Inspection·March 14, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm On 3/13/24 at 0910 hours, Resident 130 was observed lying in bed watching TV. The call light was observed hanging down from the bed rail. When asked about the call light, Resident 130 stated he preferred to have it within reach at all times. He further stated he felt safer when he could call for help by pressing the call light button. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 2 of 43 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 03/14/2024 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 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** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary timely assistance with the execution of an advance directive for healthcare and failed to ensure the POLST and Advance directive acknowledgement form was obtained for two of 14 final sampled residents (Residents 12 and 18). * Resident 18 was admitted to the facility on [DATE] and she informed the facility on 1/16/24, that she wished to execute an advance directive for health care. The facility attempted to contact the Ombudsman on 1/19/24, to schedule a time in which the Ombudsman could sign Resident 18's advance directive; however, the facility failed to follow up with the Ombudsman and Resident 18 had yet to formulate an advance directive. * The facility failed to ensure the POLST and Advance directive acknowledgement form were obtained from Resident 12's responsible party. These failures had the potential for the residents' decisions regarding their healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives revised 12/2016 showed if the resident indicates that she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 1. Medical record review for Resident 18 was initiated on 3/11/24. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 1/12/24, showed Resident 18 had the capacity to understand and make decisions. Review of Resident 18's Advance Directive Acknowledgement dated 1/16/24, showed Resident 18 had not executed an advance directive, and wished to execute an advance directive. Review of Resident 18's Social Services Note dated 1/19/24 at 1230 hours, showed Resident 18's family member (Family Member 1) was given information regarding the advance directive for healthcare. The SSD/AD documented she reached out to the Ombudsman for the schedule, to schedule a time to come to the facility to sign (the advance directive). The SSD/AD documented she was waiting for the Ombudsman's reply. On 3/12/24 at 0910 hours, an interview was conducted with Resident 18. Resident 18 stated she had yet to formulate an advance directive for health care. Resident 18 stated she wished to have Family Member 1 act as her power of attorney specific to health care decisions. On 3/12/24 at 0937 hours, an interview and concurrent medical record review was conducted with the SSD/AD. The SSD/AD verified Resident 18's Advance Directive Acknowledgement dated 1/16/24, showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 3 of 43 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 03/14/2024 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 Resident 18 had not executed an advance directive and Resident 18 wished to execute an advance directive. The SSD/AD verified she documented in her Social Services Note dated 1/19/24 1230 hours, that she provided Family Member 1 with information specific to advance directive for healthcare. The SSD/AD verified she reached out to Ombudsman (on 1/19/24) in an attempt to schedule a time in which the Ombudsman could come to the facility, to sign Resident 18's advance directive for healthcare; however, the SSD/AD was waiting for the Ombudsman to reply. Further review of Resident 18's medical record failed to show any documentation (after 1/19/24) specific to Resident 18 formulating an advance directive for healthcare. The SSD/AD verified the findings and stated she should have followed up with the Ombudsman within two weeks from her first attempt to contact the Ombudsman on 1/19/24, in order to facilitate Resident 18's request to formulate an advance directive for healthcare. 2. Medical record review for Resident 12 was initiated on 3/11/24. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 12's responsible party was listed as self. Review of Resident 12's H&P Examination dated 11/5/23 and 3/10/24, showed Resident 12 did not have the capacity to understand and make decisions and Resident 12's surrogate decisionmaker was the resident's daughter. Review of Resident 12's Physician Orders for Life-Sustaining Treatment (POLST) dated 11/3/23, showed a signature by Resident 12 under Section D, signature of patient or legally recognized decisionmaker. Review of the Advance Directive Acknowledgement form dated 11/3/23, showed Resident 12's acknowledgement of information regarding an Advance Directive. The form showed two areas for signature, one for resident with decision making capacity and another for resident without decision making capacity. However, Resident 12's signature was under option for the resident with decision making capacity. Review of the Consent to Treat dated 11/3/23 and 3/11/24, showed Resident 12's responsible party was herself and had signed the Consent to Treat forms. On 3/12/24 at 0910 to 0917 hours, an interview and concurrent record review was conducted with the SSD/AD and Business Office Manager. The SSD/AD stated Resident 12's responsible party was herself. The SSD/AD was asked how the responsible party was determined. The SSD/AD stated it would be if the person had the capacity to make decisions, they could be the responsible party if he/she wished to. The SSD/AD stated the capacity would be based on the H&P examination. The SSD/AD and Business Office Manager were informed and verified the POLST and consents should have been updated to be signed by Resident 12's responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 4 of 43 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 03/14/2024 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to obtain the physician's order for the discharge to home as well as documentation of the physician's notification upon leaving the facility for one of two closed medical records reviewed (Resident 28). This failure had the potential to affect the health and safety of the resident during the transition of care. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation last revised on 12/2016 showed the details of the transfer/discharge will be documented in the medical record and appropriate information will be communicated to the provider. On 3/13/24 at 0956 hours, closed medical record review was conducted for Resident 28 and showed Resident 28 was admitted to the facility for respite care from 12/10/23 to 1/3/24, and discharged home on 1/3/24. However, there was no physician's order for the resident's discharge in the closed medical record. Further review of Resident 28's Discharge summary dated [DATE], showed, Resident went home with wife on 1/3/24. Nurse reviewed medications with wife and returned all remaining medications and belongings at time of discharge. There was no documented evidence the physician was notified of the resident's discharge from the facility on 1/3/24. On 3/13/24 at 1057 hours, an interview conducted with DON. The DON verified there was no physician's order for th resident's discharge. The DON further stated a physician's order must be obtained for a safe discharge as well as ensuring the progress note showing the physician was notified at the time of discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 5 of 43 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 03/14/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDS discharge assessment was completed for one nonsampled resident (Resident 26). This failure posed the risk for not being able to monitor the resident's decline and progress over time. Residents Affected - Some Findings: Closed medical record review for Resident 26 was initiated on 3/11/24. Resident 26 was admitted to the facility on [DATE], and discharged home on [DATE]. Review of Resident 26's MDS discharge assessment dated [DATE], showed the facility failed to entered the data specific to section J0200 (Pain assessment interview) and the MDS discharge assessment dated [DATE], was subsequently rejected by the CMS system. On 3/14/24 at 1425 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON stated Resident 26 was discharged home on [DATE]. The DON verified Resident 26's MDS discharge assessment dated [DATE], was rejected. The DON reviewed Resident 26's rejected MDS discharge assessment dated [DATE], and determined the MDS discharge assessment was rejected as a result of the facility having failed to enter data specific to section J0200 (Pain assessment interview). The DON stated she would ensure the required data was added to the MDS discharge assessment and would then resubmit the MDS discharge assessment (to the CMS system). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 6 of 43 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 03/14/2024 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 0655 Level of Harm - Potential for minimal harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of two closed record sampled residents (Resident 27) was initiated upon admission. This failure had the potential for Resident 27 to not receive the necessary care and services in accordance with his care needs. Findings: Review of the facility's P&P titled Care Plan-Baseline revised 12/2016 showed to assure the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Closed medical record review for Resident 27 was initiated on [DATE]. Resident 27 was admitted to the facility on [DATE], and had expired on [DATE]. Review of Resident 27's closed medical record failed to show a baseline care plan was initiated for Resident 27. On [DATE] at 1358 hours, an interview and concurrent closed medical record review for Resident 27 was conducted with the DON. The DON verified the above findings. The DON verified Resident 27 did not have a baseline care plan. The DON stated the purpose of the baseline care plan was to ensure the basic needs of the residents are met. The DON further stated on admission, the admitting nurse was responsible for initiating the baseline care plan. On [DATE] at 1637 hours, the DON and Administrator 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 43 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 03/14/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for two of 14 final sampled residents (Residents 16 and 19). Residents Affected - Few * Resident 16 was evaluated to have blanchable redness to his left hip on 1/19/24. Resident 16 developed with DTI on the left hip on 2/11/24. The facility failed to ensure Resident 16's left hip was reassessed per the physician's order. The facility failed to provide the appropriate and necessary services to ensure Resident 16 did not develop a pressure ulcer in the facility. * The facility failed to ensure the LAL mattress setting was consistent with Resident 19's weight. These failures had the potential for the residents to develop the pressure ulcers or worsening of existing pressure ulcers. Findings: Review of the facility's P&P titled Prevention of Pressure Ulcers/Injuries revised 1/2017 showed to evaluate, report and document potential changes in the skin and review the interventions and strategies for effectiveness on an ongoing basis. Review of the National Pressure Injury Advisory Panel's (NPIAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries dated 2019 showed maintaining skin integrity is essential in the prevention of pressure injures. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage. The NPIAP defines the pressure ulcer stages as follows: - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. - Suspected Deep Tissue Injury (DTI) - intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 8 of 43 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 03/14/2024 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 0686 tissue injury or may resolve without tissue loss. Level of Harm - Minimal harm or potential for actual harm 1. Medical record review for Resident 16 was initiated on 3/11/24. Resident 16 was readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 16's MDS dated [DATE], showed Resident 16 had severe cognitive impairment and was dependent on the assistance of staff to roll to left and right. Review of Resident 16's Braden Risk Assessment Report dated 12/20/23, showed Resident 16 was at high risk for developing pressure injuries. Review of the Physician's Telephone Order dated 1/19/24, showed to cleanse with normal saline, pat dry to the left hip redness, apply skin barrier every shift for 14 days and evaluate. * Review of Resident 16's medical record failed to show a progress note or skin assessment completed regarding the change in Resident 16's skin on 1/19/24. * Further review of Resident 16's medical record showed Resident 16's skin was monitored for three days after the physician was notified of the left hip redness, however, there was no documented evidence a skin evaluation was completed 14 days after the physician's order on 1/19/24. Further review of the resident's medical record failed to show any additional assessment regarding Resident 16's left hip until 2/11/24. Review of Resident 16's Wound Assessment Report dated 2/11/24, showed Resident 16's skin was reevaluated to have a left hip DTI measuring 4 cm (length) x 4 cm (width) dark discoloration. The report also showed an order for treatment to cleanse with normal saline, pat dry, apply betadine and cover with dry dressing for 14 days. * Resident 16's medical record failed to show documented evidence of wound monitoring for Resident 16's left hip DTI was completed until 2/19/24. Review of Resident 16's General Nurses Note dated 2/19/24, showed Resident 16 with open DTI/unstageable to the left hip. The note also showed the following: - The physician was notified and wound consult was ordered. - Low air loss mattress to be delivered today. - The daughter was made aware. Review of Resident 16's Care Plan showed a care plan problem dated 11/30/23, to address Resident 16's risk for Pressure Ulcers; however, there was no revision or update to the care plan to address Resident 16's development of the DTI on 2/11/24. On 3/14/24 at 1100 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 stated Resident 16 was dependent for all bathing, toileting, and mobility. LVN 4 stated for change of condition, upon the physician's order, would do 72 hours monitoring and the treatment nurse would reassess the wound with the treatments. LVN 4 verified there was no progress note addressing Resident 16's change of condition on 1/19/24 or 2/11/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 9 of 43 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 03/14/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/14/24 at 1356 hours, a concurrent interview and medical record review was conducted with the DON and QA/IP Nurse. The DON and QA/IP Nurse were informed of the above findings. The QA/IP Nurse verified Resident 16's left hip redness was not reevaluated after 14 days as per the physician's order and verified there was no assessment completed until 2/11/24. The DON stated the charge nurse would be responsible for updating the care plan and verified there was no care plan initiated on 2/11/24, to address Resident 16's left hip DTI. 2. Review of the manual titled Drive Med-Air Eight Inch Alternating Pressure Mattress Replacement System with Low Air Loss Manual revised 1/2/17, under the section Operation, showed the pump is preset in alternating mode and its cycle time is set at 10 min/60 Hz (the unit of frequency in the International System of Units (SI), equivalent to one event, or cycle per second) or 12 min/50 Hz. Press the Static button to set it in static mode, and the Static indicator will come on. NOTE! In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode prevents the patient from bottoming out when in a sitting position. Further review of the manual under the section Pressure Set Up, showed the users can easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. Medical record review for Resident 19 was initiated on 3/11/24. Resident 19 was admitted to the facility on [DATE], and readmitted don 1/15/24. Review of Resident 19's MDS dated [DATE], showed Resident 19 was at risk for developing a pressure ulcers/injuries and admitted with two unstageable (not stageable due to coverage of wound bed by slough and/or eschar) pressure injuries/ulcers. Further review of the MDS showed Resident 19 was totally dependent for bed mobility to roll from left and right and from sit to lying. Review of Resident 19's Physician Orders for March 2024 showed an order dated 1/15/24, for LAL mattress for wound management. Review of Resident 19's plan of care showed a care plan problem initiated on 1/16/24, addressing Resident 19's risk for pressure injuries related to impaired skin integrity. The interventions included to provide pressure reducing surfaces on the bed and chair. Review of Resident 19's Weight Change History dated 3/14/24, showed on 3/7 and 3/12/24, Resident 19 weighted 108 pounds (lbs). On 3/11/24 at 0946 hours, Resident 19 was observed lying on a LAL mattress. The LAL mattress was turned on and set at 150 pounds and the static setting was on. On 3/11/24 at 1613 and 1630 hours, Resident 19 was observed lying in bed on a LAL mattress. The LAL mattress was turned on and set at 150 pounds and the static setting was on. The staff was not observed in Resident 19's room providing care. On 3/12/24 at 0753 hours, Resident 19 was observing lying in bed on a LAL mattress, positioned on his right side. The LAL mattress was turned on and set at 150 pounds and the static setting was on. On 3/12/24 at 0931 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 19 had multiple wounds and was on a special mattress. When asked about the settings for the LAL mattress, CNA 1 stated she did not know the settings on the LAL mattress and she did not touch the unit when providing care for Resident 19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 10 of 43 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 03/14/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/12/24 at 1550 hours, an interview and concurrent observation of Resident 19 was conducted with LVN 2. LVN 2 stated Resident 19 had a LAL mattress to help relieve pressure while in bed. LVN 2 also stated she was unfamiliar with the LAL mattress unit or the settings. Concurrent observation of Resident 19's LAL mattress unit was conducted with LVN 2. LVN 2 verified the LAL mattress unit was set at 150 pounds for firmness and the static setting was on. When asked about Resident 19's current weight, LVN 2 stated Resident 19 weighed 108 pounds on 3/12/24. On 3/12/24 at 1615 hours, an interview and concurrent observation was conducted with the Hospice RN. The Hospice RN verified the firmness setting was set at 150 pounds and the static light was on. The Hospice RN stated she did not know what the LAL mattress setting should be. On 3/13/24 at 0810 hours, Resident 19 was observed lying on his back in bed on a LAL mattress. The LAL mattress was turned on and set at 350 pounds for firmness. On 3/13/24 at 0910 hours, a concurrent interview and medical record review was conducted with the DON. When asked about Resident 19's current weight, the DON stated Resident 19 weighed 104 pounds as of 3/1/24. When asked about the facility's role in the maintenance of the LAL mattress, the DON stated she expected the nurses to check the LAL mattress unit daily, to check that the unit was functioning and the settings were appropriate to the resident's weight. A concurrent observation of Resident 19's LAL mattress unit was conducted with the DON. The DON verified the setting for mattress firmness was set at 150 pounds, the DON was observed adjusting the dial to 100 pounds. Concurrent review of the Drive LAL Mattress manual was conducted with the DON. When asked about the Static setting, the DON stated in static mode, the mattress would be firm all the time. The DON was informed of the above findings and stated the purpose of the LAL mattress was to provide alternating pressure and aid in the prevention of pressure related issues. The DON further stated it should not have been on static mode. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 11 of 43 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 22) and one nonsampled resident (Resident 8) remained free from accident hazards. * The facility failed to ensure CNA 1 locked the wheelchair brakes during a transfer for Resident 22 on 1/23/24, resulting in Resident 22 falling to the ground. * The facility failed to ensure the tab alarm was in place as per the physician's order for Resident 8. These failures had the potential to not prevent further falls for these rresidents. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed according to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. 1. Medical record review for Resident 22 was initiated on 3/11/24. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's H&P examination dated 7/17/23, showed Resident 22 could make her needs known but could not make medical decisions. Review of Resident 22's MDS dated [DATE], showed Resident 22 had moderately impaired cognition and required substantial/maximal assistance with transfers to and from a bed to a chair. Review of Resident 22's Physician Orders for March 2024 showed an order dated 8/7/22, may have a low bed with bedside floor mats. Review of Resident 22's plan of care showed an active care plan problem initiated on 7/30/22, addressing Resident 22's high risk for falls. The care plan showed Resident 22 had falls on 8/7 and 8/13/22. Review of Resident 22's General Nurse Note of a nursing entry dated 1/24/24 at 0716 hours, showed on 1/23/24 at 0930 hours, during the transfer from Resident 22's bed to the wheelchair by CNA 1, one of the brakes on the wheelchair was not locked and Resident 22 slipped to the floor. Resident 22 was assessed and administered Tylenol (analgesic) 323 mg two tablets for a pain level of 3 (on a 0-10 pain scale, with 0 = no pain and 10 = worst pain). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 12 of 43 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 22's Post Fall assessment dated [DATE], showed the probable cause of fall was the wheelchair was not fully locked during assistance causing the wheelchair to move. Further review of the document showed the facility educated the CNA to ensure the wheelchair was fully locked when assisting the resident to/from the wheelchair. Review of Resident 22's IDT Incident Review dated 1/26/24, showed the IDT had conducted a post fall care conference and recommended to continue with the current plan of care. Additionally, the CNA was given an education regarding ensuring the wheelchair was locked during transfers. On 3/12/24 at 0940 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 22 required assistance with transfers from bed to wheelchair and back. CNA 1 stated Resident 22 had a recent fall in January 2024 when CNA 1 was assisting the resident to transfer from her bed to the wheelchair. CNA 1 stated during the assisted transfer to the wheelchair, Resident 22 grabbed the wheelchair handles and lost her balance, subsequently falling onto the bedside mat. On 3/14/24 at 0904 hours, an interview was conducted with the DON. The DON stated Resident 22 required one staff to assist during the transfers. The DON verified Resident 22 had a fall in January 2024 and the facility determined Resident 22's fall was related to staff failure to lock the wheelchair. The DON further stated the CNA was provided one on one in-service following the incident. On 03/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings. 2. Medical record review for Resident 8 was initiated on 3/13/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 12/7/23, showed the resident with a history of fall risk. Resident 8 required full assistance with the ADL care. Review of the physician's order dated 12/7/23, showed an order for a tab alarm in bed to alert the staff when getting up unassisted. Review of the care plan initiated on 12/9/23, for fall risk and prevention of falls failed to show the use of a tab alarm as ordered as one of the preventative measures to prevent falls. On 3/13/24 at 0827 hours, Resident 8 was observed lying in bed sleeping with the bilateral upper side rails up. The call light was within reach, but no tab alarm was attached as ordered. On 3/13/24 at 0835 hours, an interview was conducted with RNA 1. RNA 1 confirmed the findings and stated the resident had an order for a tab alarm in bed to alert the staff when the resident tried to get up without assistance. On 3/14/24 at 0925 hours, Resident 8 was observed lying in bed with HOB approximately 30 degrees. There was no tab alarm attached to the resident when in bed as ordered. On 3/14/24 at 0939 hours, an interview was conducted with CNA 3. The CNA confirmed Resident 8 had no tab alarm on when in bed. She further stated the resident should had a tab alarm in bed for safety purpose due to risk of falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 13 of 43 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 3/14/24 at 1050 hours, a concurrent interview and medical record review conducted with LVN 4. LVN 4 showed a physician's order for a tab alarm in bed initiated on 12/7/23. She further stated it was utilized for the residents with the fall risk. On 3/14/24 at 1115 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the order for the tab alarm in bed was not followed, with no informed consent and a care plan. When asked for a facility P&P related to the use of tab alarm, the DON stated there was no facility P&P for tab alarm usage at this time. Event ID: Facility ID: 555651 If continuation sheet Page 14 of 43 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 03/14/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services related to GT for one of 14 final sampled residents (Resident 23). * The facility failed to ensure Resident 23's HOB was elevated during the enteral feeding to reduce the risk of aspiration. * The facility failed to ensure the licensed staff managed the GT feeding for Resident 23. RNA 1 was observed to turn off the GT feeding to assist with repositioning for Resident 23. These failures posed the risk for complications related to the use of GT for Resident 23. Findings: Review of the facility's P&P titled Enteral Feedings- Safety Precautions revised 11/2018 showed all personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. Under the section preventing aspiration showed to elevate the HOB at least 30 degrees during tube feedings. Medical record review for Resident 23 was initiated on 3/11/24. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 2/28/23, showed Resident 23 had a GT. Review of Resident 23's Physician Orders for March 2024 showed an order dated 4/12/23, to infuse Jevity 1.2 (enteral feeding formula) at 60 milliliters per hour (ml/hr) for 20 hours to provide 1200 ml/1440 kcal. a. Review of Resident 23's Physician Orders for March 2024 showed an order dated 2/21/23, for aspiration precaution, to elevate the HOB 30-45 degrees at all times during GT feeding. Review of Resident 23's plan of care showed an active care plan problem initiated on 10/5/22, addressing Resident 23's nutrition via GT. The care plan interventions included to maintain in an upright position during the GT feeding. On 3/11/24 at 1020 hours, Resident 23 was observed lying in bed with his legs hanging off of the right side of the bed. The GT feeding was observed infusing Jevity 1.2 at 60 ml/hr. CNA 1 was observed in Resident 23's room. CNA 1 stated Resident 23 needed to be repositioned. CNA 1 was then observed using the bed control to lower Resident 23's HOB. Resident 23's HOB was observed flat with the GT feeding still infusing. On 3/11/24 at 1024 hours, an interview was conducted with CNA 1. CNA 1 stated GT feedings should not be infusing when the resident was lying with the HOB flat. CNA 1 verified she placed Resident 23's HOB flat while the GT feeding was still infusing. CNA 1 stated she should have asked the nurse to put the GT feeding on hold before lying Resident 23 flat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 15 of 43 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 03/14/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/12/24 at 1546 hours, an interview was conducted with LVN 2. LVN 2 stated the residents on the GT feeding should be placed with the HOB elevated at a 45 degree angle to prevent aspiration. LVN 2 further stated she did not expect the GT feeding to be infusing if the resident was lying with the HOB flat. On 3/13/24 at 0922 hours, an interview was conducted with the DON. The DON stated the staff were aware they should not lower the HOB when the GT feeding was infusing due to the risk of aspiration. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings. b. On 3/11/24 at 1020 hours, Resident 23 was observed lying in bed with the GT feeding infusing Jevity 1.2 at 60 ml/hr. Resident 23 was observed with the HOB flat. RNA 1 was in the room to assist CNA 1 to reposition Resident 23. RNA 1 was observed turning of the enteral tube feeding. On 3/11/24 at 1024 hours, an interview was conducted with RNA 1. RNA 1 verified she turned off the GT feeding for Resident 23. On 3/12/24 at 1441 hours, a follow-up interview was conducted with RNA 1. RNA 1 stated the HOB should be elevated more than 30 degrees when the GT feeding was infusing to prevent aspiration. When asked about operation of the GT feeding, RNA 1 stated she needed to get a licensed nurse to hold the GT feeding before lying the resident flat. RNA 1 further stated the LVNs were responsible for resuming and holding GT feedings. On 3/12/24 at 0922 hours, an interview was conducted with the DON. The DON stated the CNAs were expected to notify the charge nurse to hold GT feedings when providing care. The DON further stated the CNAs should not put the GT feedings on hold or to resume the feedings. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 16 of 43 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 03/14/2024 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** 4. Medical record review for Resident 18 was initiated on 3/11/24. Resident 18 was admitted to the facility on [DATE]. Residents Affected - Few On 3/11/24 at 0907 hours, an observation and concurrent interview was conducted with Resident 18. An oxygen concentrator was observed adjacent to Resident 18's bed. Unlabeled oxygen tubing/nasal cannula was observed lying on top of the oxygen concentrator. Resident 18 stated she utilized the oxygen as needed for shortness of breath. Resident 18 stated she last utilized oxygen via nasal cannula a few weeks ago. On 3/11/24 at 0929 hours, an observation and concurrent interview was conducted with the DON. The DON verified the unlabeled oxygen tubing/nasal cannula was observed lying on top of an oxygen concentrator adjacent to Resident 18's bed. The DON stated the nasal cannula should be stored in a respiratory bag when not in use for infection control. 3. Medical record review for Resident 16 was initiated on 3/11/24. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's physician's order dated 11/30/23, showed an order to administer Iprat-albut 0.5-3 (2.5) mg/3 ml (a medication used to reduce inflammation in the airways), give one unit via nebulizer inhalation every four hours as needed for shortness of breath. On 3/11/24 at 0921 hours, Resident 16 was observed in bed. A nebulizer facemask and tubing was attached to the nebulizer machine. The facemask was stored inside a box labeled non-woven drain sponges. The facemask and tubing were not observed with a label. On 3/11/24 at 0929 hours, an observation and concurrent interview was conducted with the DON. The DON verified the above findings and stated the nebulizer facemask was just thrown on the side and should be labeled and stored in a respiratory bag. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for four of 14 final sampled residents (Residents 1, 2, 16, and 18). * The facility failed to follow the physician's order for administering the oxygen at 2 LPM instead of 3.5 LPM for Resident 1. * The facility failed to ensure the oxygen tubing was stored and labeled properly for Resident 2. In addition, the facility failed to obtain a physician's order for the oxygen therapy for Resident 2. * The facility failed to ensure the oxygen nebulizer mask and tubing were stored properly and labeled for Resident 16. * Resident 18's nasal cannula was improperly stored. These failures posed the risk for the residents' safety and respiratory related complications including infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 17 of 43 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 03/14/2024 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 Findings: Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify that there is a physician's order for this procedure; review the physician's orders or facility protocol for oxygen administration; change the oxygen cannula and tubing every seven days, or as needed; and keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Residents Affected - Few 1. On 3/12/24 at 0825 hours, Resident 1 was observed receiving oxygen via nasal cannula at 3.5 L/min. The oxygen tubing was labeled and dated 3/11/24. Medical record review for Resident 1 was initiated on 3/11/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Physician's Orders dated March 2024 showed a physician's order dated 9/12/22, for the oxygen inhalation at 2 LPM via nasal cannula for SOB and to keep the oxygen saturation levels greater than 92%. On 3/12/24 at 0829 hours, an interview and concurrent record review was conducted with LVN 3. LVN 3 verified Resident 1 should have had his oxygen administration on at 2 LPM as ordered by the physician. 2. On 3/11/24 at 1001 hours, an observation and concurrent interview of Resident 2 was conducted. An oxygen concentrator was observed next to Resident 2's bed. The oxygen concentrator was turned off. An oxygen tubing was connected to the concentrator and lying on top of the oxygen concentrator. The oxygen tubing was not labeled and bagged. Resident 2 stated she received oxygen when she needed it. Medical record review for Resident 2 was initiated on 3/11/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Physician Orders for March 2024 failed to show a physician's order for the oxygen administration. On 3/12/24 at 1444 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified there was no physician's order for the oxygen administration for Resident 2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 18 of 43 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 03/14/2024 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, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 14 final sampled residents (Resident 2). Residents Affected - Few * The facility failed to monitor and accurately document Resident 2's fluid intake. * The facility failed to show evidence Resident 2's monthly weight was monitored and recorded. * The facility failed to update Resident 2's comprehensive plan of care to reflect the current dialysis access site. These failures had the potential to result in health complications for Resident 2. Findings: Review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident revised 9/2010 showed the residents with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the facility's P&P titled Encouraging and Restricting Fluids revised 10/2010 showed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain ioptimum health. This may include encouraging or restricting fluids. Follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of the facility's P&P titled Weighing and Measuring the Resident revised 3/2011 showed the purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Weight is usually measured upon admission and monthly during the resident's stay. The height and weight of the resident should be recorded in the resident's medical record. Medical record review for Resident 2 was initiated on 3/12/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had the capacity to understand and make decisions. Further review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had a diagnosis of CKD-5 (Chronic Kidney Disease-Stage 5- a condition meaning kidney failure, also known as end-stage kidney disease) and on hemodialysis (the process of filtering wastes and water from the blood as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 19 of 43 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 03/14/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few kidneys did when they were healthy. It helps control blood pressure and balance important minerals such as potassium, sodium, and calcium in the blood). a. Review of Resident 2's Physician's Orders dated 3/2024 showed a physician's order dated 8/30/23, for 1000 ml/24 hr fluid restriction as follows: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml. On 03/11/24 at 0945 hours, an interview was conducted with Resident 2. Resident 2 stated she was on fluid restriction; however, she did not know how much. Review of Resident 2's MAR dated January 2024 showed the 1000 ml/24 hr fluid restriction order: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml, with an order date of 8/30/23. The scheduled times were at 0600, 1400, and 2200 hours. Further review of the January 2024 MAR showed on 1/2, 1/4, 1/6, 1/8, 1/10, 1/12, 1/14, 1/16, 1/18, 1/20, 1/22, 1/24, 1/26, 1/28, and 1/30/24, did not have the amount of fluid intake recorded for the scheduled times for Resident 2. The dates and times were marked with asterisks. In addition, the MAR for the whole month of January 2024 showed documentation of total fluid intake consumed from all three shifts, even when there were no fluid amount recorded on the specified dates. Review of Resident 2's MAR dated February 2024 showed the 1000 ml/24 hr fluid restriction order: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml, with an order date of 8/30/23. The scheduled times were at 0600, 1400, and 2200 hours. Further review of the February MAR showed one 2/1, 2/3, 2/5, 2/7, 2/9, 2/11, 2/13, 2/15, 2/17, 2/19, 2/21, 2/23, 2/25, 2/27, and 2/29/24, did not have the amount of fluid intake recorded for the scheduled times for Resident 2. The dates and times were marked with asterisks. In addition, the MAR for the whole month of February 2024 showed documentation of total fluid intake consumed from all three shifts, even when there were no fluid amount recorded on the specified dates. Review of Resident 2's MAR from 3/1 to 3/11/24, showed the 1000 ml/24 hr fluid restriction order: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml, with an order date of 8/30/23. The scheduled times were at 0600, 1400, and 2200 hours. Further review of the March MAR showed on 3/2, 3/4, 3/6, 3/8, and 3/10/24, did not have the amount of fluid intake recorded for the scheduled times for Resident 2. The dates and times were marked with asterisks. In addition, the MAR showed documentation of total fluid intake consumed from all three shifts, even when there were no fluid amount recorded on the specified dates. On 3/12/24 at 1347 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 2's fluid restriction of 1000 ml/24 hrs as ordered by the physician. LVN 3 also verified the MAR for January, February, and March 2024 showed blank boxes with asterisks and Resident 2's fluid intake was not documented daily on the MAR. When asked what the asterisk meant, LVN 3 stated it looked like the facility was checking the fluid restriction every other day. LVN 3 also stated the total fluid intake was recorded at midnight for the day prior. On 3/14/24 at 1146 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the charge nurse knew how much fluids Resident 2 consumed and they factored in the fluids given to Resident 2 during medication administration. The DON stated fluid restriction should be documented in the MAR every shift and the night shift documented the total fluid intake. The DON verified the fluid was not documented accurately and there was a total fluid intake for the 3 shifts in spite of the missing fluid documented in the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 20 of 43 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 03/14/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. Review of Resident 2's form titled MONTHLY RECORD OF V/S AND WTS showed a weight was recorded for 7/2023, as 133 (not specified whether pounds or kilograms). The form did not show documentation of Resident 2's weight for August through December 2023 and January through March 2023. Review of the Resident 2's Weight Change History dated 6/19/23 through 3/12/24, showed documentation of post-dialysis weights. Review of Resident 2's Plan of Care showed a care plan problem dated 6/18/23, for Nutrition: at risk d/t ESRD; on Dialysis. The interventions included to take admission weight and weekly x 4 weeks, then monthly; re-eval as needed. On 3/14/24 at 0821 hours, an interview and concurrent medical record review was conducted with the Dietary Supervisor. The Dietary supervisor stated there was a binder from dialysis. All residents were weighed monthly unless there was a different order, and weights were documented in a binder and in the computer. The Dietary supervisor verified the monthly vital sign and weight records did not have weights recorded form August 2023 to February 2024. On 3/14/24 at 1128 hours, an interview was conducted with the DON. When asked regarding the facility's process in weighing the residents, the DON stated the residents were weighed monthly unless the residents had a different order. The DON stated for the dialysis residents, the facility used the post-dialysis weight that was sent back with the resident. When asked if the facility should have recorded the monthly weights for the dialysis, the DON stated yes. On 3/14/24 at 1204 hours, the DON provided the facility's monthly weight log for 2023 and 2024. Resident 2 did not have documentation of monthly weights on the log for 2023 and 2024. The DON verified the findings. c. Review of Resident 2's Physican Orders dated March 2024 showed a physician's order dated 6/26/23, to monitor LUA AV Shunt for Bruit/Thrill EQS. On 3/11/24 at 0955 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 stated she had been on hemodialysis for 12 years and scheduled to receive dialysis three times per week (Monday, Wednesday, and Friday). Resident 2 showed and was observed to have her dialysis access site on her a left upper arm. Review of Resident 2's Plan of Care showed a care plan problem dated 6/18/23, for renal disease requiring dialysis. The care plan interventions included the following: - Monitor the right Upper Chest Permacath for s/sx (signs and symptoms) of infection and for dressing intact - Monitor the Dialysis Access site Right Femoral Permacath for s/sx of infection - Monitor the LUA (left upper arm) AV (arteriovenous shunt) Shunt for Bruit/Thrill EQS On 3/13/24 at 1034 hours, an interview was conducted with Resident 2. Resident 2 stated the only access used for dialysis was in the left upper arm. Resident 2 further stated she used to have a dialysis catheter in her chest, but it was removed a year ago. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 21 of 43 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 03/14/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 3/14/24 at 1127 hours, an interview was conducted with the DON. The DON verified Resident 2 had a left upper arm AVF currently in use for dialysis treatment. The DON stated Resident 2 did have a femoral site in the right groin, which was temporary, until the permanent shunt was placed. The DON also verified the care plan still showed the femoral permacath and right upper chest permcath as still active and stated it should have been removed. The DON further stated the staff should review the care plan for accuracy and update it as needed. Event ID: Facility ID: 555651 If continuation sheet Page 22 of 43 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 03/14/2024 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 - Few 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 two of 14 final sampled residents (Residents 1 and 12) remained free from accident hazards related to the use of elevated side rails. * Resident 12 was observed with elevated side rails in place. The facility failed to review the risks and benefits of the side rails with Resident 12 and/or responsible party and failed to obtain the informed consent for the use of the side rails. * Resident 1 was observed in bed with the elevated side rails. However, there was no physician's order, care plan, and informed consent for the use of side rails. These failures had the potential to place the residents at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Proper Use of Side Rails revised 12/2016 showed the consent for using restrictive devices will be obtained from the resident and legal representative per facility protocol. The consent for the side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 1. On 3/11/24 at 0906 hours, and 3/12/24 at 1205 hours, Resident 12 was observed lying in bed with the bilateral upper side rails elevated. Medical record review for Resident 12 was initiated on 3/11/24. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's Physician Orders dated 3/2024 showed a physician's order dated 3/11/24, may have bilateral upper side rails up while in bed for increased bed mobility and repositioning. Further review of Resident 12's medical record failed to show the informed consent was obtained for the use of bilateral side rails. On 3/13/24 at 1347 hours, the DON acknowledged the above findings and verified there was no informed consent completed for the use of bilateral side rails. On 3/13/24 at 1611 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 12 used the side rails for turning and needed moderate assistance to turn. 2. Review of the facility's P&P titled Proper Use of Side Rails last revised on 12/16 showed an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. In addition, consent for side rail use must be obtained from the resident or legal representative after presenting potential benefits and risks. On 3/13/24 at 0817 hours, Resident 1 was observed resting in bed with the bilateral upper side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 23 of 43 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 03/14/2024 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 rails elevated. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 1 was initiated on 3/13/24. Resident 1 was admitted to the facility on [DATE]. Further review the resident's medical record failed to show documented evidence a physician's order for the use of bilateral side rails for Resident 1. Residents Affected - Few In addition, Resident 1's medical record failed to show the informed consent was obtained for the use of the bilateral side rails. On 3/13/24 at 0824 hours, an interview conducted with RNA 1. RNA 1 stated the resident should not have the side rails up. On 3/13/24 at 0940 hours, a concurrent record review and interview with LVN 3 was conducted. LVN 3 verified Resident 1 had no consent and care plan for side rails use. LVN 3 further stated the consent, care plan, and entrapment risks assessment were required prior to the use of side rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 24 of 43 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 03/14/2024 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** Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 14 final sampled residents (Resident 2). * The facility failed to administer Sevelamer Carbonate (medication to treat too much phospate in the blood in residents with chronic kidney disease who are on dialysis) with meals as ordered by the physician. * The facility failed to monitor and document the blood pressure prior to administration of Midodrine (medication to increase blood pressure) as ordered by the physician. These failures had the potential to negatively affect the resident's health. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019, showed medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 2 was initiated on 3/11/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had the capacity to understand and make decisions. 1. Review of Resident 2's Physician Orders dated March 2024 showed a physician's order dated 6/18/23, for Sevelamer Carbonate 800 mg TAB PO TID with meals for hyperphosphatemia (too much phosphate in the blood). On 3/14/24 at 0805 hours, LVN 4 was observed going inside Resident 2's room to administer medications. On 3/14/24 at 0810 hours, an interview was conducted with LVN 4. LVN 4 verified one of the medications she administered to Resident 2 was the Sevelamer Carbonate 800 mg. LVN 4 also verified the direction and physician's order was to administer Sevelamer with meals. LVN 4 verified she did not administer the Sevelamer with meals to Resident 2 because she was busy with another resident. LVN 4 acknowledged she should have given the Sevelamer with meals. 2. Review of Resident 2's Physician Orders dated March 2024, showed a physician's order dated 9/17/23, to give Midodrine HCL 5 mg one tablet PO Q eight hours for hypotension. HOLD if SBP>130 mmHg. Review of Resident 2's MAR for February and from 3/1 -3/12/24, showed the Midodrine was administered at 0600, 1400, and 2200 hours. The last administration of the medication at the time of record review was 3/123/24, at 0600 hours. The MARs failed to show documented evidence Resident 2's blood pressure was monitored and recorded prior to the administration of Midodrine. On 3/14/24 at 1416 hours an interview and concurrent medical record review was conducted wit the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 25 of 43 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 03/14/2024 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 DON. The DON verified the blood pressure was not documented in the MAR as ordered prior to administering Midodrine to Resident 2. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 26 of 43 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 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one of 14 final sampled (Resident 10). This failure had the potential for the resident not receiving the necessary care and services. Findings: Medical record review for Resident 10 was initiated on 3/11/24. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's Physician Orders for 3/2024, showed a physician's order dated 1/19/24, to administer metoprolol tartrate 25 mg tablet PO (by mouth/orally) two times a day for hypertension (high blood pressure); and to hold if the heart rate less than 60 beats per minute or systolic blood pressure greater than 110 mmHg. Review of the facility document titled Medication Regimen Review Report dated 1/2024 showed a medication review completed by the Pharmacist Consultant for Resident 10. The recommendation showed for metoprolol tartrate (blood pressure medication) to be given with food and to consider adding vitamin C 500 mg once daily with ferrous sulfate to help with iron absorption. On 3/12/24 at 1558 hours, a concurrent interview and record review was conducted with the DON. The DON verified the Pharmacist Consultant's recommendations regarding the metoprolol administration and vitamin C were not acted upon. The DON stated the charge nurse was responsible to complete the recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 27 of 43 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 03/14/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 12) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure the informed consent was obtained from Resident 12's responsible party for the use of Remeron (an antidepressant drug which can be taken as an appetite stimulant). This failure posed the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed the residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternative. Medical record review for Resident 12 was initiated on 3/11/24. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's H&P examination dated 11/5/23 and 3/10/24, showed Resident 12 did not have the capacity to understand and make decisions and Resident 12's surrogate decisionmaker was Resident 12's family member. Review of Resident 12's Physician Orders dated 3/2024 showed a physician's order dated 3/11/24, for Remeron 15 mg tablet, take one tablet by mouth at bedtime for depression manifested by poor appetite. Further review of Resident 12's medical record failed to show Resident 12 and the resident's responsible party were informed of the risks, benefits, and alternatives of taking the psychotropic medication Remeron and consented to the use of the medication. On 3/13/24 at 0940 hours, a concurrent interview and medical record review was conducted with the DON. The DON was asked regarding the facility's process for psychotropic medication use. The DON stated if the medication was initiated in the facility, they needed to have attempted alternatives, documentation of behaviors, and informed consent. The DON stated Resident 12's Remeron was started in the facility on her previous admission and the facility should have consent. On 3/13/24 at 1347 hours, the DON verified there was no informed consent completed for the use of Remeron medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 28 of 43 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 03/14/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medications in the Medication Cart. The facility failed to ensure treatment supplies were not expired in the Treatment Cart. The Facility failed to ensure the expired hand sanitizer bottles were discarded. * Discontinued prednisone (steroid) tablets were observed in the Medication Cart. * The facility failed to ensure a container of germicidal alcohol wipes was stored separately from the residents' medications. * An unlabeled and unpackaged vial of ipratropium and albuterol (combination medication that relaxes muscles in the airways and increase air flow to the lungs) inhalation solution was observed lying in the Medication Cart. * Within the Medication Cart, two 30-ounce bottles of wild cherry Pro-Stat (protein supplement) and one 16-ounce bottle of Milk of Magnesia (laxative & antacid) were observed with an unknown substance accumulated on the outside of the bottles. * A used surgical mask was observed inside the top drawer of the Medication Cart. The surgical mask was observed adjacent to the medications/supplements. * Ipratropium and albuterol inhalation solution unit dose vials were packaged in clear plastic versus foil and were not used within 1 week of removal from foil packaging. * The expired supplies were observed in the Treatment Cart. * The hand sanitizer bottles expired between 7/2022 through 5/2023 were utilized in the resident rooms, hallways, dining room, and medication cart. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2019 showed antiseptics, disinfectants, and germicides used in any aspect of resident care have legible, distinctive labels that identify the contents and the directions for use, and are stored separately from regular medications. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Drugs and biologicals are stored in the packaging, containers, or other dispensing system in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the facility's P&P titled Discontinued Medications revised 4/2017 showed staff shall destroy discontinued medications. No medication shall be returned to the dispensing pharmacy once received by the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 29 of 43 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 03/14/2024 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 1. On [DATE] at 0825 hours, a medication administration observation was conducted with LVN 4. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 12 was initiated on [DATE]. Residents Affected - Few Review of Resident 12's physician's telephone order dated [DATE] at 1822 hours, showed an order to discontinue prednisone (corticosteroid medication) 10 mg orally daily, and change prednisone to 5 mg orally daily. However, Resident 12's prednisone 10 mg medication bubble pack was observed inside the Medication Cart. The bubble pack contained several prednisone 10 mg tablets, with instructions to administer daily in the morning. LVN 4 stated on [DATE], Resident 12's physician discontinued prednisone 10 mg orally daily. LVN 4 stated Resident 12's physician changed Resident 12's prednisone dose to 5 mg orally daily to begin on [DATE]. LVN 4 stated she would remove Resident 12's discontinued prednisone 10 mg tablets from the Medication Cart and place the discontinued medications in the medication room to be discarded. LVN 4 stated removal of discontinued medications from the resident medication cart was to ensure discontinue medications were not administered in error. 2. On [DATE] at 1400 hours, an inspection of the facility's Medication Cart was conducted with LVN 4. The following was observed: a. A container of germicidal alcohol wipes was observed stored in the bottom drawer of the medication cart adjacent to boxes (60 units) of resident inhalation medication (Albuterol Sulfate inhalation solution 2.5 mg/3 ml). LVN 4 verified the finding. b. An unlabeled and unpackaged vial of ipratropium and albuterol inhalation solution was observed in the Medication Cart, lying on the bottom of the bottom drawer. LVN 4 verified the findings and stated she would discard the medication vial. c. Within the Medication Cart, two 30-ounce bottles of wild cherry Pro-Stat and one 16-ounce bottle of Milk of Magnesia were observed with an unknown substance accumulated on the outside of the bottles. LVN 4 verified the findings. d. A used surgical mask was observed inside the top drawer of the Medication Cart. The surgical mask was observed adjacent to the medications/supplements, including, fish oil soft gels, throat lozenges, multivitamin tablets, loperamide (anti-diarrheal medication) tablets, and phenylephrine hcl (nasal decongestant medication) tablets. LVN 4 verified the findings and stated she utilized the mask during the medication pass and should have thrown the mask in the trash for infection control, and not stored the mask in the Medication Cart adjacent to the resident's medications. 3. According to [NAME] drug, ipratropium and albuterol inhalation solution unit dose vials should be stored in a foil pouch until use and used within one week of the removal from the foil pouch. On [DATE] at 0945 hours, an inspection of the facility's Medication Cart was conducted with the DON. Medical record review for Resident 19 was initiated on [DATE]. Review of Resident 19's physician's orders showed an order dated [DATE], for ipratropium and albuterol 0.5-3(2.5) mg /3 ml inhalation one vial via handheld nebulizer every four hours as needed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 30 of 43 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 03/14/2024 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 shortness of breath. Level of Harm - Minimal harm or potential for actual harm Inside of the Medication Cart, a clear plastic bag labeled with Resident 19's name contained eight vials of ipratropium and albuterol 0.5-3(2.5) mg/3 ml inhalation solution. The label showed a fill date of [DATE]. The DON verified the ipratropium and albuterol 0.5-3(2.5) mg/3 ml inhalation solution was not packaged in foil. Residents Affected - Few 5. Review of the US FDA's consumer update titled Safely Using Hand Sanitizer dated [DATE], showed hand sanitizers are regulated as over-the-counter (nonprescription) drugs by the US FDA. On [DATE] at 0912 hours, an isolation cart was observed outside of Resident 16's room. There was a hand sanitizer bottle and germicidal wipes on top of the cart. The hand sanitizer bottle's expiration date was [DATE]. On [DATE] at 0825 hours, a concurrent observation and interview was conducted with the Housekeeping staff. The Housekeeping staff verified there were hand sanitizer bottles in all the rooms, dining room, and in the hallways. The Housekeeping staff stated the hand sanitizer bottles in the hallways and rooms were changed when they were done. Three different bottles of hand sanitizer were observed with expiration dates of 7/2022, 5/2023, and 4/2023. The Housekeeping staff verified the hand sanitizer bottles were expired. On [DATE] at 0834 to 0844 hours, a concurrent observation and interview was conducted with the DON. The DON stated she ordered the supplies for the facility and would replace the hand sanitizer bottles when the staff let them know. The DON stated the hand sanitizer bottles were in every room or by the room and medication cart. The DON verified the above findings and stated the IP and charge nurses were responsible to make sure the hand sanitizers were not expired. The DON and QA/IP nurse were observed to collect all the 25 hand sanitizer bottles out of the medication cart, rooms and hallways. The DON verified the facility had three more cases of 24 expired hand sanitizer bottles in the facility (a total of 97 expired bottles). 4. Review of the facility's P&P titled Storage of Medication revised 4/2019 showed the discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On [DATE], at 1115 hours, a wound care observation was made with the QA/IP for Resident 1. The QA/IP stated the LVNs usually provided wound care treatment; however, she also assisted as needed. The QA/IP stated prior to wound care, she would take the following steps: perform hand hygiene, verify order, gather supplies, provide privacy, and explain to the resident about the procedure. In addition, she would assess for wound site, pain tolerance, and inform the physician if abnormal findings were noted. The QA/IP reviewed the physician's order for the wound care initiated on [DATE], for the right shoulder cancer wound showed to cleanse with NS, pat dry, apply TAO, and leave open to air QD (daily) for 14 days and re-evaluate on [DATE]. When the treatment cart was inspected and opened, the following expired items were found: 4 Sureprep pads and one suture kit. The QA/IP verified the findings and stated the wound care cart was checked monthly and should not have any expired items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 31 of 43 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 03/14/2024 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 requirements were met in the kitchen when: Residents Affected - Some * Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not accurately monitored to ensure proper cool down process was followed. * The facility failed to ensure the handwashing sink was used for handwashing only. * The facility failed to ensure proper labeling and dating of food in the refrigerator used for resident foods. * The facility failed to ensure the kitchen utensils were clean and stored in sanitary condition. * The facility failed to ensure the cutting boards were kept in sanitary condition. * The facility failed to ensure the kitchen utensils and equipment were kept in good repair. * The facility failed to ensure the kitchen equipment were air dried. * The facility failed to ensure the dented cans were removed. These failures had the potential to cause foodborne illness in a highly susceptible resident population of 23 facility residents who consumed food prepared in the kitchen. Findings: Review of the facility's matrix showed 23 of 26 residents consumed food prepared in the kitchen. 1. According to the USDA Food Code 2022, Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) within two hours from 135 degrees Fahrenheit (F) to 70 degrees F; and (2) within a total of six hours from 135 degrees F to 41 degrees F or less, (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Review of the facility's P&P titled Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023 showed cooked potentially hazardous foods (PHF) or time/temperature control for safety (TCS) foods shall be cooled and reheated in a method to ensure food safety. The Procedure section, showed when cooked PHF or TCS food are not served right away, it must be cooled as quickly as possible using the Two-Stage Method: (a) cool cooked food from 140 degrees F to 70 degrees F within two hours, and (b) then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours. The facility's P&P also showed to use the Cool Down Log to document proper procedure when cooling down food. Review of the facility's Menu for 3/8/24, showed the following entrees were served for dinner: turkey salad on bed of lettuce, corn chowder, tomato slice, wheat roll, and baked apricot crunch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 32 of 43 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 03/14/2024 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 Review of the Daily Food Temperatures Log showed on 3/8/24, for dinner, the main entrée was documented as 36 degrees F. Review of the facility's Cool Down Log showed once food drops to 140 degrees, to begin the cooling procedure; the temperature at 2 hours or less: if 70 degrees F or less, you have four more hours to get temperature to 41 degrees F or less. If more than 70 degrees after two hours, to take corrective actions per policy. Further review of the Cool Down Log showed an entry dated 3/8/24, for roast turkey. The log showed on 3/8/12 at 1200 hours, the temperature of the roast turkey was 190 degrees F. The entry also showed the roast turkey was cooled to 70 degrees F; however, a time was not indicated. Furthermore, the log failed to show when the roast turkey reached 41 degrees F or below. On 3/12/24 at 1400 hours, an interview and concurrent review of the Cool Down Log was conducted with the DSS. The DSS stated the cooling process for meats should start at 140 degrees F, and after two hours, the temperature should reach 70 degrees F, followed by four hours to reach at 41 degrees F. Concurrent review of the Cool Down Log was conducted with the DSS. The DSS stated she did not know what time the cool down process was started for the roast turkey on 3/8/24, and she did not know what time the temperature reached at 70 degrees F. The DSS further stated it was important to know the times because certain foods at certain temperatures and durations of time may cause bacteria growth. On 3/14/24 and 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. 2. According to the USDA Food Code 2022 5-205.11 Using a Handwashing Sink, a handwashing sink may not be used for purposes other than handwashing. On 3/11/24 at 0810 hours, an initial tour of the kitchen was conducted with [NAME] 1. The handwashing sink was observed with red and green sanitation and cleaning buckets near the faucet. A sign above the handwashing sink showed for handwashing only. [NAME] 1 verified the above finding. On 3/11/24 at 1620 hours, and interview was conducted with the DSS. The DSS stated the handwashing station should be used for handwashing only. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledge the findings. 3. Review of the facility P&P titled Labeling and Dating of Foods dated 2023 showed all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. On 3/11/24 at 1224 hours, an observation of the refrigerator used to store the resident's food brought in by the visitors and concurrent interview was conducted with the DSS. An unopened ready care shake was noted in the refrigerator, without a resident's name or a use-by date. The label on the shake showed to use within 14 days of thawing. The DSS stated she did not know when the shake was removed from the freezer or when it was placed in the refrigerator. A frozen plastic water bottle was observed in the freezer without a resident name and use-by date. The DSS stated she did not know who the water bottle belonged to. The DSS was observed removing the two items and discarding in the trash. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 33 of 43 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 03/14/2024 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 4. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Residents Affected - Some According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use articles, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored in a clean, dry location. Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. On 3/11/24 at 0810 hours, during the initial tour of the kitchen, two scoops were observed with dry white remnants in the inner side of the scoop, and stored in a drawer of clean kitchen utensils. The drawer was observed with dry, yellow-brown food particles at the bottom of the drawer. [NAME] 1 verified the above findings. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. 5. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 3/11/24 at 0810 hours, during the initial tour of the kitchen, two cutting boards were observed heavily marred with knife marks. [NAME] 1 verified the above findings. On 3/11/24 at 1620 hours, an interview was conducted with the DSS. The DSS stated cutting boards were replaced once a year or depending on the condition of the cutting boards. The DSS was shown pictures of the cutting boards obtained during the initial tour and stated the cutting boards should be changed. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. The DSS stated the cutting boards have been replaced. 6. According to the 2022 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. Review of the facility's P&P titled Sanitation dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. On 3/11/24 at 0810 hours, during an initial tour of the kitchen, one white spatula was observed chipped and discolored, a portion server was observed with a partially melted green handle, and a can opener was observed with chipped stainless steel coating, exposing the blade. [NAME] 1 verified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 34 of 43 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 03/14/2024 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 above findings. [NAME] 1 stated the can opener blade should be changed when the coating on the blade have noticeable chips. On 3/11/24 at 1620 hours, an interview was conduced with the DSS. The DSS was shown the pictures of the spatula, melted green handle, and chipped coating from the can opener blade. The DSS stated the items should be changed. On 3/14/24 at 1426 hours, the DSS and Administrator were notified and acknowledged the above findings. The DSS stated the can opener blade had been replaced, and the spatula and melted server scoop had been removed. 7. According to the USDA Food Code 2022 Section 4-901.11, Equipment and Utensils, Air-Drying Required, after cleaning and sanitizing, equipment and utensils shall be air dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. Review of the facility's P&P titled Sanitization revised 2008 showed food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. On 3/11/24 at 0810 hours, during a tour of the kitchen, an interview and concurrent observation was conducted with [NAME] 1. Multiple clear containers and one container lid were observed stored inside a cabinet, stacked upside down. The clear containers were observed still wet with visible water inside. [NAME] 1 verified the above findings and stated the containers should be air dried. [NAME] 1 was then observed laying the containers on a silver cart to air dry. On 3/11/24 at 1620 hours, an interview was conducted with the DSS. The DSS stated containers should be air dried completely before putting away. On 3/14/24 at 1426 hours, the DSS and Administrator were notified and acknowledged the above findings. 8. Review of the facility's P&P titled Food Storage-Dented Cans dated 2023 showed all dented cans and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. On 3/11/24 at 0810 hours, during an initial tour of the kitchen, an interview and concurrent observation was conducted with [NAME] 1. In the dry storage, two dented cans were observed on the shelf. [NAME] 1 verified the above finding and stated the dented cans should be moved to the area specified for dented cans. On 3/11/24 at 1620 hours, an interview was conducted with the DSS. The DSS stated she was responsible for checking the dented cans and removal of the cans from the shelf. The DSS stated she was informed by [NAME] 1 regarding the dented cans. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledge the above findings. The DSS stated the dented cans had been removed from the shelf. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 35 of 43 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 03/14/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpsters. This failure had the potential to attract the pest/rodents that carried diseases. Residents Affected - Some Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Review of the facility's P&P titled Food Related Garbage and Refuse Disposal revised 10/2017 showed the outside dumpsters provided by the garbage pickup services will be kept closed. On 3/11/24 at 0737 hours, an observation of the facility's outside garbage dumpster was conducted. The garbage dumpster was observed with the lid propped open by garbage preventing the lid from fully closing. On 3/11/24 at 1427 hours, an interview was conducted with Maintenance 1. Maintenance 1 verified the garbage dumpster was overflowing with garbage this morning, with the dumpster lid propped open with garbage. Maintenance 1 stated the trash company was scheduled to empty the garbage dumpster on Monday, Wednesday, and Friday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 36 of 43 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 03/14/2024 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** 3. Review of the facility's P&P titled Handwashing/ Hand Hygiene, undated, showed the facility considers hand hygiene the primary means to prevent the spread of infections. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Residents Affected - Some - before and after direct resident contact - before and after assisting a resident with meals, - after removing gloves or aprons. Further review of the facility's P&P showed in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situations: - before and after direct contact with residents - after removing gloves. The P&P also showed hand hygiene is always the final step after removing and disposing of personal protective equipment. On 3/11/24 at 0849 hours, during the initial tour of the facility, an Enhanced Standard Precautions (ESP) sign was observed posted outside of Resident 19's room alerting anyone entering the room to don gloves and gown for the following high contact resident care activities: morning and evening care, toileting and changing incontinent briefs, caring for devices and medical treatments, wound care, mobility assistance and preparing to leave the room, or cleaning and disinfecting the environment. The sign showed for the residents who are on ESP, when performing activities from the six groups of care activities, to use hand hygiene, gloves, and gowns. On 3/11/24 at 1205 hours, CNA 1 was observed in Resident 19's room wearing gloves and no gown. CNA 1 was observed feeding Resident 19. CNA 1 was observed removing and discarding her gloves and leaving the room without performing hand hygiene. On 3/11/24 at 1207 hours, an interview was conducted with CNA 1. CNA 1 verified she did not perform hand hygiene after removal of her gloves and leaving Resident 19's room. CNA 1 stated hand hygiene should be performed before entering and exiting the residents' room and after removal of the gowns and gloves. On 3/13/24 at 0925 hours, an interview was conducted with the DON. The DON stated for the residents who were placed on ESP, the staff should don gloves and gown when providing certain care activities to prevent the spread of resistant organisms that could be potentially transferred to other residents. The DON stated Resident 19 was on ESP due to his urinary indwelling catheter and multiple wounds. The DON also stated the staff were expected to perform hand hygiene in between the residents and after removal of the gloves. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 37 of 43 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 03/14/2024 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 findings. Level of Harm - Minimal harm or potential for actual harm 4. Review of the facility's P&P titled Infection Control last revised 10/2018 showed further support that infection control practice is intended to facilitate maintaining a safe, sanitary and comfortable environment and to help present and manage transmission of diseases and infections. Residents Affected - Some On 3/11/24 at 1026 hours, an observation and concurrent interview were conducted with Resident 130. Resident 130 stated he had been at the facility for two months. Resident 130 had a roommate who shared the bathroom with the resident; however, the urinals, basins, and tubs were in the shared bathroom shelf not labeled. Resident 130 stated he preferred to have his belongings and supplies labeled. On 3/11/24 at 1115 hours, an interview was conducted with LVN 4. LVN 4 confirmed the resident should have all his belongings and supplies labeled, including urinal, basin and tubs. She further stated this approach assisted with maintaining sanitary and preventing the spread of diseases and illnesses. Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to show documentation of Legionella testing protocols. * The facility failed to ensure the personal items and food were not stored in the laundry room with clean linens for the residents. In addition, the facility failed to ensure the laundry soap, fabric softener, and Clorox were stored properly and in clean condition in the laundry room. * The facility failed to ensure CNA 1 performed hand hygiene after assisting Resident 19 with lunch and doffing her gloves. * The facility failed to ensure the urinals, basins, and tubs stored in a shared bathroom shelf were labeled. These failures had the potential to result in the transmission of infection to the vulnerable population of residents in the facility. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 38 of 43 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 03/14/2024 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 Review of the facility's P&P titled Policy and Procedure pertaining to Legionella Bacteria dated 12/1/23, showed Legionella bacteria are common and can be found naturally in environmental water sources such as [NAME], lakes and reservoirs, usually in low numbers. Legionella bacteria may also enter purpose built water systems and can be found in cooling tower systems, hot and cold water systems and other plant which use or store water. Residents Affected - Some On 3/14/24 at 1119 hours, an interview was conducted with the Administrator regarding the process for testing for Legionella bacteria in the water. The Administrator stated the facility had a fish tank in the lobby with one fish. The Administrator stated the fish tank was cleaned every two weeks and 15 to 25% of water was changed, and anything more than 25%, the fish would die. When asked if the facility conducted testing for Legionella, the Administrator stated, not in the fish tank and the facility did not have any free standing water. The Administrator further stated the facility followed the CDC guidelines. The facility failed to show documentation of its testing protocols for Legionella and other opportunistic pathogens in building water system, other than the fish tank located in the lobby. On 3/14/24 at 1329 hours, the Administrator verified the facility did not have documentation of its testing protocols for Legionella and other opportunistic pathogens in the building water systems other than the fish tank. On 3/14/24 at 1630 hours, a telephone interview was conducted the Maintenance Supervisor. The Maintenance Supervisor verified there was no testing done in the facility for Legionella. 2. Review of the the facility's P&P titled Policies and Procedures - Infection Control revised 10/2018 showed the facility's infection control practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. On 3/14/24 at 1425 hours, an observation of the laundry room and concurrent interview with Laundry 1 staff was conducted. An observation of the table designated for folding clothes, linens, sheets were observed with three one-gallon water bottles, one portable radio, cookies, one can of Coke, and one tostada stored on the second shelf of the table with the clean linens for the residents' use. Laundry 1 verified the personal items and food and stated she did not have a locker to store her personal items. In addition, two buckets of liquid Clorox, two buckets of liquid fabric softeners, and two buckets of liquid soap were found stacked on top of each other directly on the floor behind the dryer. One additional bucket of liquid fabric softener was found on a pedestal behind the dryer with dust and a black residue. Laundry 1 verified all the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 39 of 43 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 03/14/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document review, and facility P&P review the facility failed to implement their Antibiotic Stewardship Program when the facility failed to conduct an accurate assessment for the McGeer's criteria for one of 14 final sampled residents (Resident 3) and one nonsampled resident (Resident 6). This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. Residents Affected - Some Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The World Health Organization cites antibiotic resistance as one of the biggest threats to human health. Review of the facility's P&P titled Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes revised 12/2016 showed antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Review of the closed medical records for Residents 3 and 6 was initiated on 3/11/24. - Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's facesheet showed Resident 3 was discharged from the facility on 3/11/24. -Resident 6 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 6's facesheet showed Resident 6 was discharged from the facility on 2/28/24. Review of the facility's McGeer's binder failed to show documented evidence the McGeer's assessments were conducted accurately to assess for true infection for the antibiotics prescribed for Residents 3 and 6. Further review showed Residents 3 and 6 had the McGeer's Criteria for Surveillance Checklist filled out showing the residents met the McGeer's Criteria, when in fact, the residents did not. Review of Resident 3's McGeer's Infection Surveillance record dated 1/10/24, showed Resident 3 only had one symptom checked for Pneumonia and one symptom checked for lower respiratory tract infection, which did not meet the McGeer's criteria; however, the assessment showed the McGeer's guidelines for true infection was met. Resident 3 was prescribed Invanz 1 gm vial IVPB QD for 7 days. In addition, another McGeer's Infection Surveillance record dated 1/10/24, showed Resident 3 only had one symptom checked for UTI, which did not meet the McGeer's criteria; however, the assessment showed the McGeer's guidelines for true infection was met. Resident 3's antibiotic order for UTI was also ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 40 of 43 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 03/14/2024 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 0881 as Invanz 1 gm IVPB QD for 7 days. Level of Harm - Minimal harm or potential for actual harm Review of Resident 6's McGeer's Infection Surveillance record dated 1/9/24, showed Resident 6 only had two symptoms present for Pneumonia and two symptoms present for lower respiratory tract, which did not meet the McGeer's criteria; however the assessment showed the McGeer's guidelines for true infection was met. Resident 6 was prescribed Cefuroxime Axetil 500 mg one tab BID x 10 days. Residents Affected - Some On 3/14/24 at 1018 hours, an interview and concurrent facility document review was conducted with the IP. The IP verified the criteria for true infection was not met for Residents 3 and 6. The IP stated the McGeer's tool was a data collection to see if a true infection was met, and it was a guideline for infections to prevent unnecessary antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 41 of 43 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 03/14/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccine was administered to one of 14 final sampled residents (Resident 17). This failure put Resident 17 at risk for pneumonia. Residents Affected - Few Findings: Review of the facility's P&P titled Pneumococcal Vaccine revised 10/2019 showed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provisions of such education shall be documented in the resident's medical record. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. Medical record review for Resident 17 was initiated on 3/14/24. Resident 17 was admitted to the facility on [DATE]. Review of the Pneumococcal Vaccine Informed Consent dated 5/9/23, showed a consent was obtained for Resident 17 to receive the pneumococcal vaccination. Review of the facility's Immunization History Report with a date range of 3/14/20 to 3/14/24, failed to show documented evidence Resident 17 received the pneumococcal vaccination. On 03/14/24 at 1055 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified a consent for Resident 17 was obtained on 5/9/23, to receive the pneumococcal vaccination and no documented evidence the facility's Immunization History Report showing Resident 17 received the pneumococcal vaccination. On 03/14/24 at 1508 hours, a follow-up interview was conducted with the IP. The IP stated Resident 17's consent dated 5/9/23, to receive the pneumococcal vaccination was not followed through and there was no physician's order for Resident 17 to have the pneumococcal vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 42 of 43 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 03/14/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents. Residents Affected - Few Findings: Review of the facility P&P titled Sanitization revised 12/08 showed ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the ice machine instruction manual titled Automatic Ice Maker undated, under the section for Cleaning and Maintenance, showed the ice machine must be cleaned by use of a water jet; for interior cleaning, the ice storage bin should be sanitized occasionally by wiping down the interior with a sanitizing solution made of 28 grams (g) of household bleach or chlorine and 7.5 liters (L) of hot water. Further review of the manual, under the section Ice Making Part Cleaning, showed the water tank and the ice-full detecting plate are very important to keep the ice cube hygienic. The instructions showed to put the mixture of neutral cleaner and water into a clean water jet, then spray all the inner surface of the tank and the ice detecting plate. On 3/12 /24 at 0945 hours, an observation of the facility's ice machine located in the activity room and concurrent interview with the DSS was conducted. The DSS was asked to describe how she cleaned the ice machine. The DSS stated the ice machine was deep cleaned every six months. The DSS stated she removed all the ice and cleaned the inside by wiping down the inside with the recommended Nu-Calgon [NAME] Safe Ice-machine Cleaner. Then, she rinsed the inside with a water and Sani-10% (Disinfectant Sanitizer) solution to sanitize, followed by a rinse with the regular water. On 3/ 13/24 at 1043 hours, a follow-up interview and concurrent review of the ice machine manufacturer instruction manual was conducted with the DSS. The DSS was asked to clarify how she cleaned the inner parts of the ice machine. The DSS stated she used a disposable towel with Nu-Calgon [NAME] Safe Ice-Machine Cleaner solution to wipe the crevices and the ice tray. The DSS stated she then used Sani-10% solution to rinse the inside of the ice machine, followed by a rinse with water. Concurrent review of the ice machine instruction manual was conducted with the DSS. The DSS verified she did not use a water jet to clean the internal parts of the ice machine and verified the manual instructed to use household bleach or chlorine to sanitize the ice machine. The DSS stated Sani-10% did not contain bleach or chlorine. On 3/14/24 and 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 43 of 43