Health inspection·June 25, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/19/25 at 0832 hours, an observation of Resident 1 and a concurrent interview was conducted with the DSD. The DSD verified the Yankauer suction had some fluid residue, was used and the storage bag was dated 6/8/25. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the night shift LVN to change the Yankauer suction every week and label the and supposed to label the plastic bag with resident's name and date. In addition, review of Resident 1's Order Summary as of 6/22/25, failed to show a physician's order for suctioning. On 6/25/25 at 1530 hours, an interview and concurrent record review was conducted with the DON. The DON verified Resident 1's Order Summary failed to show an order to suction the resident. The DON stated there should be an order for suctioning of the airway. 2. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised on 11/2011 showed in infection control considerations related to oxygen administration, to keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Review of Resident 2's medical record was initiated on 6/19/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 3/13/25, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Order Summary showed a physician's order dated 5/1/25, to administer oxygen at 2-5 liters per minute via nasal cannula as needed. Review of Resident 2's MDS assessment dated [DATE], showed resident had BIMS score of 3 indicating the resident had severe cognitive impairment. Review of Resident 2's plan of care failed to show a care plan was developed for the resident's use of the oxygen. On 6/19/25 at 0812 hours, an observation was conducted of Resident 2 in the resident's room. Resident 2's oxygen concentrator was turned off at the resident's bedside. The nasal cannula tubing was not properly stored in the plastic bag hanged on the oxygen concentrator and part of the tubing was out of the plastic bag and touching the floor. On 6/19/25 at 0825 hours, an observation and a concurrent interview was conducted with the DSD. The DSD verified the nasal cannula was not properly stored in the plastic bag. The DSD stated the nasal cannula tubing should be stored properly and should not touch the floor for infection control. The DSD removed the nasal cannula tubing. The DSD further stated she will replace the nasal cannula. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the nurses to store the entire nasal cannula tubing in the bag when not in use. 3. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised on 11/2011 showed in infection control considerations related to medication nebulizers/ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 2 of 4 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 06/25/2025 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm continuous aerosol, store the circuit in plastic bag, marked with date and resident's name, between uses; and discard the administration set-up every seven days. Review of Resident 3's medical record was initiated on 6/19/25. Resident 3 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 3's H&P examination dated 3/13/25, showed Resident 3 could make needs known but could not make medical decisions. Review of Resident 3's MDS assessment dated [DATE], showed resident had BIMS score of 6 indicating the resident had severe cognitive impairment. Review of Resident 3's Order Summary showed a physician's order dated 5/31/25, to administer ipratropium-albuterol (a bronchodilator medication used to relax the muscles around the airways in the lungs, making it easier to breathe) inhalation solution 0.5-2.5 mg/ml 1 vial every four hours as needed for coughing or wheezing. On 6/19/25 at 0816 hours, Resident 3's nebulizer tubing was observed on the resident's nightstand in a plastic bag with no name and was dated 6/10/25. On 6/19/25 at 0820 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified Resident 3's nebulizer tubing was in the plastic bag with no name and was dated 6/10/25. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the night shift LVN to change the nebulizer tubing every week and supposed to label the plastic bag with resident's name and date. 4. Review of the facility's P&P titled CPAP/ BiPAP Support dated 3/2015 showed under the general guidance for cleaning: to clean humidifier weekly and air dry; rinse washable filter under running water once a week to remove dust and debris; and mask, nasal pillows and tubing, clean daily by placing in warm, soapy water and soaking/ agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Review of Resident 4's closed medical record was initiated on 6/19/25. Resident 4 was admitted to the facility on [DATE] and was discharged to acute care hospital on 5/29/25. Review of Resident 4's H&P examination dated 3/13/25, showed Resident 4 could make needs known but could not make medical decisions. Review of Resident 4's MDS assessment dated [DATE], showed resident had BIMS score of 15 indicating the resident had intact cognitive function. Review of Resident 4's Order Summary dated 5/31/25 showed a physician's order dated 5/12/25, may use CPAP machine at bedside, pressure setting 4.0, oxygen at 2 liters per minute, no humidification, for sleep apnea. Further review of Resident 4's medical record failed to show evidence the CPAP's washable filter, mask, nasal pillows and tubing were cleaned while the resident was in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 3 of 4 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 06/25/2025 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm On 6/19/25 at 1510 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified Resident 4 uses CPAP at night. The DON verified CPAP's washable filter, mask, nasal pillows and tubing were not cleaned while the resident was in the facility. The DON further stated she would provide in-service to the licensed staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555651 If continuation sheet Page 4 of 4