Health inspection·January 28, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to implement policy and procedure on safeguarding of all prescribed medications for one of three sampled residents (Resident 3) by failing to ensure Resident 3's prescribed medication was stored in the medication cart of the nursing station where Resident 3 was located. This deficient practice had the potential for non-authorized access to Resident 3's medications. Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 2/21/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), 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 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/27/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were intact. During a concurrent observation and interview on 1/28/2025 at 9:20 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 opened the first top drawer at nurse station 400 and observed a medication container labeled Airshield (a medication brand name) dietary supplement with Resident 3's name and room number. LVN 1 stated Resident 3 was a current resident in the facility. LVN 1 stated medications should be placed inside the locked medication cart or inside the locked medication room. During a follow up interview on 1/28/2025 at 10:35 a.m. and a concurrent record review of Resident 3's medical records, reviewed with LVN 1, LVN 1 stated Resident 3's Physician Order did not indicate an order for Airshield dietary supplement. LVN 1 stated medications that were discontinued should be disposed inside the locked medication room. LVN 1 stated residents' medications stored in an unlocked nurse station drawers had the potential for another resident to ingest the medication and result I adverse effects (unwanted and undesirable effects of a medication). During an interview on 1/28/2025 at 2:40 p.m. with the Director of Nursing (DON), the DON stated Resident 3's discontinued medication should be inside the locked medication room. The DON stated other residents had the potential to have access to Resident 3's medication and cause the other resident adverse effects. The DON stated the facility failed to follow the policy and procedures on (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555583 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 555583 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 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)