Health inspection·May 29, 2025

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide written information to the residents about a bed-hold information upon the resident transferring to an acute care hospital for three of three sampled residents (Residents 1, 2, and 3). These failures had the potential for the residents not receiving accurate information to determine if they wanted a bed-hold and to return to the facility. Findings: Review of the facility'sP&P titled Bed-Holds and Returns revised March 2017 showed prior to a transfer, written information will be given to the residents and their representative that explains in detail the residents' rights and limitations regarding bed-holds, the reserve bed payment policy, and the per diem rate to hold a bed beyond the state's bed-hold period. Review of the facility's Bedhold Notification Upon Transfer form showed the form was to be completed upon transfer and to provide a copy to the resident or their responsible party. The form showed the resident, or their responsible party was notified of their options to hold the bed and had check boxes to show if a bed-hold was desired, not desired, not appliable, or not eligible for a bed-hold, but still desired to pay privately for a bed-hold. 1. Closed medical record review for Resident 1 was initiated on 5/29/25. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care hospital on 5/17/25. Review of Resident 1's medical record failed to show the resident was provided information on the bed-hold options. 2. Medical record review for Resident 2 was initiated on 5/29/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's EHR census showed the resident went on an acute care hospital on a paid leave on 5/1/25, and returned to the facility on 5/5/25. Review of Resident 2's medical record failed to show the resident or her responsible party was provided with the information on their bed-hold options. 3. Medical record review for Resident 3 was initiated on 5/29/25. Resident 3 was admitted to the facility on [DATE]. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 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 05/29/2025 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)