Health inspection·March 22, 2025

F 0583 facility failed to ensure Resident 9 ' s right for privacy was protected. Level of Harm - Minimal harm or potential for actual harm 2. During a record review of Resident 10 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/27/2025 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness. Residents Affected - Some During a record review of Resident 10 ' s MDS, dated [DATE], the MDS indicated Resident 10 ' s cognitive skills for daily decision making was moderately impaired. During a record review of Resident 11 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/21/2025 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness. During a record review of Resident 11 ' s MDS, dated [DATE], the MDS indicated Resident 11 ' s cognitive skills for daily decision making was intact. During a record review of Resident 12 ' s admission Record, the admission Record indicated the facility admitted the resident on 11/28/2023 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness. During a record review of Resident 12 ' s MDS, dated [DATE], the MDS indicated Resident 12 ' s cognitive skills for daily decision making was moderately impaired. During a concurrent observation and interview on 3/21/2025 at 9:04 a.m. with RN 2, observed nurse station 3 ' s computer had Resident 10, Resident 11, and Resident 12 ' s clinical records on the screen. RN 2 stated the nurse station 3 computer screen indicated the access belonged to Licensed Vocational Nurse (LVN) 4, an 11 p.m. to 7 a.m. shift nursing staff. RN 2 stated Residents 10, 11, and 12 ' s clinical information was left unattended and had the potential for unauthorized access from other facility staff that were not involved on the residents ' care, visitors, and other outside agencies. RN 2 stated the facility failed to ensure Residents 10, 11, and 12 ' s right for privacy was protected. During a record review of the facility ' s Policy and Procedure (PnP) titled, Electronic Medical Records, last reviewed on 4/2025, the PnP indicated only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system. The PnP indicated the medical records system safeguards the prevent unauthorized access of electronic protected health information (e-PHI). These safeguards included administrative, technical, and physical safeguards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 2 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) 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 being subjected to physical abuse by Resident 2 while under the care of the facility. On 3/16/2025 at 8:29 a.m., Resident 1 sustained 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). Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) on 3/16/2025 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). Based on the Reasonable Person Concept (what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer because of the noncompliance), due to Resident 1 ' impaired cognition (mental action or process of acquiring knowledge and understanding) and medical condition, an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). On 3/19/2025 at 4:12 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ – a situation in which the facility ' s non-compliance with one or more requirements of participations had 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 ensure that Resident 1 was kept free from physical abuse, as evidenced by Resident 2 injuring (to hurt or cause physical harm to another person) Resident 1 with a knife in the facility ' s smoking patio. On 3/22/2025 at 5:48 p.m., the Administrator 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 keep Resident 1 free from physical abuse. 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 and determined the IJ situation was no longer present. The IJ situation was removed while onsite, 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 1 (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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 3 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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 knife. 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 abrasion (a superficial injury where the outermost layer of skin is rubbed or torn off, often caused by contact with a rough surface) on Resident 2 ' s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any 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 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. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 4 of 29 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 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 apprehended Resident 2. Level of Harm - Immediate jeopardy to resident health or safety 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 areas of the facility. Residents Affected - Few 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 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 to 3/22/2025, the DSD, Administrator, DON, and Assistant Administrator conducted in-services to staff regarding resident-to-resident verbal altercation and separating the residents to avoid escalation (an increase in the intensity or seriousness of something), recognizing potential threats, and handling situations where a weapon may be involved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 5 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 11. 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. 12. On 3/22/2025, RN Mentor in-serviced the Administrator and DON on the policy and procedure for abuse, how to detect and what is the definition of Abuse. 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. 14. Upon admission and during quarterly Interdisciplinary Team (IDT – a collaborative group of individuals from different discipline who work together to achieve a common goal) meetings, the Social Services will educate residents and their representatives about the policy and procedure on abuse and the facility ' s protocol of not bringing any sharp objects or weapons to the facility. Anyfindings of such will be confiscated immediately and will be handed to the Administrator/DON. 15. Upon returning from out on pass (refers to a planned, temporary absence of a resident from the facility, authorized by a physician ' s order, for a specific purpose, with the expectation of the resident ' s return), if residents or representatives bring any items back to the facility, the charge nurse or RN supervisor will be asking for any items the resident would like to be added to the inventory list. (Cross Reference to 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] 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 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 6 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident 2 was admitted on [DATE] 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], 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. 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 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 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). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 7 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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. 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 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 8 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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. 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 abuse and shall take every precaution possible to prevent resident abuse by anyone, including . other residents Residents have the right to be free from abuse 1. Providing a safe environment for the resident is 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 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) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 9 of 29 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 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 potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident to resident altercation was 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. Residents Affected - Few 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] 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] 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 H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 10 of 29 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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). 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 3/16/2025 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 3/18/2025 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. 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 3:16 p.m. with the Administrator, the Administrator stated she should have requested the surveillance videos on all cameras to see the residents ' (Resident 1 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 11 of 29 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 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 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 12 of 29 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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] 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], 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. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 13 of 29 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Evaluation indicated Resident 2 had diagnoses of Psychotic disorder and had episodes of delusions (having false or unrealistic 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. 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) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 14 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision (refers to the 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. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 15 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and noted an abrasion (a superficial injury where the outermost layer of skin is rubbed or torn off, often caused by contact with a rough surface) on Resident 2 ' s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any 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 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. 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 areas of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 16 of 29 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 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 Level of Harm - Immediate 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 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: Residents Affected - Few 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. 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, the MDS Nurse conducted a Smoking Risks Evaluation to determine if a smoker requires supervision or is an independent smoker during smoking time. The MDS Nurse have identified eight residents who require 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 17 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility shall provide 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] 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). 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 policy and was on the patio during non-smoking time, turning the ash tray dispenser upside down to remove cigarette butts to chew. The care plan indicated Resident 1 will not smoke without supervision. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 18 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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] 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], 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. 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. 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 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 19 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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. 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 20 of 29 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 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 b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance. Level of Harm - Immediate jeopardy to resident health or safety 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. Residents Affected - Few 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. 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, Smoking Policy-Residents, last 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 21 of 29 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 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 Level of Harm - Immediate jeopardy to resident health or safety 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. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 22 of 29 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 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 potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a face-to-face visit (a required in-person 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). Residents Affected - Some 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], 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. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 23 of 29 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 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 Level of Harm - Minimal harm or potential for actual harm hypertension (an abnormally high blood pressure that was not a result of a medical condition), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a record review of Resident 8 ' s MDS, dated [DATE], the MDS indicated Resident 8 ' s cognitive skills for daily decision making were intact. Residents Affected - Some 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) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 24 of 29 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. During an interview on 3/21/2025 at 10:45 a.m. with the Health Information Director (HID), the HID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 25 of 29 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 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], the MDS indicated Resident 6 ' s cognitive skills for daily decision making was intact. 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 Summary. Resident 6 ' s medical records indicated a physician ' s signature, signed by the NP, on the following blank forms: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 26 of 29 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 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 1. One set of admission Diagnosis Worksheet. Level of Harm - Minimal harm or potential for actual harm 2. Two sets of Facility Verification of Informed Consents. 3. One set of Certification and Recertification for Medicare A Skilled Nursing Facility. Residents Affected - Some 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. 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 - a lung disease characterized by long term poor airflow), epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), and depression. During a record review of Resident 7 ' s MDS, dated [DATE], the MDS indicated Resident 7 ' s (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 27 of 29 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 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 cognitive skills for daily decision making was intact. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Some 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. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 28 of 29 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 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 visit to the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 29 of 29