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 Page 1 of 2 555583 555583 07/09/2025 MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and/or Roommate Change Authorization/Notification form, dated 6/13/2025 (no time listed) and again on 7/2/2025, the Room and/or Roommate Change Authorization/Notification form indicated Resident 2 gave Verbal Consent to move rooms. The record did not have Resident 2's signature of acknowledging and agreeing to the room change and the facility staff signature/identifier on who completed the form. During an interview on 7/2/2025 at 3:12 p.m. with Resident 2, Resident 2 stated he (Resident 2) was told he (Resident 2) needed to move rooms and he (Resident 2) had no choice. Resident 2 stated he (Resident 2) was moved to the current room just earlier in the day. Resident 2 stated, When they moved me, I felt bad being stuck in another room. I didn't sign any papers to agree to the move, they just moved me. During an interview on 7/2/2025 at 3:58 p.m. with Social Services Assistant (SSA) 1, SSA 1 stated Resident 2 was moved into different rooms on 6/13/2025 and earlier today, 7/2/2025. SSA 1 stated, The failure is that it is important to notify and document the notification of the room changes because it is their right to agree or disagree to the room changes. Ultimately, it is up the resident or responsible party to make that decision. During a review of the facility provided P&P titled, Changes in Resident Condition, dated 11/3/2023, the P&P indicated The resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. The guidelines include: A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: -An accident involving the resident which results in injury and has the potential for requiring physician intervention; During a review of the facility provided P&P titled, Resident Rights, with last revision date of 12/2021, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity. The P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; e. self-determination; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal form the facility; j. be informed about his or her rights and responsibilities; o. be notified of his or her medical condition and of any changes in his or her condition; p. be informed of, and participate in, his or her care planning and treatment; ai. refuse a transfer from a distinct part within the institution. 555583 Page 2 of 2