Health inspection·July 9, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) affecting two of five sampled residents (Resident 1 & Resident 2) by failing to: A. Notify Resident 1's doctor and responsible party on 6/30/2025 that Resident 1 encountered a change of condition with injury. B. Provide Resident 2 with the right to refuse room changes. These deficient practices denied the residents and their responsible parties' their rights, and to information needed to make decisions related to residents' care needs. Findings: A. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/7/2022 with the diagnoses including muscle weakness, dysphagia (having difficulty swallowing), and hemiplegia and hemiparesis following cerebral infarction (weakness or lack of movement to one side of the body after a brain injury) affecting the left side. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 1 had moderate impairments with decision making tasks and understanding of questions. During a concurrent interview and observation on 7/2/2025 at 2:44 p.m. with Resident 1, Resident 1 stated, I was injured here like two days ago. Resident 1 showed his left elbow noted with skin discoloration of dark purple and blue partially covered with a band-aid. Resident 1 stated the incident happened while staff were using a lift machine (a device used for transferring residents to and from bed to wheelchair) and Resident 1's elbow hit the metal parts of the machine. During a concurrent interview and observation on 7/2/2025 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 observed Resident 1's left elbow and stated it was a hematoma. LVN 1 stated, A hematoma is internal bleeding under the skin or pretty much a bruise on his left elbow covered with a band aid. During an interview on 7/9/2025 at 12:43 p.m. with LVN 2, LVN 2 stated on 6/30/2025, LVN 2 was informed by a Certified Nursing Assistant (unknown) to go to Resident 1 because Resident 1 was bleeding. LVN 2 stated she (LVN 2) went to Resident 1's room and saw discoloration on the resident's left elbow. LVN 2 stated she (LVN 2) did not inform the Registered Nurse on duty, Resident 1's doctor, or the responsible party of Resident 1's change of condition with injury. LVN 2 stated, I failed to start the change of condition timely, I failed to notify the Registered Nurse supervisor, the family/responsible party, and the doctor of the change of condition. B. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/27/2023 with diagnoses including type two diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), polyneuropathy (muscle weakness, pain, numbness due to damaged peripheral nerves), and depression (a serious mental health condition affecting how one feels, thinks, and acts, impacting day to day functions). The admission Record indicated Resident 2 was self-responsible for decision making tasks related to care. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was fully alert and able to understand and answer questions. During a review of Resident 2's Room (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555583 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555583 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 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)