Health inspection·July 19, 2024

F 0600 A review of Resident 2's MDS dated [DATE] indicated Resident 2 had severely impaired cognition. Level of Harm - Actual harm A review of Resident 2's COC Evaluation Form, dated 7/3/2024, timed at 1:30 p.m., indicated that Resident 2 was hit by Resident 1 and sustained a cut on the left eye area with minimal bleeding, skin discoloration, and swelling to the left periorbital (the area around the left eye). The COC form further indicated that Resident 2 required ice packs to the left eye to decrease the swelling. Residents Affected - Few A review of Resident 2's Comprehensive Skin Assessment Report dated 7/23/2024, indicated Resident 2 sustained a cut on the left eye area with a width of 1.5 centimeters (cm- a unit of measurement) with bleeding noted on Resident 2's left eye area. A review of Resident 2's Physician Order dated 7/3/2024 indicated to cleanse the cut on the left eye area with Normal Saline Solution (NSS - a wound cleansing solution), pat dry, then apply antibiotic (a medication applied topically [to the skin surface] to prevent wound infection) and leave the area open to air daily for 14 days. During a concurrent observation and interview on 7/19/2024 at 12:35 p.m., with Director 1 (DIR 1), observed Resident 2 lying in his bed with visible purplish discoloration and swelling around Resident 2's left eye. DIR 1 stated that Resident 2's left eye had purplish discoloration and swelling. During an interview on 7/19/2024 at 1:50 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 7/3/2024 (unable to recall specific time) she (LVN 1) saw Resident 1 walk past Resident 2 while in front of the nursing station. LVN 1 stated that she (LVN 1) then turned away when LVN 1 suddenly heard a disruption. LVN 1 stated that she (LVN 1) turned and saw Resident 1 and Resident 2 struggling and grabbing each other's arms. LVN 1 stated that she (LVN 1) ran and separated Resident 1 and Resident 2. LVN 1 stated that upon separating Resident 1 and Resident 2, LVN 1 noticed discoloration to Resident 2's left eye. LVN 1 stated that Resident 1 likely hit Resident 2 during the altercation because Resident 2 did not have discoloration to the left eye prior to the incident. During a concurrent interview and record review on 7/19/2024 at 2:30 p.m. with the Director of Nursing (DON), the DON reviewed Resident 2's COC Evaluation Form dated 7/3/2024. The DON stated Resident 2's injury (cut and swelling with discoloration to the left periorbital area) that was sustained on 7/3/2024, after Resident 2's altercation with Resident 1, was consistent with someone being hit. The DON stated that Resident 1 hitting Resident 2 was physical abuse which should not have been allowed to happen. During an interview on 7/19/2024 at 2:55 p.m., with the Administrator in Training (AIT), the AIT stated that he (AIT) is the facility's abuse coordinator (the person that investigates allegations of abuse in the facility). The AIT stated that the altercation that occurred between Resident 1 and Resident 2 on 7/3/2024 was physical abuse. The AIT stated that Resident 2 sustained physical injuries (cut and swelling with discoloration to the left periorbital area) from the altercation. During a concurrent interview and record review on 7/19/2024 at 3:05 p.m., with the DON, the DON reviewed the facility's policy titled Abuse Prevention Program, dated 12/2016. The DON stated that the facility failed to ensure that Resident 2 was free and protected from abuse when on 7/3/2024, Resident 1 hit Resident 2, causing Resident 2 to sustain a cut, discoloration and swelling to the left periorbital area. The DON stated that this failure indicated that the facility did not follow the facility's policy for the prevention of abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555574 If continuation sheet Page 2 of 3 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 555574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stoney Point Healthcare Center 21820 Craggy View St. Chatsworth, CA 91311 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 A review of the facility's policy titled, Abuse Prevention Program, dated 12/2016, last reviewed on 1/16/2024 indicated that the facility's residents have the right to be free from abuse . this includes physical abuse. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555574 If continuation sheet Page 3 of 3