Maclay Healthcare Center

F-F689)

Findings:

1. During a review of Resident 1 ' s Admission Record (undated), the Admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE REDACTED] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0600 During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024,

the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s Level of Harm - Immediate mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by jeopardy to resident health or human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated safety Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS Residents Affected - Few indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating.

During a review of Resident 1 ' s COC, dated 3/16/2025 at 9 a.m., the COC indicated Resident 1 came to the nursing station on 3/16/2025 at approximately around 8:40 a.m. with bleeding on left thumb. The COC indicated RN 1 conducted a body assessment on Resident 1 with noted laceration on left thumb and abrasion to bilateral knees. The COC indicated the paramedics transferred Resident 1 to GACH 1 for further evaluation.

2. During a review of Resident 2 ' s Admission Record (undated), the Admission Record indicated Resident 2 was admitted on [DATE REDACTED] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (loss of blood flow to

a part of the brain) affecting right dominant side.

During a review of Resident 2 ' s Inventory of Personal Effects (an itemized list of belongings of a resident), dated 7/19/2024, the Inventory of Personal effects did not indicate that Resident 2 was in possession of a knife. The form was completed and documented by CNA 4 and counter signed (a signature attesting the authenticity of a document already signed by another) by Resident 2.

During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions.

During a review of Resident 2 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 2 ' s cognition was intact.

The MDS indicated Resident 2 ' s mobility devices included the use of a walker (a mobility aid designed to assist individuals with difficulty walking) and manual wheelchair. The MDS indicated Resident 2 needed partial/moderate assistance with toilet transfer.

During a review of Resident 2's COC Evaluation, dated 3/17/2025, the COC indicated that on the morning of 3/16/2025 Resident 2 had an altercation with another resident (Resident 1).

During a concurrent observation and interview on 3/18/2025 at 10:10 a.m., with Resident 1 in Resident 1 ' s room, Resident 1 ' s left thumb was observed covered in a foam dressing. Resident 1 stated Resident 2 was disrespectful and used inappropriate words. Resident 1 stated, He (referring to Resident 2) has no respect for anybody, he (Resident 2) can ' t talk like that.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0600 During an interview on 3/18/2025 at 10:34 a.m. with RN 1, RN 1 stated on 3/16/2025 at approximately 8:40 a. m. Resident 1 came to the nursing station and informed RN 1 that Resident 2 cut his (Resident 1) hand while Level of Harm - Immediate Resident 1 was trying to take a knife from Resident 2 in the smoking patio. RN 1 also stated that Resident 1 jeopardy to resident health or was bleeding from the laceration on his left thumb. RN 1 stated while in the smoking patio, he (RN 1) safety questioned Resident 2 regarding possession of a knife but Resident 2 denied. RN 1 stated he (RN 1) did not inspect Resident 2 for the possession of a knife since Resident 2 denied having a knife. RN 1 stated it was Residents Affected - Few him (RN 1) who opened the door to the smoking patio for a resident (name not specified) and left it open allowing Resident 1 and Resident 2 to enter the smoking patio without staff supervision. RN 1 stated that he (RN 1) was in the nursing station when Resident 1 and Resident 2 had a physical altercation.

During an interview on 3/18/2025 at 11:56 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/16/2025. CNA 1 stated she was with another resident (name not specified) when the physical altercation between Resident 1 and Resident 2 happened in the smoking patio. CNA 1 stated the next time she (CNA 1) saw Resident 1 was in the hallway near the nursing station with RN 1 applying pressure on Resident 1 ' s bleeding hand. CNA 1 stated she (CNA 1) heard Resident 1 saying he (Resident 1) was trying to get a knife from another resident (Resident 2).

During an interview on 3/19/2025 at 9:15 a.m., with RN 1, RN 1 stated on 3/16/2025 between 8 a.m. and 8:30 a.m., Resident 1 and Resident 2 were smoking in the smoking patio without staff supervision. RN 1 stated Residents 1 and 2 should have been supervised while smoking in the patio. RN 1 stated the physical abuse incident could have been prevented if a staff member was supervising the two residents (Resident 1 and Resident 2).

During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs and were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times:

a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen.

b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance.

c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and started exchanging words.

d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0600 e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face.

Level of Harm - Immediate f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s jeopardy to resident health or hands. safety g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at Residents Affected - Few 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in

the video surveillance.

During an interview on 3/19/2025 at 1:36 p.m., with the DON, the DON stated the facility failed to provide supervision to Resident 1 and Resident 2 on 3/16/2025 in the smoking patio, which led to a physical altercation between the two residents (Resident 1 and Resident 2) and Resident 1 sustaining an injury. The DON stated the facility has not found the knife used by Resident 2. The DON stated there is a possibility that

the knife is still in the facility or in the possession of another resident.

During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated Resident 1 had informed the Administrator that Resident 2 was using inappropriate words towards Resident 1. The Administrator also stated the physical altercation between Resident 1 and Resident 2 could have been prevented if the two residents (Resident 1 and Resident 2) were supervised in the smoking patio and were immediately separated by staff once the verbal altercation started between Resident 1 and Resident 2. The Administrator stated there was physical abuse and that Resident 2 willfully acted on injuring Resident 1.

During an interview on 3/20/2025 at 2:45 p.m. with the Administrator, the Administrator stated the knife used by Resident 2 to injure Resident 1 was not found. The Administrator also stated body inspection was not done on Resident 2 since Resident 2 refused. The Administrator stated there was a possibility Resident 2 ' s knife is still in the facility.

During a review of the current facility-provided policy and procedure titled, Abuse, Neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress), Exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion) and Misappropriation (the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident ' s belongings or money without the resident ' s consent) Prevention Program, revised on 4/2021 and reviewed on 4/2024, the policy and procedure indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: . b. other residents 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents

During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0600 During a review of the current facility-provided policy and procedure titled, Abuse Policy, last reviewed on 4/2024, the policy and procedure indicated, Communities does not condone (accept and allow) resident Level of Harm - Immediate abuse and shall take every precaution possible to prevent resident abuse by anyone, including . other jeopardy to resident health or residents Residents have the right to be free from abuse 1. Providing a safe environment for the resident is safety one of the most basic and essential duties of our facility 4. Identification of abuse shall be the responsibility of every employee Resident abuse is defined as the willful infliction of injury, unreasonable . resulting in Residents Affected - Few physical harm or pain, mental anguish Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking . and willful neglect of the resident ' s basic needs If abuse happens: 1. Separate the assailant from the victim. 2. Isolate the assailant to protect others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50961 potential for actual harm Based on interview and record review, the facility failed to ensure a resident to resident altercation was Residents Affected - Few thoroughly investigated for two of four sampled residents (Resident 1 and Resident 2). On 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1.

This failure had the potential to place the residents at risk for further abuse.

Findings:

During a review of Resident 1 ' s Admission Record (undated), the Admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE REDACTED] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024,

the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating.

During a review of Resident 1 ' s care plan on chronic (recurring) disruptive behavior (actions that interfere with the functioning of an individual or a group and cause disturbances to those around them, often involving aggression, defiance, or violation of social norms), revised on 9/28/2024, the care plan indicated Resident 1 had a history of physical abuse with another resident (name not indicated).

During a review of Resident 1 ' s History and Physical (H&P), dated 3/12/2025, the H&P indicated Resident 1 had the mental capacity to understand and make decisions.

During a review of Resident 2 ' s Admission Record (undated), the Admission Record indicated Resident 2 was admitted on [DATE REDACTED] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0610 During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2 ' s care plan, dated 3/16/2025, the care plan indicated Resident 2 was involved in an alleged altercation with another resident (Resident 1). Residents Affected - Few

During an interview on 3/18/2025 at 12:28 p.m. with the Administrator, the Administrator stated Registered Nurse (RN) 1 notified the Administrator that on 3/16/2025 at approximately 8:40 a.m., Resident 2 allegedly injured Resident 1 with a knife. The Administrator stated that on 3/16/25 police officers arrived at the facility and had requested the video surveillance of Resident 1 and Resident 2 ' s physical altercation in the East Smoking Patio. The Administrator stated she was not able to provide immediately the video surveillance to

the police officers on that day. The Administrator stated the police officers left the faciity on [DATE REDACTED] at approximately 11:30 a.m. The Administrator stated the video surveillance requested was provided to the police on 3/17/2025. The Administrator stated the police officers came back to the facility on [DATE REDACTED] and informed the Administrator that after reviewing the video surveillance provided they were arresting Resident 2.

During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs, were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times:

a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen.

b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance.

c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and they were exchanging words.

d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2.

e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face.

f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0610 g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in Level of Harm - Minimal harm or the video surveillance. potential for actual harm

During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated she should Residents Affected - Few have requested the surveillance videos on all cameras to see the residents ' (Resident 1 and Resident 2) location after the incident of Resident 1 ' s and Resident 2 ' s physical altercation. The Administrator stated her investigation was not thorough.

During an interview on 3/21/2025 at 6:04 p.m. with the Administrator, the Administrator stated the location of

the knife used by Resident 2 to injure Resident 1 was not known.

During a review of facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last reviewed on 4/2024, the P&P indicated, All allegations are thoroughly investigated. The administrator initiates investigations The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50961

Residents Affected - Few Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident

Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I Screening (preliminary screening to identify individuals potentially needing specialized services due to mental illness or intellectual/developmental disabilities) was completed for one of four sampled residents (Resident 2).

This deficient practice had the potential to result in a delay of necessary care and services to Resident 2.

Findings:

During a review of resident 2 ' s PASSR Level I Screening, dated 7/12/2024, the PASSR Level I Screening indicated Resident 2 did not have serious mental diagnoses. The PASRR Level I Screening also indicated Resident 2 did not require PASRR Level II Screening (a comprehensive evaluation to confirm the diagnosis and determine appropriate placement and [NAME]).

During a review of Resident 2 ' s Admission Record (undated), the Admission Record indicated Resident 2 was admitted on [DATE REDACTED] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side.

During a review of Resident 2 ' s Admission Diagnosis Worksheet, dated 7/23/2024, the Admission Diagnosis Worksheet indicated Resident 2 had diagnoses of stroke, asthma (a condition that causes swelling and narrowing of airways causing difficulty in breathing), hypertension (high blood pressure), and anxiety.

During a review of Resident 2 ' s Admission Minimum Data Set (MDS - resident assessment tool), dated 7/25/2024, the Admission MDS indicated Resident 2 was diagnosed with anxiety disorder.

During a review of Resident 2 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 2 was diagnosed with depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety disorder.

During a review of Resident 2 ' s History and Physical (H&P), dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions.

During a review of Resident 2 ' s care plan, initiated on 3/17/2025, the care plan indicated Resident 2 had a mood challenge related to anxiety disorder, psychosis, and depression.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0644 During a concurrent interview and record review with MDS Specialist on 3/22/2024 at 2:42 p.m., Resident 2 ' s Initial Psychiatric Evaluation, dated 9/25/2024 was reviewed. The Initial Psychiatric Evaluation indicated Level of Harm - Minimal harm or Resident 2 had diagnoses of Psychotic disorder and had episodes of delusions (having false or unrealistic potential for actual harm beliefs) and hallucinations (a sensory experience that appears real but is not based on actual external stimuli). The MDS Specialist stated Level 1 PASRR Screening should have been completed for Resident 2. Residents Affected - Few

During an interview on 3/22/2025 at 6:45 p.m. with the Director of Nursing (DON), the DON stated PASRR Screening provide the recommended behavioral interventions and care residents need. The DON stated PASRR Level I Screening should have been completed for Resident 2. The DON also stated the facility ' s failure could potentially cause delay in provision of necessary care to Resident 2.

During a review of the current facility-provided policy and procedure (P&P) titled, Subject: PASRR, dated 9/26/23, the P&P indicated status change Level I PASRR screening should be completed for a resident if there is a change in psychiatric diagnoses or if there is a discrepancy between PASRR diagnoses and diagnoses given by the attending physician or psychiatrist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50961 safety Based on observation, interview, and record review, the facility failed to provide supervision (refers to the Residents Affected - Few ongoing monitoring and guidance provided by staff to ensure the safety and well-being of residents) for two of four residents (Resident 1 and Resident 2) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1.

This deficient practice resulted in Resident 1 sustaining abrasions (when the surface layers of the skin have been broken) on bilateral (both) knees and left thumb laceration (a deep cut or tear in skin) on 3/16/2025 at 8:29 a.m. On 3/16/2025, Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) for further evaluation and wound treatment. Resident 1 ' s left thumb laceration, measuring three (3) centimeters (cm - unit of measurement) in length, 0.2 cm in width, with unknown depth, required eight stitches (fine, threadlike materials used to hold the edges of a wound together, promoting healing).

On 3/19/2025 at 4:12 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and

the Director of Nursing (DON) for the facility ' s failure to provide staff supervision on 3/16/2025 at 8:26 a.m., when Resident 1 and Resident 2 were both in the facility ' s smoking patio.

On 3/22/2025 at 7:41 p.m., the DON provided an acceptable IJ removal plan (a plan that identifies all actions

the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility ' s failure to provide supervision on 3/16/2025 at 8:26 a.m., to Resident 1 and Resident 2.

On 3/22/2025 at 8:15 p.m., while onsite and after verifying the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, the SSA removed the IJ situation in the presence of the Administrator and the DON.

The acceptable IJ Removal Plan included the following summarized actions:

1. On 3/16/2025 at 8:31 a.m., Resident 1 approached Nursing Station 500 for assistance. Registered Nurse (RN) 1 noted that Resident 1 had a cut on his left thumb with bleeding. RN 1 immediately gave first aid (initial assistance and care given to a resident who has been injured) and called Licensed Vocational Nurse (LVN) 1 to attend to Resident 1. RN 1 asked Resident 1 how he (Resident 1) got the cut on his (Resident 1) left thumb and Resident 1 stated, The guy (referring to Resident 2) is waving his (Resident 2) knife and I tried to seize (take hold of) it (knife). RN 1 immediately went to the smoking patio to check and found Resident 2 about to go inside the facility with no visual (sight) of the alleged knife.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 2. On 3/16/2025 at 9 a.m., RN 1 initiated a change of condition (COC - when there is a sudden significant change in a resident ' s health status) on Resident 2. RN 1 did a body check on Resident 2 and noted an Level of Harm - Immediate abrasion (a superficial injury where the outermost layer of skin is rubbed or torn off, often caused by contact jeopardy to resident health or with a rough surface) on Resident 2 ' s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any safety pain. RN 1 called Resident 2 ' s primary medical doctor (MD) 1 on 3/16/2025 at approximately 9 a.m. who ordered to transfer Resident 2 to GACH 2 for further evaluation. Resident 2 was assigned a 1:1 sitter (refers Residents Affected - Few to a facility staff dedicated to providing continuous, one-on-one observation and care to a single resident, often to ensure their safety and prevent potential harm) to monitor his (Resident 2) aggressive behavior (any behavior intended to harm or cause distress to another person, either physically or emotionally). Resident 2 was transferred to GACH 2 for further psychiatric evaluation (a comprehensive assessment of an individual ' s mental health status, conducted by a qualified mental health professional) and treatment on 3/16/2025 at 6:10 p.m.

3. On 3/16/2025 at approximately 9:15 a.m., RN 1 initiated body assessment on Resident 1 and noted abrasions on both of his (Resident 1) knees. RN 1 initiated the COC on Resident 1. RN 1 called the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) who arrived on 3/16/2025 at around 9:20 p.m. and transferred Resident 1 to GACH 1. RN 1 called the local police.

4. On 3/16/2025 at 9:05 p.m., Resident 1 came back from GACH 1 with eight stitches of sutures on Resident 1 ' s left thumb cut. Resident 1 was monitored for 72 hours for any fall complications and symptoms of emotional distress related to the altercation with Resident 2. Social Services staff continued to do a wellness visit to Resident 1 from 3/16/2025 to 3/19/2025 for emotional support and feeling of safety. The Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) visited Resident 1 on 3/17/2025 at 4 p.m. A Psychologist (a mental health professional who specializes in understanding and treating mental, emotional, and behavioral disorders) visited Resident 1 on 3/19/2025.

5. On 3/16/2025 at 2:30 p.m., the Director of Nursing (DON) via telephone had provided a 1:1 education (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) to RN 1 regarding facility policies for abuse prevention that included all type of abuse and educating on the facility ' s policy and procedure on resident supervision specifically on following the residents ' smoking schedule to ensure that supervision is provided to residents in the smoking patio and on

the other areas of the facility like the front entrance backyard and other patio location to ensure each resident ' s safety. On 3/21/2025 and 3/22/2025, the DON provided 1:1 education to RN 2, Certified Nursing Assistant (CNA) 1, and CNA 2 regarding resident safety, supervision, and abuse prevention and management. Licensed Vocational Nurse (LVN) 1, who is currently on vacation, will be educated prior to coming back on

the floor.

6. On 3/17/2025 at 2 a.m., the facility readmitted Resident 2 from GACH 2. The facility provided 1:1 sitter to Resident 2 to monitor his aggressive behavior. Social Services staff continued doing wellness visit (an appointment to create or update a personalized prevention plan focusing on preventative care and health risk assessments) to Resident 2 starting on 3/17/2025 at 1:17 p.m. who verbalized he (Resident 2) is doing well

in the facility. On 3/18/2025 at 2:30 p.m., The Psychiatrist had seen Resident 2. On 3/18/2025 at 12:44 p.m., four local police officers came to the facility and apprehended Resident 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 7. On 3/17/2025, the Administrator posted signs of No Weapons Allowed in the facility. The signs are posted

in the front entrance door, facility entrance, and employee lounge. Additional posts will be done in other Level of Harm - Immediate areas of the facility. jeopardy to resident health or safety 8. On 3/17/2025 until 3/22/2025, the Director for Staff Development (DSD), the Administrator, DON, and Assistant Administrator provided all facility staff with an in-service (a planned, workplace-based training Residents Affected - Few program designed to enhance staff competency, improve job performance, and keep staff up to date with current best practices and new techniques) for all types of Abuse.

9. The facility made the following efforts to locate the knife used by Resident 2 to injure Resident 1:

a. On 3/16/2025, RN 1 and LVN 1 attempted to search Resident 2, however, Resident 2 refused.

b. On 3/16/2025, RN 1 and LVN 1 searched the Smoking Patio but could not locate the knife.

c. On 3/16/2025, the Administrator asked the police officer to conduct body search on Resident 2, the police officer stated that he cannot conduct it at this time.

d. On 3/16/2025, LVN 2 conducted a search in Resident 2 ' s room, in the trash cans, all drawers, closets, inside the shoes, under the mattresses, and the bathroom. Resident 2 ' s knife was not located.

e. On 3/16/2025, the housekeeper and laundry employees searched all trash carts, and laundry area, knife was not located.

f. On 3/19/2025, the Department heads conducted searches in all residents' rooms and belongings. Resident 2 ' s knife was not located.

g. On 3/19/2025, the Maintenance Supervisor searched the roof top, knife was not located.

h. On 3/22/2025, Administrator started reviewing the video footage to find the location of the knife. The Administrator is new, who started on 12/7/2024, was not given yet the capability to review the surveillance camera but is now able to review as of 3/22/2025. The Administrator is currently working with the Information Technology (IT) staff to assist if there will be any issues regarding the video surveillance footages.

i. The Administrator/designee will coordinate all efforts to exhaustively and continuously search for the missing knife used by Resident 2 until it (the knife) is found. Once knife is found the administrator will take a picture of where the knife was found, will place it in a bag, will handle with caution, and will turn it in to the police department. A notification will be sent to the SSA.

10. On 3/19/2025 and 3/20/2025, the Department Heads conducted resident safety check on their assigned rooms using the resident inventory of personal belongings log to identify presence of any weapons or sharp objects after obtaining consents from self-responsible and alert residents and from residents ' responsible parties for residents who are not self-responsible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 11. On 3/19/2025 and 3/20/2025, the MDS Nurse, DON, and Activity Staff smoking attendant conducted 1:1 smoking observation of residents smoking in the smoking patio. After the smoking observation of residents, Level of Harm - Immediate the MDS Nurse conducted a Smoking Risks Evaluation to determine if a smoker requires supervision or is an jeopardy to resident health or independent smoker during smoking time. The MDS Nurse have identified eight residents who require safety supervision during smoking and ten residents who can independently smoke in the smoking patio. All the 18 residents have the potential to be affected by the deficient practice therefore the facility shall provide Residents Affected - Few residents supervision both for supervised and independent smokers to ensure residents ' safety.

12. On 3/21/2025, a new policy and procedure for Firearms and Other Weapons was initiated and will be presented to the Medical Director on 3/24/2025 during an emergency meeting.

13. Department head managers during their routine rounds will conduct a safety room check on their assigned rooms to inspect the presence of sharp objects. Any kinds of sharp objects will be seized and reported to the Administrator for further follow-up.

Findings:

1. During a review of Resident 1 ' s Admission Record (undated), the Admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE REDACTED] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024,

the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating.

During a review of Resident 1 ' s Non-Compliance for Smoking Policy warning, dated 1/11/2024, the Non-Compliance for Smoking Policy warning indicated Resident 1 was given a verbal warning after Resident 1 was found on the smoking patio during a non-smoking time turning an ashtray dispenser (a device or container designed to hold and dispense ashtrays) upside down to remove any cigarettes that had already been discarded and Resident 1 chewed on the cigarette butts.

During a review of Resident 1 ' s care plan on chronic (recurring) disruptive behavior (actions that interfere with the functioning of an individual or a group and cause disturbances to those around them, often involving aggression, defiance, or violation of social norms), revised on 9/28/2024, the care plan indicated Resident 1 had a history of physical abuse with another resident (name not indicated).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 During a review of Resident 1 ' s care plan with the focus on the resident as a smoker and chews tobacco, revised on 10/3/2024, the care plan indicated Resident 1 was non-compliant (disobedient) with the smoking Level of Harm - Immediate policy and was on the patio during non-smoking time, turning the ash tray dispenser upside down to remove jeopardy to resident health or cigarette butts to chew. The care plan indicated Resident 1 will not smoke without supervision. safety

During a review of Resident 1 ' s COC, dated 3/16/2025 at 9 a.m., the COC indicated Resident 1 came to the Residents Affected - Few nursing station on 3/16/2025 at approximately around 8:40 a.m. with bleeding on left thumb. The COC indicated RN 1 conducted a body assessment on Resident 1 with noted laceration on left thumb and abrasion to bilateral knees. The COC indicated the paramedics transferred Resident 1 to GACH 1 for further evaluation.

2. During a review of Resident 2 ' s Admission Record (undated), the Admission Record indicated Resident 2 was admitted on [DATE REDACTED] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side.

During a review of Resident 2 ' s Inventory of Personal Effects (an itemized list of belongings of a resident), dated 7/19/2024, the Inventory of Personal effects did not indicate that Resident 2 was in possession of a knife. The form was completed and documented by CNA 4 and counter signed (a signature attesting the authenticity of a document already signed by another) by Resident 2.

During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions.

During a review of Resident 2 ' s care plan on resident as a supervised smoker (refers to an individual who, due to assessed needs or identified risks, requires direct supervision or assistance when smoking to ensure their safety and the safety of those around them), revised on 10/10/2024, the care plan indicated Resident 2 was non-compliant with the use of the smoking apron, schedule time, and was at risk for injury from unsafe smoking practices. The care plan indicated Resident 2 ' s risk to smoke without supervision will be minimized, and Resident 2 will be monitored for any unsafe smoking practices.

During a review of Resident 2 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 2 ' s cognition was intact.

The MDS indicated Resident 2 ' s mobility devices included the use of a walker (a mobility aid designed to assist individuals with difficulty walking) and manual wheelchair. The MDS indicated Resident 2 needed partial/moderate assistance with toilet transfer.

During a review of Resident 2's COC Evaluation, dated 3/17/2025, the COC indicated that on the morning of 3/16/2025 Resident 2 had an altercation with another resident (Resident 1).

During a review of the facility ' s Smoking Schedule, (undated), the Smoking Schedule indicated that on Saturdays and Sundays, residents are scheduled to smoke between 9 a.m. to 9:30 a.m., 11 a.m. to 11:30 a. m., 1 p.m. to 1:30 a.m., 3 p.m. to 3:30 p.m., and 7 p.m. to 7:30 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 During a concurrent observation and interview on 3/18/2025 at 10:10 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 ' s left thumb was observed covered in a foam dressing. Resident 1 stated Resident 2 was Level of Harm - Immediate disrespectful and used inappropriate words. Resident 1 stated, He (referring to Resident 2) has no respect jeopardy to resident health or for anybody, he (Resident 2) can ' t talk like that. safety

During an interview on 3/18/2025 at 10:34 a.m. with RN 1, RN 1 stated on 3/16/2025 at approximately 8:40 a. Residents Affected - Few m. Resident 1 came to the nursing station and informed RN 1 that Resident 2 cut his (Resident 1) hand while Resident 1 was trying to take a knife from Resident 2 in the smoking patio. RN 1 also stated that Resident 1 was bleeding from the laceration on his left thumb. RN 1 stated while in the smoking patio, he (RN 1) questioned Resident 2 regarding possession of a knife but Resident 2 denied. RN 1 stated he (RN 1) did not inspect Resident 2 for the possession of a knife since Resident 2 denied having a knife. RN 1 stated it was him (RN 1) who opened the door to the smoking patio for a resident (name not specified) and left it open allowing Resident 1 and Resident 2 to enter the smoking patio with no staff present to supervise the two residents (Resident 1 and Resident 2). RN 1 stated that he (RN 1) was in the nursing station when Resident 1 and Resident 2 had a physical altercation.

During an interview on 3/18/2025 at 11:56 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/16/2025. CNA 1 stated she was with another resident (name not specified) when the physical altercation between Resident 1 and Resident 2 happened in the smoking patio. CNA 1 stated the next time she (CNA 1) saw Resident 1 was in the hallway near the nursing station with RN 1 applying pressure on Resident 1 ' s bleeding hand. CNA 1 stated she (CNA 1) heard Resident 1 saying he (Resident 1) was trying to get a knife from another resident (Resident 2).

During a concurrent observation and interview on 3/18/2025 at 3:18 p.m. with Activity Staff (AS) 1 in the hallway, AS 1 was sitting in the hallway, near the smoking patio with doors closed. Two residents (names not indicated) were observed smoking in the patio through the glass panel on the doors. AS 1 stated the residents smoking in the patio are independent smokers but require supervision since occasionally, they pick up cigarette butts from the floor and try to chew them. AS 1 also stated she should have supervised residents while staying outdoors in the smoking patio. AS 1 stated the entire smoking patio is not visible from behind the hallway doors and she is not able to see all the residents in the patio. AS 1 stated all residents smoking in the patio should be supervised to prevent resident injury.

During an interview on 3/19/2025 at 9:15 a.m., with RN 1, RN 1 stated on 3/16/2025 between 8 a.m. and 8:30 a.m., Resident 1 and Resident 2 were smoking in the smoking patio without supervision. RN 1 stated Residents 1 and 2 should have been supervised while smoking in the patio.

During a concurrent interview and record review on 3/19/2025 at 11:22 a.m. with the MDS Specialist, Resident 2 ' s Smoking Evaluation, dated 10/10/2024, was reviewed. The Smoking Evaluation indicated Resident 2 was noted with episode of non-compliance with the use of the smoking apron and required periodic supervision. The MDS Specialist stated Resident 2 was a supervised smoker. The MDS Specialist also stated residents should not be smoking outside of the scheduled smoking times and all residents should be supervised by the facility staff while smoking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. Level of Harm - Immediate (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified jeopardy to resident health or Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and safety Resident 2) were on their wheelchairs, were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of Residents Affected - Few advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times:

a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen.

b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance.

c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and they were exchanging words.

d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2.

e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face.

f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s hands.

g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in

the video surveillance.

During an interview on 3/19/2025 at 1:36 p.m. with the DON, the DON stated the facility failed to provide supervision to Resident 1 and Resident 2 on 3/16/2025 in the smoking patio, which led to a physical altercation between the two residents (Resident 1 and Resident 2) and Resident 1 sustaining an injury. The DON stated the facility has not found the knife used by Resident 2. The DON stated there is a possibility that

the knife is still in the facility or in the possession of another resident.

During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated Resident 1 had informed the Administrator that Resident 2 was using inappropriate words towards Resident 1. The administrator also stated the physical altercation between Resident 1 and Resident 2 could have been prevented if the two residents (Resident 1 and Resident 2) were supervised in the smoking patio.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 During an interview on 3/20/2025 at 2:45 p.m. with the Administrator, the Administrator stated the knife used by Resident 2 to injure Resident 1 was not found. The Administrator also stated body inspection was not Level of Harm - Immediate done on Resident 2 since Resident 2 refused. The Administrator stated there was a possibility Resident 2 ' s jeopardy to resident health or knife is still in the facility. safety

During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, last Residents Affected - Few reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

During a review of the current facility-provided policy and procedure titled, Safety and Supervision of Residents, last reviewed on 4/2024, the policy and procedure indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision Systems Approach to Safety: . 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for

the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment of if there is a change in the resident ' s condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46445 potential for actual harm Based on interview and record review, the facility failed to ensure a face-to-face visit (a required in-person Residents Affected - Some meeting between a healthcare provider and a resident) was made by a physician or alternate visits by a Nurse Practitioner (NP) was conducted timely according to the facility ' s policy and procedure on Physician Visits for three of four sampled residents (Resident 5, Resident 6, and Resident 8).

This deficient practice had the potential to result in an undetected decline in Residents 5, 6, and 8's medical, health or psychosocial conditions and can lead to a delay in the necessary provision of care, treatment, and services.

Findings:

During a record review of Resident 5 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 12/10/2024 with diagnoses including cellulitis (a bacterial infection of the skin and tissues, causing redness, swelling, and pain) of the left upper extremity (shoulder, arm and leg), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness.

During a record review of Resident 5 ' s Attending Progress Note, dated 11/21/2024, the Attending Progress Note indicated NP 1 visited and assessed the resident. The note did not indicate that the Attending Physician (MD) visited Resident 5.

During a record review of Resident 5 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2024, the MDS indicated Resident 5 ' s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact.

During a record review of Resident 5 ' s History and Physical (H&P), dated 12/11/2024, the H&P indicated MD 1 and NP 2 visited and assessed the resident. There was no documented H&P or Attending Progress Note in Resident 5 ' s electronic health record (EHR) and printed medical records after 12/11/2024.

During a record review of Resident 6 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 7/8/2024 with diagnoses including type 2 diabetes mellitus, cystitis (inflammation of

the bladder [a hallow organ that stores urine in the body]), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).

During a record review of Resident 6 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 6 ' s cognitive skills for daily decision making were intact.

During a record review of Resident 6 ' s H&P, dated 7/8/2024, the H&P indicated NP 3 visited and assessed

the resident. The note did not indicate that MD 2 visited Resident 6. There was no documented H&P or Attending Progress Note in Resident 6 ' s EHR and printed medical records after 7/8/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0712 During a record review of Resident 8 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 6/8/2023 with diagnoses including type 2 diabetes mellitus, essential hypertension Level of Harm - Minimal harm or (an abnormally high blood pressure that was not a result of a medical condition), and anxiety disorder potential for actual harm (persistent and excessive worry that interferes with daily activities).

Residents Affected - Some During a record review of Resident 8 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 8 ' s cognitive skills for daily decision making were intact.

During a record review of Resident 8 ' s H&P, dated 12/20/2024 and 3/7/2025, the H&P indicated MD 1 and NP 2 visited and assessed the resident. There was no documented H&P or Attending Progress Note in Resident 8 ' s EHR and printed medical records for 1/2025 and 2/2025.

During an interview on 3/21/2025 at 9:04 a.m. and a concurrent record review of Resident 5, Resident 6, and Resident 8 ' s H&Ps and Attending Physician Notes, reviewed with Registered Nurse (RN) 2, RN 2 stated there were no documented evidence that Resident 8 ' s MD visited the resident on 1/2025 and 2/2025. RN 2 stated a physician ' s progress notes should be in the residents ' medical records. RN 2 stated no documented physician progress notes indicated the MD did not assess the resident. RN 2 stated the residents ' condition had the potential to worsen. RN 2 stated the facility failed to ensure the attending physicians visited the residents and documented the visit according to the facility ' s policy and procedure.

During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated the physician progress notes were proof that the MD assessed the residents and verified the residents ' medications were accurate. The DON stated the staff involved in the residents ' care had the potential to make inconsistent or inaccurate medical decisions that had the potential to cause harm to the residents.

During a record review of the facility ' s Policy and Procedure (PnP) titled, Physician Visits, last reviewed on 4/2024, the PnP indicated the attending physician must visit his/her patients at least once every 30 days for

the first 90 days following the resident ' s admission and then at least every 60 days thereafter. The policy indicated that after the first 90 days, if the attending physician determines that a resident need not be seen by him every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A physician assistant or NP may make alternate visits after the initial 90 days following admission.

During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the Attending Physician will visit the residents in an timely The PnP indicated the MD will provide progress notes in a timely manner for placement in the medical record. The PnP indicated

the note should either be written of entered at the time of the visit or should be returned to the facility for placement on the chart within one week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46445

Residents Affected - Some Based on interview and record review, the facility failed to ensure the medical records of three of four sampled resident ' s (Resident 5, Resident 6, and Resident 7) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:

1. Ensure Resident 5 and Resident 7 ' s physician telephone orders were dated and signed.

2. Ensure Resident 5, Resident 6, and Resident 7 ' s Attending Physician (MD) reviewed and signed the residents ' Order Summary every month.

3. Ensure Resident 6 ' s medical records do not contain blank worksheet forms and blank consent forms with Nurse Practitioner's (NP) signatures.

These deficient practices had the potential for inaccurate medical interventions and inaccurate information on Residents 5, 6, and 7 ' s medical records.

Findings:

a. During a record review of Resident 5 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 12/10/2024 with diagnoses including cellulitis (a bacterial infection of the skin and tissues, causing redness, swelling, and pain) of the left upper extremity (shoulder, arm and leg), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and muscle weakness.

During a record review of Resident 5 ' s Physician Order for oxycodone-acetaminophen (a medication used to relieve severe pain) 10-325 milligrams (mg - unit of measurement) and tramadol hydrochloride (a medication used to relieve moderate to severe pain), dated 12/10/2024, the order did not indicate the physician ' s signature and the date the physician orders were signed. The transcribed physician ' s order in

the electronic health record (EHR) indicated the communication method (the method the order was received) for the physician orders were through telephone.

During a record review of Resident 5 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2024, the MDS indicated Resident 5 ' s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact.

During an interview on 3/20/2025 at 12:34 p.m. and concurrent record review of Resident 5 ' s Order Summary, dated 12/10/2025, reviewed with Licensed Vocational Nurse (LVN) 3, the Order Summary did not indicate a physician ' s signature and date Resident 5 ' s orders were signed. MD 1 signed Resident 5 ' s Order Summary on 9/4/2024. LVN 3 stated MD 1 ' s signature on the Order Summary indicated MD 1 approved the listed orders for Resident 5. LVN 3 stated the medical records staff were responsible to ensure

the physicians signed Resident 5 ' s physician telephone orders and the resident ' s Order Summary. LVN 3 stated unsigned physician ' s orders had the potential for Resident 5 ' s unapproved and inaccurate orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0842 During an interview on 3/21/2025 at 10:45 a.m. with the Health Information Director (HID), the HID stated

she was responsible for ensuring the facility audits were done timely and the residents ' medical records Level of Harm - Minimal harm or were complete. The HID stated she was responsible to ensure the MDs sign the residents ' medical records. potential for actual harm The HID stated the physicians should not sign blank consent forms. The HID stated there should be three months of printed and signed resident ' s Order Summary in the residents ' medical records. The HID stated Residents Affected - Some incomplete resident medical records had the potential for residents to receive inaccurate and incomplete care. The HID stated the facility failed to ensure the residents ' medical records were complete and accurate.

During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated Resident 5 and Resident 7 ' s physician telephone orders and Order Summary were not signed. The DON stated the MDs should review and sign the Order Summary for Resident 5 and Resident 7 every month. The DON stated unsigned physician orders had the potential for resident harm due to inaccurate or incorrect orders.

The DON stated the facility failed to follow the telephone order policy and failed to ensure the physician telephone orders and the residents ' Order Summary were signed and dated.

During a record review of the facility ' s Policy and Procedure (PnP) titled, Medication and Treatment Orders, reviewed on 4/2024, the PnP indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. The PnP indicated verbal orders must be signed by the prescriber at his or her next visit.

During a record review of the facility ' s PnP titled, Telephone Orders, last reviewed on 4/2024, the PnP indicated verbal telephone orders may be accepted from each resident ' s Attending Physician. The PnP indicated telephone orders must be countersigned by the physician during his or her next visit.

During a record review of the facility ' s PnP titled, Charting and Documentation, last reviewed on 4/2024, the PnP indicated that documentation in the medical record will be objective, complete, and accurate.

During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the physician will periodically review all medications prescribed for the resident

The PnP indicated the physician will verify accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident.

b. During a record review of Resident 6 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 7/8/2024 with diagnoses including type 2 diabetes mellitus, cystitis (inflammation of

the bladder [a hallow organ that stores urine in the body]), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities).

During a record review of Resident 6 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 6 ' s cognitive skills for daily decision making was intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0842 During an interview on 3/20/2025 at 12:55 p.m. and concurrent record review of Resident 6 ' s medical records, reviewed with LVN 3, Resident 6 ' s medical records did not have a printed and signed Order Level of Harm - Minimal harm or Summary. Resident 6 ' s medical records indicated a physician ' s signature, signed by the NP, on the potential for actual harm following blank forms:

Residents Affected - Some 1. One set of Admission Diagnosis Worksheet.

2. Two sets of Facility Verification of Informed Consents.

3. One set of Certification and Recertification for Medicare A Skilled Nursing Facility.

4. One set of MD Query on Malnutrition form.

LVN 3 stated Resident 6 ' s Order Summary should be in the resident ' s medical records. LVN 3 stated MD 2 should sign Resident 6 ' s Order Summary every month to indicate that MD 2 approved the orders required for Resident 6 ' s care. LVN 3 stated the Facility Verification of Informed Consents were consents used for residents that required psychotropic medications (medications used to stabilize or improve mood, mental status, or behaviors) and restraints. LVN 3 stated Resident 6 ' s physicians should sign the resident ' s medical record forms after it was completed. LVN 3 stated signed blank forms and consents had the potential for Resident 6 to receive inappropriate or wrong care.

During an interview on 3/21/2025 at 10:45 a.m. with the Health Information Director (HID), the HID stated

she was responsible for ensuring the facility audits were done timely and the residents ' medical records were complete. The HID stated she was responsible to ensure the MDs sign the residents ' medical records.

The HID stated the physicians should not sign blank consent forms. The HID stated there should be three months of printed and signed resident ' s Order Summary in the residents ' medical records. The HID stated incomplete resident medical records had the potential for residents to receive inaccurate and incomplete care. The HID stated the facility failed to ensure the residents ' medical records were complete and accurate.

During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated Resident 5 and Resident 7 ' s physician telephone orders and Order Summary were not signed. The DON stated the MDs should review and sign the Order Summary for Resident 5 and Resident 7 every month. The DON stated unsigned physician orders had the potential for resident harm due to inaccurate or incorrect orders.

The DON stated the facility failed to follow the telephone order policy and failed to ensure the physician telephone orders and the residents ' Order Summary were signed and dated.

During a record review of the facility ' s PnP titled, Charting and Documentation, last reviewed on 4/2024, the PnP indicated that documentation in the medical record will be objective, complete, and accurate.

During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the physician will periodically review all medications prescribed for the resident .

The PnP indicated the physician will verify accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0842 c. During a record review of Resident 7 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 12/11/2009 with diagnoses including chronic obstructive pulmonary disease (COPD Level of Harm - Minimal harm or - a lung disease characterized by long term poor airflow), epilepsy (a condition that affects the brain and potential for actual harm causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), and depression. Residents Affected - Some

During a record review of Resident 7 ' s MDS, dated [DATE REDACTED], the MDS indicated Resident 7 ' s cognitive skills for daily decision making was intact.

During a record review of Resident 7 ' s Physician Order for Lotensin (a medication used to treat high blood pressure), dated 1/23/2025, did not indicate the physician ' s signature and the date the physician orders were signed. The transcribed physician ' s order in the EHR indicated the communication method for the physician orders were by telephone.

During an interview on 3/21/2025 at 9:04 a.m. and concurrent record review of Resident 7 ' s Order Summary, dated 9/4/2024, reviewed with Registered Nurse (RN) 2, RN 2 stated the printed Order Summary

in Resident 7 ' s medical record was the MD 1 signed and dated Resident 7 ' s Order Summary on 9/4/2024. RN 2 stated Resident 7 ' s medical records should have the printed and signed Order Summary for the last three months. RN 2 stated the medical records staff were responsible to ensure Resident 7 ' s medical records were complete and accurate. RN 2 stated Resident 7 ' s medical record was inaccurate and incomplete.

During an interview on 3/21/2025 at 10:45 a.m. with the Health Information Director (HID), the HID stated

she was responsible for ensuring the facility audits were done timely and the residents ' medical records were complete. The HID stated she was responsible to ensure the MDs sign the residents ' medical records.

The HID stated the physicians should not sign blank consent forms. The HID stated there should be three months of printed and signed resident ' s Order Summary in the residents ' medical records. The HID stated incomplete resident medical records had the potential for residents to receive inaccurate and incomplete care. The HID stated the facility failed to ensure the residents ' medical records were complete and accurate.

During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated Resident 5 and Resident 7 ' s physician telephone orders and Order Summary were not signed. The DON stated the MDs should review and sign the Order Summary for Resident 5 and Resident 7 every month. The DON stated unsigned physician orders had the potential for resident harm due to inaccurate or incorrect orders.

The DON stated the facility failed to follow the telephone order policy and failed to ensure the physician telephone orders and the residents ' Order Summary were signed and dated.

During a record review of the facility ' s Policy and Procedure (PnP) titled, Medication and Treatment Orders, reviewed on 4/2024, the PnP indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. The PnP indicated verbal orders must be signed by the prescriber at his or her next visit.

During a record review of the facility ' s PnP titled, Telephone Orders, last reviewed on 4/2024, the PnP indicated verbal telephone orders may be accepted from each resident ' s Attending Physician. The PnP indicated telephone orders must be countersigned by the physician during his or her next visit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 555583 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555583 B. Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

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 0842 During a record review of the facility ' s PnP titled, Charting and Documentation, last reviewed on 4/2024, the PnP indicated that documentation in the medical record will be objective, complete, and accurate. Level of Harm - Minimal harm or potential for actual harm During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the physician will periodically review all medications prescribed for the resident Residents Affected - Some The PnP indicated the physician will verify accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 555583