Health inspection·April 23, 2024

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 care plan for one of three sampled residents (Resident 1) was revised after Resident 1 had reported an abuse allegation against CNA 1. This failure put Resident 1 at risk of not receiving resident-centered care. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P showed the comprehensive, person-centered care plan will include the following: a. measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. incorporates identified problem areas; h. incorporates risk factors associated with identified problems; k. reflects treatment goals, timetables and objectives in measurable outcomes; Medical record review for Resident 1 was initiated on 4/19/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Five-Day MDS dated [DATE], showed Resident 1 with a BIMS score of 9 (according to the MDS RAI Manual, a score of 8-12 indicates the resident's cognition is moderately impaired). Further review of the medical record showed Resident 1 had an allegation of CNA 1 pushing her off the shower chair and putting the hand around her throat. However, review of Resident 1's care plan showed no documented evidence of the revised care plan related to Resident 1's reported abuse allegation. On 4/19/24 at 1416 hours, a concurrent interview and medical record review with LVN 1 was conducted. LVN 1 confirmed Resident 1 did not have a new or revised care plan to address the alleged abuse (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555651 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 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)