensure her recommendations were completed. The RDN further stated she did not check to see if the nursing had completed her recommendations. The RDN was asked how she was notified of a resident with poor PO intake. The RDN stated the CDM would either tell her verbally or write a note in the RD binder. Residents Affected - Few Resident 1's electronic medical record was reviewed with the RDN. The RDN acknowledged she wrote a note on 12/14/22, for Resident 1 regarding poor PO intake and gradual weight loss. The RDN acknowledged she recommended an appetite stimulant for Resident 1. The RDN stated she could not recall if she worked virtually in December or on site. The RDN stated if she worked virtually, she would take a picture of her recommendations and text it to the DON or call the DON and relay her recommendations. The RDN was asked if she documented she called or texted the DON with her recommendation. The RDN stated she did not document how her recommendations were communicated to the DON in December 2022. The RDN confirmed she did not have a system how to communicate the recommendations for the residents when she was working virtually. The RDN was asked what other interventions she would consider if a resident was not eating. The RDN agreed that weekly weights should have been recommended for Resident 1 in December. The RDN then stated the weekly weights were only recommended for those residents who had experienced significant weight loss. The RDN was asked if she was familiar with the term insidious weight loss. The RDN was not familiar with the term insidious weight loss but agreed that unplanned weight loss whether significant or gradual was not desirable in the elderly population. The RDN was asked when the next nutrition assessment was completed for Resident 1. The RDN stated an annual nutrition assessment was completed on 2/28/23. The RDN was asked when she received the resident monthly weights. The RDN stated she received the resident monthly weights during the first week of each month. The RDN acknowledged waiting until 2/28/23, to assess Resident 1's severe weight loss of 11 lbs, 7.9% in three months and 16 lbs, 11% in six months was not ideal. On 5/4/23 at 1546 hours, a follow-up interview was conducted with the DON. The DON was asked if she received a picture the RDN's recommendations in December via text message or email from the RDN. The DON confirmed after checking her emails and phone records, she did not receive the recommendations from the RDN. The DON further confirmed the RDN recommendations she had were from 11/29/22 to 1/3/23, the DON stated she had no other RDN recommendations between those dates. On 5/5/23 at 1035 hours, a telephone interview was conducted Physician 1. Physician 1 declined to discuss Resident 1 and stated he was on an airplane. On 5/5/23 at 1048 hours, an interview was conducted with Resident 1's family member. Resident 1's family member stated they were aware the resident had lost weight and had not been eating well for about six months. 2. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Review of the facility document titled Director, Nutritional Services Job Description signed and dated by the Certified Dietary Manager on 9/12/16, showed to ensures the timely preparation and delivery of nutritious and attractive meals and supplements to all residents according to physician order and in compliance with Federal, State and company requirements; maintains a safe and sanitary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 21 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 Level of Harm - Actual harm Residents Affected - Few working environment; ensures that meals are served according to expressed resident preferences; plan, implements and revises menus to meet resident needs; and interacts effectively with other resident services according to total care plan approach. Review of the electronic medical record for Resident 1 and concurrent telephone interview was conducted with the RDN on 5/04/23 at 1321 hours. The RDN confirmed the Certified Dietary Manager completed the quarterly nutrition evaluations for all residents. The quarterly nutrition evaluation for Resident 1 dated 12/1/22, was reviewed with the RDN. The RDN confirmed the quarterly nutrition evaluation showed Resident 1's weight of 139 lbs was from 11/1/22. The RDN confirmed the quarterly nutrition evaluation showed Resident 1 had not lost weight, was not at weight loss and dehydrations risks, and did not have any nutrition interventions/recommendations; and to continue to monitor monthly weights and po intake. The RDN agreed the 12/2/22 weight of 136 should have been included in the December quarterly nutrition evaluation and the insidious weight loss of seven lbs (6%) from 9/1/22 to 12/2/22, should have been addressed in the quarterly nutrition evaluation. The RDN further agreed that Resident 1 was at risk for weight loss and dehydration due to poor PO intake. The RDN confirmed the nutrition evaluation form did not include the residents' PO intake. The RDN was asked if she reviewed the quarterly nutrition evaluations that were completed by the Certified Dietary Manager. The RDN confirmed she did not review the quarterly nutrition evaluations completed by the Certified Dietary Manager. The RDN further stated she was not aware the CDM was not a qualified individual to perform nutrition evaluations. On 5/5/23 at 1331 hours, an interview was conducted with the Administrator. The Administrator was not aware a Certified Dietary Manager was not qualified to complete the resident assessments. The Administrator was not aware of the California business and professions code 2586 which stated the RD was the professional permitted to conduct medical nutrition therapy which includes assessment, determination of nutrition diagnosis and recommendation and implementation of nutrition care and intervention. The Administrator agreed the RD should be cosigning or completing the quarterly nutrition evaluations. Cross reference to F836. 3. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed in part, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or the resident's legal surrogate. 2. Individualized care plans will address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Timeframes and parameters for monitoring and reassessment. On 5/3/23 at 1539 hours, a review of Resident 1's electronic medical record and concurrent interview was conducted with the DON. The DON stated the nursing staff was responsible for the resident's care plans. The DON confirmed Resident 1's poor intake in December and insidious weight loss from 8/5/22 to 1/4/23, had not been added to Resident 1's care plan but should have been added. On 5/4/23 at 1321 hours an interview was conducted with the RDN. The RDN stated she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 22 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0692 involved in resident care planning. Level of Harm - Actual harm Cross reference to F657. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 23 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 14 final sampled residents (Residents 9 and 22). Residents Affected - Few * The facility failed to follow the physician's order for Resident 22's oxygen therapy. This posed the risk for Resident 22 to develop complications related to oxygen use. * The facility failed to ensure Residents 9 and 22's nasal cannula tubings were dated as per the facility's P&P. This had the potential for increased risks of infection. Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in a safe, timely manner, and as prescribed. On 5/3/23 at 0813 hours, during an observation, Resident 22 was observed sitting in her wheelchair using oxygen via nasal cannula which was attached to the oxygen machine setting at 3 liters per minute. Medical record review for Resident 22 was initiated on 5/3/23. Resident 22 was readmitted to the facility on [DATE], with diagnosis of COPD. Review of Resident 22's Order Summary Report dated May 2023 showed a physician's order dated 12/5/22, for oxygen administration at 2 liters per minute via nasal cannula (medical device to provide supplemental oxygen therapy) as needed for shortness of breath and to keep the oxygen saturation level greater than 92%. Review of Resident 22's care plan dated 12/5/22, showed to administer oxygen as ordered. On 5/3/23 at 0813 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. LVN 1 verified the oxygen machine was set at 3 liters per minute and the physician's order for the oxygen was administered at 2 liters per minute as needed for Resident 22. LVN 1 checked for Resident 22's oxygen saturation level. LVN 1 stated Resident 22's oxygen saturation level was 98%. LVN 1 removed Resident 22's oxygen tubing and stated Resident 22 did not need oxygen at that time because Resident 22's oxygen saturation level above 92%. LVN 1 further stated the importance of following physician's order was to prevent Resident 22 in the development of codependence on oxygen use. On 5/3/23 at 1647 hours, an interview was conducted with the DON. The DON was informed and verified the above findings and stated the licensed nurses were expected to follow the physician's orders as prescribed. 2. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to change the oxygen cannula and tubing every seven days or as needed. a. On 5/2/23 at 0815 hours during an initial tour, Resident 22 was observed sitting up in her wheelchair with the oxygen nasal cannula in her nose. Resident 22's oxygen tubing was observed attached (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 24 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0695 to an oxygen machine. Resident 22's oxygen tubing was observed not dated. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 22 was initiated on 5/2/23. Resident 22 was readmitted to the facility on [DATE], with diagnosis of COPD. Residents Affected - Few Review of Resident 22's Order Summary Report dated May 2023, showed a physician's order dated 12/5/22, for an oxygen inhalation at 2 liters per minute via nasal cannula PRN for SOB and to keep the oxygen saturation level greater than 92%. Review of Resident 22's care plan titled Receiving Oxygen Therapy dated 12/5/22, showed an intervention to change the oxygen tubing per the facility's protocol. On 5/2/23 at 0824 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified the above findings and stated it was important to change the oxygen tubing to prevent infection. On 5/5/23 at 1342 hours, an interview was conducted with the DON. The DON stated the oxygen tubings were expected to be changed weekly to prevent infection. b. On 5/2/23 at 0829 hours, during an initial tour, Resident 9 was observed lying in bed with the head of the bed elevated and the oxygen nasal cannula in her nose. The oxygen tubing was observed attached to an oxygen machine. Resident 9's oxygen tubing was observed not dated. Medical record review for Resident 9 was initiated on 5/2/23. Resident 9 was admitted on [DATE]. Review of Resident 9's Order Summary Report dated May 2023, showed a physician's order dated 3/22/23, for an oxygen at 2 liters per minute via nasal cannula, may titrate up to 5 liters per minute PRN for SOB. Review of Resident 9's care plan titled Receiving Oxygen Therapy dated 3/24/23, showed an intervention to change the oxygen tubing per the facility's protocol. On 5/2/23 at 0838 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified the above findings and stated it was important to change the oxygen tubing to prevent infection. On 5/5/23 at 1342 hours, an interview was conducted with the DON. The DON stated the oxygen tubings were expected to be changed weekly to prevent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 25 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for one of 14 final sampled residents (Resident 529). Residents Affected - Few * The facility failed to ensure a diet change order recommendation for Resident 529's fluid restriction (a diet which limits the amount of daily fluid consumption) from the dialysis center was followed and carried out in a timely manner. This had the potential for Resident 529 having excess fluids which may affect other vital organs in the body due to impaired kidney functions. Findings: Review of the facility's P&P titled Encouraging and Restricting Fluids revised 10/2010 showed when a resident has been placed on a restricted fluid, remove the water pitcher from the room. On 5/2/23 at 1034 hours, during an initial tour, Resident 529 was observed sitting up in her bed. There was a green water pitcher and two plastic cups half filled with water observed on Resident 529's bed side table. Resident 529 stated she was on a fluid restriction and could only drink a little. Medical record review for Resident 529 was initiated on 5/2/23. Resident 529 was readmitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease required hemodialysis. Review of Resident 529's H&P examination dated 4/9/23, showed Resident 529 had the capacity to understand and make decisions. Review of Resident 529's Order Summary Report dated April and May 2023 showed a physician's order dated 4/4/23, for Resident 529 to go to dialysis on Mondays, Wednesdays, and Fridays, with a chair time of 1400 hours. Review of Resident 529's facility's document titled SNF: Pre and Post Dialysis assessment dated [DATE], showed the completed assessment form from the dialysis unit with a recommendation of a diet change to fluid restriction of 1200 ml. Review of Resident 529's facility document titled SNF: Pre and Post Dialysis assessment dated [DATE], showed a post it note attached to the document showing Does patient have any fluid restriction? We don't have any order for fluid restriction for her, but we recommend it to her. Review of Resident 529's Progress Notes for April 2023 did not show documentation of a follow up with the dialysis unit recommendation of diet change for fluid restriction of 1200 ml. Review of Resident 529's Order Summary Report dated April 2023 did not show an order for Resident 529's fluid restriction of 1200 ml recommended by the dialysis center. Review of Resident 529's Medication Administration Record dated April 2023 did not show an order for Resident 529's fluid restriction of 1200 ml recommended by the dialysis center. Review of Resident 529's Nutrition Evaluation dated 4/4/23, showed Resident 529's diet of regular, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 26 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0698 consistent carbohydrate (CCHO), no added salt (NAS), renal, and no fluid restriction. Level of Harm - Minimal harm or potential for actual harm Review of Resident 529's Order Summary Report dated May 2023, showed a physician's order dated 5/3/23, to have 1200 ml/ 24-hour fluid restriction with the breakdown as follows: Residents Affected - Few * Dietary: - Breakfast = 240 ml - Lunch = 240 ml - Dinner = 240 ml * Nursing: - 7 am - 3 pm shift = 180 ml - 3 pm - 11 pm shift = 180 ml - 11 pm - 7 am shift = 120 ml Review of Resident 529's care problem titled Renal Disease dated 5/3/23, showed an intervention for 1200 ml/ 24-hour fluid restriction. On 5/5/23 at 1004 hours, Resident 529 was observed sleeping on her bed in her room. There was a green water pitcher filled with water observed on her bed side table. On 5/5/23 at 0958 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 529 was on fluid restriction and a water pitcher should not be on Resident 529's bedside table to control Resident 529's fluid intake and to prevent fluid overload. On 5/5/23 at 1005 hours, an observation, medical record review, and concurrent facility document review was conducted with LVN 2. LVN 2 verified the above findings and stated the recommendation for fluid restriction of 1200 ml from the dialysis center on 4/5/23, should have been followed up right away. On 5/5/23 at 1043 hours, an interview, medical record review, and concurrent facility document review was conducted with the DON. The DON was informed and verified the above findings. The DON stated the resident on dialysis should not have a water pitcher at the bed side. The DON did not find documentation of the licensed nurses carrying out the recommendation written in the SNF: Pre/Post Dialysis Assessment on 4/5/23 or 4/17/23, for the 1200 ml fluid restriction. On 5/5/23 at 1118 hours, an interview was conducted with the RDN. The RDN stated she did not receive a diet slip (a communication sheet used by the nurses and the RDN with resident's diet order change) from the nurses and was not aware of the dialysis center recommendation for a diet change of fluid restriction of 1200 ml on 4/5/23 or 4/17/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 27 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the entrapment assessments, alternative to side rails, and/or obtained informed consents were completed for the use of side rails for seven of 14 final sampled residents (Residents 5, 8, 9, 21, 24, 26, and 529). These failures had the potential to put the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and ed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Use of Restraints revised 4/2017 showed restraint shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Prior to placing a resident in restraint, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. Restraints shall only be used upon the written order of a physician and after determining consent from the resident and/or representative (sponsor). Resident and/or surrogate shall be informed about the potential risks and benefits for all options under consideration, including the use of restraint, not using restraint, and the alternatives to restraint use. Restraint individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 1. On 5/2/23 at 0838 hours, and 5/3/23 at 0756 hours, Resident 9 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 9 was initiated on 5/2/23. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE], showed Resident 9 was moderate impared cognitively and required extensive assistance of two staff for bed mobility. Review of Resident 9's Order Summary Report dated May 2023 did not show the physician's order for Resident 9's bilateral half side rails use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 28 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 9's Restraint Assessment undated, did not show the indication for the use of Resident 9's bilateral half bed side rails, the use of least restrictive measures, and the licensed nurse who completed the form. Further medical record review for Resident 9 did not show an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails, nor completed an entrapment assessment. On 5/4/23 at 0837 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 9 used the bed side rails to prevent Resident 9 from falling and to aide in turning when repositioning. On 5/4/23 at 0856 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 9 used the bed side rails to help in turning from side to side. On 5/4/23 at 1050 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the facility did not have an entrapment assessment, orders for side rails, nor informed consent for the use of the side rails. 2. On 5/2/23 at 0842 hours, 5/3/23 at 0806 hours, and 5/4/23 at 0818 hours, Resident 529 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 529 was initiated on 5/2/23. Resident 529 was readmitted to the facility on [DATE]. Review of Resident 529's H&P examination dated 4/9/23, showed Resident 529 had the capacity to understand and make decisions. Review of Resident 529's MDS dated [DATE], showed Resident 529 required extensive assistance of one staff for bed mobility. Review of Resident 529's Order Summary Report dated April and May 2023 did not show the physician's order for Resident 529's bilateral half bed side rails use. Review of Resident 529's Restraint Assessment undated, did not show the indication for the use of Resident 529's bilateral half bed side rails, the use of least restrictive measures, nor the licensed nurse who completed the form. Further medical record review for Resident 529 did not show documentation of an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails, nor completed an entrapment assessment. On 5/3/23 at 0806 hours, an interview was conducted with Resident 529. Resident 529 stated she used the bed side rails to grab onto for turning side to side. Resident 529 was asked if she was able to put down the side rails and stated no. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the facility did not have an entrapment assessment, physician's order, and informed consent for the use of the side rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 29 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm 3. On 5/2/23 at 1413 hours, Resident 24 was observed to be sitting at the edge of the bed with half side rails elevated. Medical record review for Resident 24 was initiated on 5/4/23. Resident 24 was admitted to the facility on [DATE]. Residents Affected - Some Review of Resident 24's MDS dated [DATE], showed Resident 24 had severe cognitive impairment. Review of Resident 24's H&P examination dated 2/5/23, showed Resident 24 with diagnosis of recurrent seizures (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movement, feelings, and levels consciousness). Review of the Resident 24's Order Summary Report dated May 2023, showed a physician's order dated 3/2/23, may have bilateral upper side rails up while in bed for mobility and repositioning. Further medical record review for Resident 24 did not show documentation of the entrapment assessment and informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails. On 5/4/23 at 0843 hours, an interview was conducted with RNA 1. RNA 1 stated Resident 24 was mostly independent and preferred to be on his own. On 5/4/23 at 0900 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 24 was mostly independent and preferred to be on his own. CNA 1 stated she was not aware the side rails were a form of restrain when elevated. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the facility did not have an entrapment assessment and informed consent for the use of the side rails. 4. On 5/2/23 at 0906 hours, Resident 26 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 26 was initiated on 5/2/23. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's MDS dated [DATE], showed Resident 26 required extensive assistance of one staff for bed mobility. Review of Resident 26's Order Summary Report dated May 2023, showed a physician's order dated 3/28/23, may have bilateral upper side rails up while in bed for increased bed mobility and repositioning Review of Resident 26's Restraint Assessment undated, did not show the indication for the use of Resident 26's bilateral half bed side rails, the use of least restrictive measures, and the licensed nurse who completed the form. Further medical record review for Resident 26 did not show documentation of the entrapment assessment and informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 30 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/4/23 at 0900 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 26 was confused and hard of hearing. CNA 1 stated Resident 26 used the elevated half side rails for repositioning. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON stated the residents with side rails were the ones who repositioned themselves. The DON verified the above findings and stated the Restraint Assessments should be dated and the licensed nurse who completed the assessment should have signed the form. The DON further stated the assessment for entrapment was not performed. 5. On 5/2/23 at 0834, 5/3/23 at 0809 hours, and 5/3/23 at 1345 hours, Resident 8 was observed in bed with bilateral side rails elevated. Medical record review for Resident 8 was initiated on 5/2/23. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 had severe cognitive impairment and required extensive assistance of two persons for bed mobility. Review of Resident 8's Order Summary Report dated May 2023 showed a physician's order dated 2/25/23, may have side rails up while in bed for increased mobility and repositioning. Further medical record review for Resident 8 did not show documentation of entrapment assessment and informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails. On 5/2/23 at 0834 hours, an interview was conducted with CNA 4. CNA 4 stated the resident did not use the side rails and the side rails were used to prevent Resident 8 from falling. On 5/4/23 at 1023 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the residents with side rails were for turning and repositioning. The DON further stated there were no entrapment assessments and no specific form to indicate there was an informed consent for the use of side rails. 6. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE]. On 5/2/23 at 0834 hours, during an initial tour of the facility, Resident 5 was observed asleep in bed with upper bilateral side rails elevated. On 5/3/23 at 1136 hours, during an observation, Resident 5 was observed in bed with bilateral upper side rails elevated. Review of Resident 5's H&P examination dated 12/24/22, showed Resident 5 did not have the capacity to understand or make decisions. Review of Resident 5's MD'S dated 12/21/22, showed Resident 5 required total dependence on staff for bed mobility and required assistance from more than two staff. Review of Resident 5's Physician Orders showed an order dated 1/27/23, for bilateral upper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 31 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0700 siderails while in bed for mobility and repositioning. Level of Harm - Minimal harm or potential for actual harm Review of Resident 5's Restraint Assessment undated, did not show an indication for the use of side rails. Residents Affected - Some Review of Resident 5's medical record did not show an informed consent was obtained for the use of side rails. On 5/4/23 at 1032 hours, an interview was conducted with the DON. When asked about the Restraint Assessment form, the DON stated the Restraint Assessment form was not for a bed rails assessment. When asked if they provided side rail information and consent to the residents, she stated the facility did not have a side rails consent in place. On 5/4/23 at 1108 hours, an interview was conducted with the Maintenance Supervisor. When asked if he had documents regarding the bed rails from the manufacturer, he stated any paperwork regarding the bed rails was kept with the previous DSD who no longer worked at the facility. On 5/4/23 at 1124 hours an interview was conducted with the DSD. When asked if she had any paperwork regarding the facility's bed rails, she stated she did not handle the bed rails in the facility. 7. Medical record review for Resident 21 was initiated on 5/2/23. Resident 21 was admitted to the facility on [DATE], with a diagnosis of dementia. On 5/2/23 at 0815 hours, and on 5/3/23 at 0800 hours, during an initial tour of the facility, Resident 21 was observed with the bilateral upper side rails elevated. Review of Resident 21's H&P examination dated 12/01/22, showed Resident 21 did not have the capacity to understand or make decisions. Review of Resident 21's MDS dated [DATE], showed Resident 5 required extensive assistance from staff for bed mobility. Review of Resident 21's Physician Orders showed an order dated 11/21/23, for bilateral upper side rails while in bed for mobility and repositioning. Review of Resident 21's Restraint Assessment undated, did not show the indication the use of side rails. Review of Resident 21's medical record did not show an informed consent was obtained for the use of side rails. On 5/4/23 at 1032 hours, an interview was conducted with the DON. When asked about the Restraint Assessment form, the DON stated the Restraint Assessment form was not use for a bed rails assessment. When asked if they provided side rail information and asked for a consent from the residents/responsible parties, she stated they did not have a side rails informed consent in place. On 5/4/23 at 1108 hours, an interview was conducted with the Maintenance Supervisor. When asked if he had documents regarding the bed rail manufacturer, he stated any paperwork regarding bed rails was kept with the previous DSD who no longer worked at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 32 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm On 5/4/23 at 1124 hours, an interview was conducted with the DSD. When asked if she had any paperwork regarding the facility's bed rails, she stated she did not handle the bed rails in the facility. Cross reference to F909 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 33 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was originally admitted to the facility on [DATE], and recently readmitted on [DATE]. Review of Resident 1's physician orders showed an order dated 4/16/21, for tramadol HCL 50 mg 1/2 tablet (25 mg) by mouth every six hours as needed for moderate to severe pain. Review of Resident 1's Individual Resident's Controlled Drug Record for tramadol HCL 50 mg tablet showed Tramadol 50 mg was signed out by the nurse on 3/7/23 at 0720 hours, 3/30/23 at 2100 hours, and 4/30/23 at 0500 hours. Review of Resident 1's MAR for March and April 2023 showed Tramadol was documented as administered on 3/5/23 only. There was no documented evidence tramadol was administered to the resident on 3/7, 3/30, and 4/30/23, when the medications were signed out. Review of Resident 1's progress notes for March and April showed no notes documented for 3/7 and 3/30/23. Review of Resident 1's progress note dated 4/30/23 at 0508 hours, showed LVN 7 stated Resident 1 had no complaints of pain. On 5/5/23 at 1022 hours, and interview was conducted with the DON. When asked what the facility process was on administering the narcotic medications, the DON stated the nurses must sign out the narcotic medication on the narcotic count sheet and must document in the MAR to show the medication was administered to the resident. When asked what the process was if a resident refused a narcotic medication, the DON stated two nurses must dispose of the narcotic and sign on the narcotic count sheet to show the medication was wasted. On 5/5/23 at 1530 hours, the Administrator, DON, CQA/IP Nurse were informed and acknowledged the above findings. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services for two of 14 final sampled residents (Residents 1 and 729) and one nonsampled resident (Resident 3) to meet the needs of each resident. The facility failed to ensure administration of the narcotic pain medications for Residents 1, 3, and 729 were accurately documented to ensure accurate reconciliation and prevent medication administration errors. These failures posed the risk for diversion of controlled medications and medication administration errors. Findings: Review of the facility's P&P titled Controlled Substances revised 4/2019 showed upon administration of controlled medication, the nurse administering the medication is responsible for recording: - Name of the resident receiving the medication; - Name, strength, and dose of the medication; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 34 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 - Time of administration; Level of Harm - Minimal harm or potential for actual harm - Method of administration; - Quantity of the medication remaining; and Residents Affected - Few - Signature of nurse administering medication. Review of the facility's P&P titled Administering Medication revised 4/2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 1. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. Review of Resident 729's H&P examination dated 4/11/23 showed Resident 729 had the capacity to understand and make decisions. Review of Resident 729's Order Summary Report dated May 2023 showed a physician's order dated 4/11/23, to administer tramadol (opioid pain medication) 50 mg tablet by mouth every six hours as needed for pain. On 5/4/23 at 1537 hours, an interview, record review, and concurrent inspection of Medication Cart A was conducted with the CQA/IP. Review of Resident 729's Individual Resident's Controlled Drug Record for the administration of tramadol 50 mg showed one tablet of tramadol 50 mg was signed out by LVN 3 on 5/3/23 at 2200 hours. The number of tablets in the bubble pack (a package used to dispense medications) matched the number of tramadol 50 mg tablets in the Individual Resident's Controlled Drug Record. However, review of Resident 729's electronic MAR dated May 2023 did not show tramadol 50 mg was administered to Resident 729 on 5/3/23 at 2200 hours. The CQA/IP verified the findings. Further review of Resident 729's Individual Resident's Controlled Drug Record for the administration of tramadol 50 mg showed one tablet of tramadol 50 mg was signed out by LVN 7 on 4/16/23 at 2030 hours. However, review of Resident 729's electronic MAR for April 2023 did not show tramadol 50 mg was administered to Resident 729 on 4/16/23 at 2030 hours. On 5/4/23 at 1356 hours, an interview was conducted with Resident 729. Resident 729 stated tramadol 50 mg was one of her pain medications. Resident 729 stated she did not receive her tramadol 50 mg on 5/3/23 at 2200 hours. 2. Medical record review for Resident 3 was initiated on 5/2/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 5/2/22, showed Resident 3 could make needs known but could not make medical decisions. Review of Resident 3's Order Summary Report dated May 2023 showed a physician's order dated 1/22/23, to administer Norco (narcotic pain medication) for 5-325 mg tablet by mouth every four hours as needed for severe pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 35 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/5/23 at 0850 hours, an interview, record review, and concurrent inspection of Medication Cart A was conducted with LVN 2. Review of Resident 3's Individual Resident's Controlled Drug Record for the administration of hydrocodone-acetaminophen (generic name for Norco) 5-325 mg showed one tablet of hydrocodone-acetaminophen 5-325 mg was signed out by LVN 8 on 4/20/23 at 1700 hours. However, review of Resident 3's electronic MAR for April 2023 did not show hydrocodone-acetaminophen 5-325 mg was administered to Resident 3 on 4/20/23 at 1700 hours. LVN 2 verified the findings. On 5/5/23 at 1022 hours, an interview was conducted with the DON. The DON verified the process for administering the controlled medications was to document the removal of the controlled medication on the narcotic count sheet and document the medication administration on the electronic MAR after administering the medication to the resident. The DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 36 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0760 Ensure that residents are free from significant medication errors. 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 14 final sampled residents (Resident 1) was free from a significant medication error when Resident 1 had duplicate metoprolol orders. This failure had the potential to cause harm to Resident 1. Residents Affected - Few Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications should be administered in accordance with prescriber orders, including any required time frames. Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident had the diagnosis of hypertension and history of falls. Review of Resident 1's physician orders showed two active orders for the metoprolol medication as follows: - metoprolol tartrate 50 mg one tablet by mouth twice a day, started on 4/13/23, and discontinued on 5/3/23. - metoprolol tartrate 50 mg one tablet by mouth twice a day, started on 4/21/23, and discontinued on 5/2/23. Review of Resident 1's MAR for April and May 2023 showed Resident 1 received metoprolol tartrate 50 mg on the following dates and times: - at 0700 hours from 4/14 to 5/3/23 - at 0900 hours from 4/11 to 4/17, 4/20 to 4/23, and 4/25 to 5/2/23 - at 1700 hours from 4/1 to 4/18, 4/20 to 4/27, and 4/29 to 5/2/23 Review of the Medication Regimen Review Report for April 2023 showed there was no recommendation from the Pharmacy Consultant regarding the use of metoprolol medication for Resident 1. On 5/3/23 at 1153 hours, an interview and concurrent medical record review was conducted with the CQA/IP who filled in as the medication cart nurse for the facility on 5/3/23. The CQA/IP stated Resident 1 had two active metoprolol orders and verified Resident 1's MAR showed the resident had received metoprolol 50 mg three times a day during April and May 2023. When asked how many doses of metoprolol Resident 1 should have received, the CQA/IP stated Resident 1 should have only received the metoprolol two times a day. The CQA/IP further stated she was unsure why there was a duplicate metoprolol order. On 5/5/23 at 1148 hours, an interview was conducted with the facility's Pharmacy Consultant . When asked about her Monthly Medication Reviews (MMR) with the facility, the pharmacy consultant stated she reviewed all residents' medication orders and MARs. The Pharmacy Consultant stated she completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 37 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility's most recent MMR on 4/26/23. When asked about Resident 1's duplicate metoprolol orders, the Pharmacy Consultant stated she either missed the duplicate order for the metoprolol or changes to the metoprolol orders were completed after her review. When asked what the risks were for a resident who received more than the ordered dose of metoprolol, the pharmacy consultant stated there was a risk of lowering the resident's heart rate and blood pressure. She further stated a resident who was overdosed on metoprolol should be monitored more frequently. On 5/5/23 at 1530 hours, the Administrator, DON, CQA/IP were informed and acknowledged the above findings. Cross reference to F684. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 38 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in a safe and secure manner when Medication Cart A was left unlocked and unattended. This failure posed the risk for non-licensed staff and visitor to have access to the medications. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2019 showed the facility stores all drugs and biologicals in a safe manner, secure, and orderly manner. Unlocked medication carts are not left unattended. On 5/3/23 at 1513 hours, Medication Cart A by the Nurse's Station A was observed unlocked and unattended. Family member from Room A and staff were observed passing by the unlocked Medication Cart A. On 5/3/23 at 1519 hours, LVN 1 was observed passing by and locked the Medication Cart A. LVN 1 acknowledged Medication Cart A was left unlocked and unattended. When asked if Medication Cart A was supposed to be left unlocked and unattended, LVN 1 stated no. On 5/3/23 at 1520 hours, LVN 3 was made aware Medication Cart A was left unlocked and unattended. An inspection of Medication Cart A was conducted with LVN 3. Medication Cart A contained the over-the-counter medications, eye drops, breathing treatments and medication bubbles packs. LVN 3 acknowledged the medication carts should not be left unlocked when unattended. On 5/5/23 at 1215 hours, an interview with the DON was conducted. When asked regarding the unlocked and unattended Medication Cart A, the DON stated the medication carts should be locked when unattended to prevent the staff, residents, or visitor to have access to the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 39 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, facility document review, and the facility P&P review, the facility failed to ensure one of four cooks (Cook 1) had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department when: * [NAME] 1 was unable to correctly calibrate a food thermometer. * [NAME] 1 failed to wash hands properly. * [NAME] 1 failed to follow the recipe for puree vegetable. These failures had the potential for unsafe food practices which could lead to foodborne illnesses in a highly susceptible population the residents who received food prepared in the kitchen. Findings: Review of the facility's document titled [NAME] Job Description - Principal Responsibilities, under the section Technical: - prepares nutritious and attractive meals and supplements for all residents in a manner. - prepare meals and supplements according to Federal, State, and Corporate requirements. - performs duties in a safe and sanitary manner. Review of the facility's document titled Standard of Performance signed by [NAME] 1 on 5/12/18, under the section Technical showed: - prepares food according to the standardized recipes. - serves food according to proper portion control, therapeutic requirements, and temperature. - prepares food under safe and sanitary conditions. Review of the facility's document titled Technical Skills Self-Assessment and Orientation Checklist for [NAME] signed by [NAME] 1 on 5/12/18, showed an orientation topic including menu, hand washing procedure, and equipment. On 5/3/23 at 1043 hours, an interview with the DSD/IP was conducted. When asked if she kept the file of employee competency evaluations, the DSD/IP stated the employee files were with the BOM. On 5/3/23 at 1051 hours, an interview with the BOM was conducted. When asked if there were more employee records for [NAME] 1, the BOM stated the facility only had one file folder for employees. On 5/4/23 at 1054 hours, an interview with the CDM was conducted. The CDM verified she conducted an annual competency for the kitchen staff; however, review of [NAME] 1's employee file did not show an annual competency evaluation done after 2018. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 40 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm 1. According to the FDA Food Code 2022, Section 4-502.11, food temperature measuring devices shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. Review of the facility's P&P titled Food Preparation and Services revised 4/2019 showed food thermometers used to check food temperatures are clean, sanitized, and calibrated. Residents Affected - Few According to ServSafe (company that provide safety training and certification for foodservice professionals) material titled How to Calibrate a Thermometer, showed thermometers should be calibrated regularly to make sure the readings are correct. The ice-point method is the most widely used method to calibrate a thermometer. According to CDN (company that sells measurement tools) material titled Cooking Thermometer dated 5/2020, under the section for How to Calibrate Your Thermometer, section for Making an Ice Slurry, showed to fill a cup measuring container with a slurry of ice water using three parts crushed ice to one part water and allow to stand for 3-5 minutes. In the section for Using the Calibration Tool on Sheath showed to immerse the stem into the middle of the ice slurry or boiling water (212 degrees Fahrenheit/100 degrees Celsius at sea level) to a depth of at least three inches. Do not let the stem touch the bottom of the container. Review of the facility's In-service Record to dietary staff conducted on 5/12/22, showed a topic on calibrating thermometers attended by [NAME] 1. On 5/3/23 at 1005 hours, a concurrent observation on food thermometer calibration and interview with [NAME] 1 was conducted. [NAME] 1 was observed filling a small cup with ice water halfway full, then inserted the CDN IRT220 food thermometer allowing the thermometer to touch the bottom and side of the cup. When asked if the thermometer should touch the bottom or side of the cup, [NAME] 1 stated she was not aware that the thermometer should not touch the bottom or side of the cup. [NAME] 1 acknowledged receiving an in-service on the food thermometer calibration; however, [NAME] 1 failed to perform the correct food thermometer calibration. 2. Review of the facility's P&P titled Food Preparation and Service revised 4/2019 showed food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illnesses. On 5/2/23 at 0902 hours, an observation in the kitchen was conducted. [NAME] 1 was observed on the dirty side of dish machine loading dirty dishes onto the dish rack, then proceeded to take the clean trays without washing her hands. On 5/3/23 at 0914 hours, an observation in the kitchen was conducted. [NAME] 1 was observed at the handwashing sink. [NAME] 1 was observed washing her hands with soap for only three seconds. On 5/5/23 at 1100 hours, an interview with [NAME] 1 was conducted. When asked regarding handwashing, [NAME] 1 did not know how long she was supposed to wash her hands. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff to perform proper hand washing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 41 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Review of the facility's In-service Records for the dietary staff showed a topic on handwashing conducted on 4/13/23, and a topic on personal hygiene conducted on 7/14/22. The facility's In-service Records showed [NAME] 1 attended the in-services; however, [NAME] 1 failed to perform the proper hand hygiene. Cross reference to F812, example #1. Residents Affected - Few 3. On 5/2/23 at 1091 hours, during the concurrent observation of puree meal preparation and interview with [NAME] 1, [NAME] 1 stated pureed food should be mashed potato consistency. [NAME] 1 was observed not following the recipe for pureed vegetables that resulted in nectar thick consistency vegetables. On 5/3/23 at 1013 hours, during an interview with the Certified Dietary Manager, the Certified Dietary Manager verified the pureed green beans served during lunch on 5/2/23, was not a correct consistency and acknowledged [NAME] 1 did not follow the recipe for pureed vegetable. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff should follow recipe when preparing food for the residents. Cross reference to F803. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 42 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and facility document review, the facility failed to ensure the puree menu was followed for six of six residents on a puree diet. Residents Affected - Few * The facility failed to follow the recipe for pureed vegetables. This failure had the potential to not meet the resident's nutritional needs. Findings: Review of the facility's document titled, Recipe: Pureed Vegetables showed for six serving recipe of vegetables, to add one to three ounces of warm fluid such as milk, or low sodium broth. Suggested amounts vary from vegetable to vegetable and some vegetables may not require any liquid at all. Under the Recipe Directions, measure out the total number of portions needed for puree diet, then puree on low speed to a paste consistency before adding any liquids, gradually add warm liquid if needed, puree on low speed, and adding stabilizer where needed. Puree should reach a consistency of applesauce. On 5/2/23 at 1019 hours, an observation of the puree meal preparation was conducted. [NAME] 1 stated pureed food should be mashed potato consistency. [NAME] 1 was observed scooping six servings of green beans using #12 scoop (1/3 cup) then added three scoops (3 ounces) of broth into the blender. [NAME] 1 pureed the green beans in the blender, then added two half teaspoons of thickener powder. [NAME] 1 verified the pureed green beans was not a correct consistency but stated it would be thicken when placed in the oven. On 5/2/23 at 1116 hours, an observation of the tray line was conducted. The pureed green beans was observed nectar thick in consistency when plated. On 5/3/23 at 1013 hours, an interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager verified the pureed green beans served during lunch on 5/2/23, was not a correct consistency and acknowledged [NAME] 1 did not follow the recipe for pureed vegetables. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff should follow the recipe when preparing food for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 43 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirement were met in the kitchen as evidenced by: Residents Affected - Some * The facility failed to ensure the kitchen staff performed proper hand hygiene. * The facility failed to ensure the expired food items in the kitchen refrigerator were discarded and food items stored in the kitchen refrigerator did not belong to the staff. * The facility failed to ensure the blender was air dried. * The facility failed to ensure the aprons worn during food production were clean. * The facility failed to ensure the cutting board was in sanitary condition. * The facility failed to ensure the cleaning cloth was stored in a sanitizing bucket in between uses. * The facility failed to ensure the food preparation sink had an air gap. These failures had the potential to cause food-borne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of residents completed by the facility dated 5/2/23, showed 26 of 28 residents in the facility received food prepared in the kitchen. 1. According to the FDA Food Code 2022, Section 2-301.12 Cleaning Procedure. (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under § 5-202.12 and Subpart 6-301. According to the FDA Food Code 2022, Section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: . (E) After handling soiled EQUIPMENT or UTENSILS. Review of the facility's P&P titled Food Preparation and Service revised 4/2019 showed food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illnesses. Review of the facility's In-service Record provided to the dietary staff conducted on 4/13/22, showed a topic for handwashing. The in-service material showed when should handwashing be done: after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 44 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some handling soiled equipment, utensils, rags, mops, or garbage and how to wash hands correctly: wash for about 20 seconds. On 5/2/23 at 0902 hours, an observation in the kitchen was conducted. [NAME] 1 was observed on the dirty side of dish machine loading dirty dishes onto the dish rack, then proceeded to take the clean trays without washing her hands. On 5/3/23 at 0914 hours, an observation in the kitchen was conducted. [NAME] 1 was observed at the handwashing sink. [NAME] 1 was observed washing her hands with soap for only three seconds. On 5/5/23 at 1100 hours, an interview with [NAME] 1 was conducted. When asked regarding handwashing, [NAME] 1 stated she did not know how long she was supposed to wash her hands. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff to perform proper hand washing. 2. Review of the facility's P&P titled Refrigerators and Freezers revised 12/2014 showed the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. The supervisors will be responsible for ensuring food items in the pantry, refrigerators, and freezers are not expired or past perish dates. Review of the facility's document titled Refrigerated Storage Guide undated, showed the non-dairy creamer should be stored for one week or longer per manufacturers date. Review of the facility's In-service Records with dietary staff conducted on 1/19/23, showed an in-service topic on no personal food in the kitchen refrigerator. The in-service material showed a P&P for Employee Meals showing food brought by employees from outside the facility shall not be kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen and employees bringing food from outside the facility may not keep their food in the refrigerator used to store food for the residents. They may bring food which can be kept in the employee lounge and food may be kept in a refrigerator supplied for the employees in the employee lounge. On 5/2/23 at 0812 hours, an inspection of the kitchen refrigerator was conducted and observed the following in the kitchen refrigerator: - a bottle of hazelnut flavored non-dairy coffee creamer labeled with Resident 15's name and dated 4/13/23, and - a bottle of french vanilla flavored non-dairy coffee creamer labeled with a first name and dated 4/17/23. The bottle of non-dairy coffee creamers showed to keep refrigerated and for best quality, use within 14 days of opening. On 5/2/23 at 0813 hours, a concurrent observation and interview with [NAME] 1 was conducted. After showing the non-dairy coffee creamer label to [NAME] 1, [NAME] 1 verified the dates when the non-dairy coffee creamers were opened and acknowledged it was stored in the kitchen refrigerator beyond 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 45 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/2/23 at 1059 hours, a concurrent observation and interview was conducted with the Certified Dietary Manager. The bottles of non-dairy coffee creamer were not observed inside the kitchen refrigerator. The Certified Dietary Manager acknowledged the bottles of non-dairy coffee creamers were stored in the refrigerator for more than 14 days after opening and the Certified Dietary Manager discarded the bottles. On 5/4/23 at 1054 hours, a follow-up interview with the Certified Dietary Manager was conducted. When asked to verify who the bottle of french vanilla flavored coffee creamer belong to, the Certified Dietary Manager verified the french vanilla flavored non-dairy creamer belonged to the Business Office Manager. The Certified Dietary Manager verified the employee's food items should not be stored in the kitchen refrigerator. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the expired food in the kitchen refrigerator should be discarded. 3. According to the FDA Food Code 2022, Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, and utensils: Equipment (A) Shall be air-dried . Review of the facility's P&P titled Sanitation revised 10/2008 showed food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. On 5/2/23 at 0842 hours, the blender was observed on the drying cart with the cover on. The blender was observed with water inside. On 5/2/23 at 0900 hours, a concurrent observation and interview with the Certified Dietary Manager was conducted. When asked if the blender should be air dried with the cover on, the Certified Dietary Manager acknowledge it should be air dried with the cover off. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified kitchen equipment should be air dried. 4. Review of the facility's P&P titled Food Preparation and Services revised 4/2019 showed food and nutrition services employees prepare and serve the food in a manner that complies with safe food handling practices and food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Review of the facility's In-service Records with dietary staff conducted on 7/14/22, showed an in-service topic of Personal Hygiene. The in-service attached material showed under proper attire to use clean apron and change aprons when soiled. On 5/2/23 at 0856 hours, an observation of the janitor's closet/employee storage located in the kitchen was conducted. One multi-colored apron and one black apron were observed hanging on the wall touching a dustpan. On 5/2/23 at 0900 hours, a concurrent observation and interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager verified the aprons were stored in the janitor's closet/employee's storage touching the dustpan. On 5/2/23 at 1015 hours, an observation of janitor's closet/employee storage was conducted. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 46 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 multi-colored and black aprons were not observed in the closet. Level of Harm - Minimal harm or potential for actual harm On 5/2/23 at 1017 hours, an observation in the kitchen was conducted. The Certified Dietary Manager was observed wearing the multi-colored apron washing dishes and [NAME] 2 was wearing a black apron prepping food for lunch. An interview with [NAME] 2 was conducted. When asked where [NAME] 2 got the black apron she was wearing, [NAME] 2 stated she got the black apron from the storage. Residents Affected - Some On 5/4/23 at 1054 hours, an interview with the Certified Dietary Manager was conducted. When asked regarding the two aprons touching the dustpan in the employee storage, the Certified Dietary Manager acknowledge the aprons were dirty and should not be worn during the food production. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the aprons worn in kitchen should be taken home every day and washed. 5. According to the FDA Food Code 2022, Section 4-501.12 Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Review of the facility's P&P titled Sanitization revised 10/2008 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning. On 5/3/23 at 0913 hours, an observation in the kitchen was conducted. A green cutting board was observed with rough surfaces. On 5/3/23 at 0919 hours, a concurrent observation and interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager acknowledged the green cutting board had rough surfaces and needed to be replaced. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the cutting board should have a cleanable smooth surface. 6. According to the FDA Food Code 2022, Section 3-304.14 Wiping Cloths, Use Limitation . (B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution . Review of the facility's P&P titled Sanitization revised 10/2008 showed between uses, cloth and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if solution becomes cloudy or visibly dirty. On 5/3/23 at 1007 hours, an observation in the kitchen was conducted. A cleaning cloth was observed on top of the ice cream freezer. When the kitchen staff was asked if the cleaning cloth was supposed to be on top of the freezer, [NAME] 1 was observed taking the cleaning cloth and placed it on top of the food preparation table. On 5/3/23 at 1008 hours, a concurrent observation and interview with [NAME] 2 was conducted. [NAME] 2 stated cleaning cloth should be in the red sanitizing bucket when not in use. [NAME] 2 was observed taking the cleaning cloth from the food preparation table and placed the cleaning cloth in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 47 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 dirty laundry area. Level of Harm - Minimal harm or potential for actual harm On 5/3/23 at 1018 hours, an interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager stated the cleaning cloth should be soaked in the red bucket sanitizing solution when not in use. Residents Affected - Some On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified cleaning cloths should be stored in red bucket sanitizing solution in between uses. 7. According to the FDA Food Code Annex 2022: 5-402.11 Backflow Prevention. Improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces. According to the FDA Food Code 2022, Section 5-402.11 Backflow Prevention. Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. On 5/3/23 at 1010 hours, a concurrent observation and interview was conducted with the kitchen staff. Cooks 1 and 2 verified the rinse sink was used as food preparation sink. The under-sink pluming was observed without an air gap. On 5/3/23 at 1023 hours, an interview with Certified Dietary Manager was conducted. The Certified Dietary Manager verified the rinse sink was being used as food preparation sink. On 5/3/23 at 1515 hours, a concurrent observation and interview with the Administrator was conducted. The Administrator acknowledged the rinse sink did not have an air gap. The Administrator stated the facility was aware and was working on getting the sink fixed. The facility was unable to provide documentation on how the facility was fixing the food preparation sink air gap. On 5/3/23 at 1530 hours, an interview with the Maintenance Staff was conducted. When asked if he was aware of the rinse sink had no air gap, the Maintenance Staff stated he was made aware this morning. On 5/4/23 at 1118 hours, an interview with the Maintenance Supervisor was conducted. When asked if he was aware of the rinse sink had no air gap, the Maintenance Supervisor stated he was made aware this morning. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the food preparation sink should have an air gap. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 48 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to implement their P&P to ensure food items brought to the resident from outside were handled to ensure safe storage, preparation, and consumption for one of the 14 final sampled residents (Resident 26) and one of nonsampled resident (Resident 25). Residents Affected - Few * The facility failed to ensure Resident 26's food items from outside were properly stored. * The facility failed to discard Resident 25's expired mango drink in the resident's refrigerator. * The facility failed to provide the family/visitors a copy of the facility's P&P for Food Brought by Family/Visitors. * The facility failed to provide in-service to the facility staff on safe food handling. * The facility failed to store Resident 25's perishable food items brought from outside were properly stored. These failures posed the risk of resident food brought to the facility from outside not being handled in a safe manner which posed the risk of food borne illnesses. Findings: Review of the facility's P&P titled Food Brought by Family/Visitors revised 10/2017 showed the following: - Nursing staff will provide family/visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format he or she can understand. - All personnel involved in preparing, handling, serving, or assisting the resident with meals or snacks will be trained in safe food handling practices. - Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. - Potentially hazardous food that are left out for resident without a source of heat or refrigeration longer than two hours will be discarded. 1. On 5/2/23 at 1143 hours, an observation of the resident's refrigerator located in the dining room was conducted. An undated food in a sealed plastic container and undated food item wrapped in foil labeled with Resident 26' name were observed in the resident's refrigerator. On 5/2/23 at 1158 hours, a concurrent observation and interview was conducted with the DSD/IP. The DSD/IP verified Resident 26's food items were undated and should have been dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 49 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the facility's P&P titled Food Brought by Family/Visitors revised 10/2017 showed the nursing staff will discard perishable foods on or before the use by date. On 5/2/23 at 1143 hours, an observation of the resident's refrigerator inside the dining room was conducted. Resident 25's open bottle of mango drink with an expiration date of 4/12/23, was observed inside the resident's refrigerator. On 5/2/23 at 1158 hours, a concurrent observation and interview was conducted with the DSD/IP. The DSD/IP acknowledged Resident 25's mango drink had expired on 4/12/23, and should have been discarded on or before the expiration date. 3. On 5/3/23 at 0950 hours, an interview with the DON was conducted. When asked if the nursing staff provided a copy of the facility's Food Brought by Family/Visitors P&P to the resident's responsible party, the DON stated the facility's P&P was included in the facility's admission packet. On 5/3/23 at 1028 hours, an interview with the Business Office Manager was conducted. When asked if the facility's P&P for Food Brought by Family/Visitors was included in the admission packet, the Business Office Manager verified it was not included in the admission packet. 4. On 5/3/23 at 0830 hours, an interview with the DSD/IP was conducted. When asked if the facility provided in-service to the staff on safe food handling, the DSD/IP stated there was no documentation of the staff in-service on safe food handling. On 5/3/23 at 0950 hours, an interview with the DON was conducted. The DON verified there was no documentation of the staff in-service on safe food handling. 5. On 5/2/23 at 0833 hours, an observation and concurrent interview was conducted with Resident 25. Resident 25 was observed to have the following food items at the bedside: - an undated, opened black plastic container with sliced oranges; - an undated, opened black plastic container with pineapple chunks and grapes; - an undated clear plastic bag of cookies; - an unopened package of uncured ham and cheese lunch kit observed with a keep refrigerated label. Resident 25 stated her friend brought the food to the facility the day before. On 5/3/23 at 0755 hours, an observation and concurrent interview was conducted with Resident 25. Resident was observed to have the following food items at the bedside: - an undated, opened black plastic container with pineapple chunks and grapes; - an unopened package of uncured ham and cheese lunch kit observed with a keep refrigerated label; -an undated, unopened chocolate and vanilla pudding; and -a bowl of yogurt dated 5/2/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 50 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 25 stated she ate half of the pineapple chunks and all the sliced oranges during breakfast. Resident 25 stated the facility staff gave her the pudding and bowl of yogurt the night before. On 5/3/23 at 0816 hours, an interview was conducted with the DSD/IP. The DSD/IP verified Resident 25 had unlabeled and undated food items at the bedside. The DSD/IP stated the yogurt, pudding, cut-up fruits and packaged uncured ham and cheese lunch kit were perishable food and required refrigeration. On 5/4/23 at 1103 hours, a follow-up interview was conducted with the DSD/IP. The DSD/IP stated she had not provided the staff any training of safe food handling practices. On 5/4/23 at 1425 hours, an interview was conducted with the DON. The DON stated perishable food items from home, including sliced oranges, pineapple chunks, and packaged uncured ham and cheese lunch kit, should be refrigerated, labeled, and dated to prevent food borne illnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 51 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nutritional assessments were performed by a qualified RD for one of 14 final sampled residents (Resident 1) when the Dietary Manager who did not meet the qualifications and skill set performed the assessment of the facility's residents' nutritional status. This failure posed the risk for residents' nutritional needs to not be met. Findings: The online dictionary defines review as a formal assessment or examination of something with the possibility of intention of instituting change if necessary this definition, therefore, implies a review as an assessment, a role designated for the RD. Based on state regulations (California business and professions code 2586), the RD is the professional permitted to conduct medical nutrition therapy which includes assessment, determination of nutrition diagnosis and recommendation and implementation of nutrition care and intervention. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Review of the facility document titled Director, Nutritional Services Job Description signed and dated by the Certified Dietary Manager on 9/12/16, showed the following: - Principle Responsibilities: Clinical: ensures the timely preparation and delivery of nutritious and attractive meals and supplements to all residents according to physician order and in compliance with Federal, State and company requirements. Maintains a safe and sanitary working environment. Ensures that meals are served according to expressed resident preferences. Plan, implements and revises menus to meet resident needs. Interacts effectively with other resident services according to total care plan approach. Review of the electronic medical record for Resident 1 and concurrent phone interview was conducted with the RDN on 5/04/23 at 1321 hours. The RDN confirmed the Certified Dietary Manager completed the quarterly nutrition evaluations for all residents. The quarterly nutrition evaluation for Resident 1 dated 12/1/22, was reviewed with the RDN. The RDN confirmed the quarterly nutrition evaluation showed Resident 1's weight of 139 lbs was from 11/1/22. The RDN confirmed the quarterly nutrition evaluation showed Resident 1 had not lost weight, was not at weight loss risk, was not at dehydration risk, did not have any nutrition interventions/recommendations, and showed to continue to monitor monthly weights and po intake. The RDN agreed the 12/2/22 weight of 136 lbs should have been included in the December quarterly nutrition evaluation and the insidious weight loss of seven lbs (6%) from 9/1/2022 to 12/2/2022, should have been addressed in the quarterly nutrition evaluation. The RDN further agreed that Resident 1 was at risk for weight loss and dehydration due to poor po intake. The RDN confirmed the nutrition evaluation form did not include resident's po intake. The RDN was asked if she reviewed the quarterly nutrition evaluations that were completed by the Certified Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 52 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Manager. The RDN confirmed she did not review the quarterly nutrition evaluations completed by the Certified Dietary Manager. The RDN further stated she was not aware the Certified Dietary Manager was not a qualified individual to perform nutrition evaluations. On 5/5/23 at 1331 hours, an interview was conducted with the Administrator. The Administrator was not aware a Certified Dietary Manager was not qualified to complete resident assessments. The Administrator was not aware of the California business and professions code 2586 that the RD was the professional permitted to conduct medical nutrition therapy which included assessment, determination of nutrition diagnosis, and recommendation and implementation of nutrition care and intervention. The Administrator agreed the RD should be cosigning or completing the quarterly nutrition evaluations. Cross reference to G692, example #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 53 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection practices to help prevent the development and transmission of diseases and infection for three of 14 final sampled residents (Residents 5, 529, and 729). Residents Affected - Few * The facility failed to ensure the licensed nurse performed hand hygiene during wound care treatment for Resident 529. * The facility failed to store Resident 729's nebulizer equipment in a sanitary condition. * The facility failed to ensure the urinary catheter tubing and bag were kept off the floor for Resident 5. These failures have the potential risk for transmission of disease-causing microorganisms and infections to the residents. Findings: 1. Review of the facility's P&P titled Handwashing/ Hand Hygiene revised 8/2019 showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The use of gloves does not replace handwashing/hand hygiene. Use of an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations: - before and after direct contact with residents; - before handling clean or soiled dressings, gauze pads, etc.; - before moving from a contaminated body site to a clean body site during resident care; - after handling used dressings, contaminated equipment, etc.; - after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; - after removing gloves Medical record review for Resident 529 was initiated on 5/3/23. Resident 529 was readmitted to the facility on [DATE]. Review of Resident 529's Order Summary Report dated April 2023, showed a physician's treatment order dated 5/3/23, for the right and left great toes surgical site to cleanse with normal saline, pat dry, paint with betadine, cover with a gauze and ABD (an abdominal wound dressing), and wrap with kerlix and ACE bandage (elastic bandage wrap) every other day for 21 days. On 5/3/23 at 1054 hours, a wound care observation for Resident 529 was conducted with LVN 1. LVN 1 was observed placing a white disposable drape underneath Resident 529's bilateral feet with gloves on. LVN 1 proceeded to remove the old ACE bandage from the right foot, and then removed the ACE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 54 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bandage from the left foot, then threw the ACE bandages to the trash can. LVN 1 doffed her gloves and donned new gloves without performing handwashing or hand hygiene. LVN 1 placed another white disposable drape underneath Resident 529's bilateral feet one at a time. LVN 1 continued to cut the wrapped gauze bandage with a scissors on the right foot, then the left foot. After removing Resident 529's old and soiled dressing, LVN 1 patted the right foot surgical toe wound with a gauze to dry, painted the wound with betadine twice, opened a new rolled gauze from its container, removed the gloves, and put on the new gloves without performing handwashing or hand hygiene. LVN 1 proceeded to providing treatment to the left great toe surgical wound. After the left great toe surgical wound was painted with iodine swabs and covered with a gauze, LVN 1 removed the gloves and put on the new gloves without performing handwashing or hand hygiene. On 5/3/23 at 1132 hours, LVN 1 was informed of the observations during wound care treatment for Resident 529. LVN 1 acknowledged the above findings and further stated she was not aware she missed performing handwashing or hand hygiene in between changing from the old gloves to new gloves. LVN 1 stated it was important to perform hand hygiene for infection control purposes. On 5/3/23 at 1624 hours, an interview was conducted with the DSD/IP. The DSD/IP stated the staff were supposed to perform the hand hygiene during the dressing change and in between changing gloves to prevent cross contamination or spread of bacteria. 5. Review of the facility's P&P Catheter Care Urinary revised September 2014 showed under Infection Control: urinary catheter tubing and drainage bags should be kept off the floor. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE], with diagnoses including UTI and sepsis. On 5/2/23 at 0834 hours, during an initial tour of the facility, Resident 5's indwelling urinary catheter tubing and bag were observed on the floor. On 5/2/23 at 0910 hours, and 5/3/23 at 0803 hours, during the observations, Resident 5's indwelling urinary catheter tubing was observed on the floor. On 5/3/23 at 0815 hours, a concurrent interview and observation was conducted with CNA 2. Upon observing Resident 5's urine catheter system, CNA 2 verified Resident 5's indwelling urinary catheter tubing was on the floor. CNA 2 further stated no part of the urine catheter system should be on the floor. On 5/4/23 at 0907 hours, an interview was conducted with the DSD/IP. When asked, the DSD/IP stated indwelling urinary catheter tubings and bags should not be on the floor. On 5/5/23 at 1530 hours, the Administrator, DON, CQA/IP Nurse were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) Nebulizer revised October 2010 showed to rinse and disinfect the nebulizer equipment according to facility protocol and when the equipment is completely dry, store in a plastic bag with the resident's name and the date on it. On 5/3/23 at 0746 hours, an observation and concurrent interview was conducted with Resident 729. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 55 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 729's nebulizer mask was observed on top of magazines on her bedside table. Resident 729 stated she last used the nebulizer mask around one hour ago. On 5/3/23 at 0800 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 729's nebulizer mask was on the resident's bedside table and on top of her magazines. LVN 1 was observed placing the nebulizer mask inside a labeled plastic bag, which was hanging on Resident 729's oxygen concentrator. LVN 1 stated Resident 729's nebulizer mask should be stored inside the plastic bag to keep the nebulizer mask clean. On 5/4/23 at 1012 hours, an interview was conducted with the DSD/IP. When asked about the proper storage of the nebulizer mask after use, the DSD/IP stated the nebulizer mask should be rinsed with water and dried with a paper towel, then stored inside a labeled plastic bag to keep the equipment sanitary. The DSD/IP stated she had not provided the licensed nurses in-services regarding the proper storage of the nebulizer equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 56 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 potential for actual harm Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential equipment was maintained according to the manufacturer's recommendations. Residents Affected - Some * The facility failed to ensure the ice machine cleaning instructions were followed. This failure had the potential to affect the equipment not functioning in the way it was intended which could affect the health status of the residents. Findings: Review of the facility's P&P titled Ice Machines and Storage Chest revised 1/2012 showed the facility has established procedures for cleaning and disinfecting the ice machines and ice storage chests which adhere to the manufacturer's instructions. Review of the facility's P&P titled Sanitization revised 10/2008 showed the ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the document titled WS 12000 Annual PM Guide provided by the facility showed the WS 12000 Unit needs preventive maintenance every year and to follow the appropriate instructions. Under Part 1: Sanitizing the Unit, it showed list of items needed including hydrogen peroxide. On 5/3/23 at 0919 hours, an interview with the Certified Dietary Manager was conducted. When asked about the facility's ice machine, the Certified Dietary Manager showed an ice maker/water dispenser machine in the dining room which was currently not working. On 5/3/23 at 1337 hours, an interview was conducted with the Certified Dietary Manager. When asked for the ice machine maintenance log, the Certified Dietary Manager was unable to provide the log for the ice machine/water dispenser. On 5/4/23 at 0940 hours, a concurrent observation and interview with the Vendor Personnel was conducted. The Vendor Personnel stated the ice machine/water dispenser unit required yearly cleaning and filter changed. The Vendor Personnel stated per company record, the last ice machine/water dispenser maintenance was done on 2/5/22. The Vendor Personnel showed the bottles of Nu-Calgon sanitizing solution and Manitowoc ice machine sanitizer being used to clean the ice machine. The sanitizing solution samples provided by the Vendor Personnel did not match the solution in the WS 12000 Annual PM Guide. On 5/4/23 at 0940 hours, during the inspection of ice machine/water dispenser conducted by the Vendor Personnel, the Administrator stated the last ice machine maintenance was not 2/5/22, however, the Administrator was unable to provide documentation to show when the ice machine/water dispenser was cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 57 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all the bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment for seven of 14 final sampled residents (Residents 5, 8, 9, 21, 24, 26, and 529). This failure had the potential to negatively impact the residents resulting to entrapment, serious injuries, 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 Bed Safety revised 12/2007 showed to try to prevent deaths/injuries from the beds and related equipment (including the frames, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote that the following approaches: - Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - Review that gaps within the bed system are within the dimensions established by the FDA; - Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; - Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 58 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA Committee for appropriate action. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. Residents Affected - Some 1. On 5/2/23 at 0838 hours and 5/3/23 at 0756 hours, Resident 9 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 9 was initiated on 5/2/23. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE], showed Resident 9 was moderate cognitively impaired and required extensive assistance on two staff for bed mobility. Further medical record review for Resident 9 did not show informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 2. On 5/2/23 at 0842 hours, 5/3/23 at 0806 hours, and 5/4/23 at 0818 hours, Resident 529 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 529 was initiated on 5/2/23. Resident 529 was readmitted to the facility on [DATE]. Review of Resident 529's H&P examination dated 4/9/23, showed Resident 529 had the capacity to understand and make decisions. Review of Resident 529's MDS dated [DATE], showed Resident 529 required extensive assistance on one staff for bed mobility. Further review of Resident 529's medical record did not show an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 3. On 5/2/23 at 1413 hours, Resident 24 was observed sitting at the edge of the bed with bilateral half side rails elevated. Medical record review for Resident 24 was initiated on 5/4/23. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's MDS dated [DATE], showed Resident 24 had severe cognitive impairment. Review of Resident 24's H&P examination dated 2/5/23, showed Resident 24 had diagnosis of recurrent seizures. Review of the Resident 24's Order Summary Report dated May 2023 showed a physician's order dated 3/2/23, may have bilateral upper side rails up while in bed for mobility and repositioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 59 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Further review of Resident 24's medical record did not show documentation of informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 4. On 5/2/23 at 0906 hours, Resident 26 was observed in bed with bilateral half side rails elevated. Residents Affected - Some Medical record review for Resident 26 was initiated on 5/2/23. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's MDS dated [DATE], showed Resident 26 required one staff extensive assistance for bed mobility. Review of Resident 26's Order Summary Report dated May 2023, showed a physician's order dated 3/28/23, may have bilateral upper side rails up while in bed for increased bed mobility and repositioning Further review of Resident 26's medical record did not show documentation of an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 5. On 5/2/23 at 0834 hours and 5/3/23 at 0809 hours, Resident 8 was observed in bed with bilateral side rails elevated. Medical record review for Resident 8 was initiated on 5/2/23. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 had severe cognitive impairment and required extensive assistance of two person for bed mobility. Review of Resident 8's Order Summary Report dated May 2023 showed a physician's order dated 2/25/23, may have side rails up while in bed for increased mobility and repositioning. Further review of Resident 8's medical record did not show documentation of an informed consent from the resident and/or representative for the potential risks and benefits of the use of the bed side rails nor completed an entrapment assessment. 6. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE]. On 5/2/23 at 0834 hours during initial tour of the facility, Resident 5 was observed asleep in bed with the upper bilateral side rails elevated. On 5/3/23 at 1136 hours, during an observation, Resident 5 was observed in bed with upper bilateral side rails. Review of Resident 5's H&P examination dated 12/24/22, showed Resident 5 did not have the capacity to understand or make decisions. Review of Resident 5's MDS dated [DATE], showed Resident 5 required total dependence on staff for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 60 of 61 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 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 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 bed mobility and required more than two staff for assistance. Level of Harm - Minimal harm or potential for actual harm Review of Resident 5's Physician Orders showed an order dated 1/27/23 for bilateral upper side rails while in bed for mobility and repositioning. Residents Affected - Some 7. Medical record review for Resident 21 was initiated on 5/2/23. Resident 21 was admitted to the facility on [DATE], with a diagnosis of dementia. On 5/2/23 at 0815 hours during an initial tour of the facility, Resident 21 was observed with the upper bilateral side rails elevated. On 5/3/23 at 0800 hours during an observation, Resident 21 was observed asleep in bed with the upper bilateral side rails elevated. Review of Resident 21's H&P examination dated 12/01/22, showed Resident 21 did not have the capacity to understand or make decisions. Review of Resident 21's MDS dated [DATE], showed Resident 5 required extensive assistance from staff for bed mobility. Review of Resident 21's Physician Orders showed an order dated 11/21/23, for bilateral upper side rails while in bed for mobility and repositioning. Further review of the facility document showed these residents' beds with side rails use were not regularly inspected for possible entrapment. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON was asked if any measurements were done for the beds with side rails nor an entrapment assessment was completed. The DON stated she had not seen any form done for the measurements of the bed nor entrapment assessments. On 5/4/23 at 1108 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he measured the side rails and bed only once before the pandemic. The Maintenance Supervisor was asked the process of installing the side rail in the bed. The Maintenance Supervisor stated the DSD before gave him a list of residents needed the side rails installed in the bed. Then, the Maintenance Supervisor stated he would measure the bed per the guidelines, document what was given from the DSD before, and would install the side rails to the bed. The Maintenance Supervisor further stated there were new beds purchased since the last measurements of the other beds in the building, but he was unable to locate the new beds in the building. The Maintenance Director was asked to provide the documents to show he measured the beds to prevent entrapment, however, he stated the previous DSD had them and was not able to show any documentations of the measurements of the beds. On 5/4/23 at 1124 hours, an interview was conducted with the DSD/IP. The DSD/IP stated she had not dealt with the side rails in the facility. The DSD/IP was asked if she could provide the records for the side rail assessments. The DSD/IP stated she would not keep the resident's assessments in her file. The DSD/IP further stated the side rail assessment should be in each resident's medical record and if the assessments were not found in resident's medical record, then there were no documents completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 61 of 61

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

30 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0580GeneralS&S Bno actual harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0692SeriousS&S Gactual harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0700GeneralS&S Epotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0802GeneralS&S Dpotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0813GeneralS&S Dpotential for harm
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
0836GeneralS&S Dpotential for harm
F836 - Licensure
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0908GeneralS&S Epotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0909GeneralS&S Epotential for harm
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
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.
0923GeneralS&S Dpotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
0030GeneralS&S Cno actual harm
List the names and contact information of those in the facility.
0037GeneralS&S Dpotential for harm
Establish staff and initial training requirements.
0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0712GeneralS&S Dpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0741GeneralS&S Dpotential for harm
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
0918GeneralS&S Epotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0920GeneralS&S Dpotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.

FAQ · About this visit

Common questions about this visit

What happened during the May 5, 2023 survey of STANLEY HEALTHCARE CENTER?

This was a inspection survey of STANLEY HEALTHCARE CENTER on May 5, 2023. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at STANLEY HEALTHCARE CENTER on May 5, 2023?

Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·May 5, 2023