Health inspection·May 16, 2025

F 0636 Level of Harm - Potential for minimal harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed medical record review, the facility failed to ensure the annual and discharge returnanticipated MDS assessments were completed within 14 calendar days after the ARD for the annual and discharge return anticipated assessments for one of two sampled residents (Resident 1). This failure had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments when the health problems had been identified. Findings: Closed medical record review for Resident 1 was initiated on 5/16/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Annual MDS assessment showed had an ARD of 4/25/25. The Annual MDS showed the status of the assessment was in progress and to be completed by 5/9/25 (seven days overdue), 21 days after the ARD of 4/25/25. Review of Resident 1's Discharge Return-Anticipated MDS had an ARD of 4/29/25. The Discharge Return-Anticipated MDS showed the status of the assessment was in progress and to be completed by 5/13/25 (three days overdue), 17 days after the ARD of 4/29/25. Review of Resident 1's progress note dated 4/29/25 at 1629 hours, showed Resident 1 was transferred to the acute care hospital. On 5/16/25 at 0952 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated Resident 1 was a long-term resident and was transferred to the acute care hospital on 4/29/25, with the anticipation of returning to the facility. The DON verified the above findings and stated the above MDS assessments for the annual and discharge return anticipated should have been completed within 14 calendar days of the ARD. 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 4 Event ID: 555651 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stanley Healthcare Center 14102 Springdale Street Westminster, CA 92683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)