Health inspection·August 28, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 1 stated CNA 1 continued to yell obscenities at him (Resident 1). Resident 1 stated he (Resident 1) called the RN Supervisor 1 (RN 1) from his (Resident 1) cell phone to come to his (Resident 1) room to help him (Resident 1). Resident 1 stated he (Resident 1) told RN 1 that CNA 1 was yelling obscenities at him (Resident 1). During an interview with Resident 2 on 8/28/2025 at 12:10 p.m., Resident 2 stated on 8/23/2025 at 6:30 a.m., his roommate (Resident 1) pressed the call light and CNA 1 came inside the room to answer the call light. Resident 2 stated he (Resident 2) heard Resident 1 told CNA 1 that Resident 1 wanted a different CNA to change Resident 1. Resident 2 stated he (Resident 2) heard CNA 1 yell out obscenities and a derogatory and racial insult at Resident 1. Resident 2 stated CNA 1 should have walked away and called the RN 1, instead of staying in the room and yelling out obscenities at Resident 1. During an interview with RN 1 on 8/28/2025 at 12:30 p.m., RN 1 stated on 8/23/2025 at 6:30 a.m., Resident 1 called her because he (Resident 1) did not want CNA 1 to change him. RN 1 stated Resident 1 reported to her (RN 1) that CNA 1 called him (Resident 1) a derogatory and racial insult. RN 1 stated she (RN 1) did not report this verbal abuse allegation to anyone because she (RN 1) did not think anything of it. RN 1 stated she (RN 1) realized this was verbal abuse and should have reported to the abuse coordinator within two hours. RN 1 stated she (RN 1) was very sorry for not reporting the verbal abuse right away. During an interview with the ADMIN and Director of Nurses (DON) on 8/28/2025 at 3:30 p.m., the ADMIN stated Resident 1 reported to her (ADMIN) and the DSD that on 8/23/2025 at 6:30 a.m., CNA 1 went to answer his (Resident 1) call light, and Resident 1 requested for a different CNA. The ADMIN stated Resident 1 reported that CNA 1 yelled a derogatory and racial insult at him (Resident 1). The ADMIN stated she (ADMIN) did not know Resident 1 had reported this to RN 1 on 8/23/2025. The ADMIN and DON stated the facility has no tolerance for any abuse and RN 1 should have reported this right away (facility reported to the State Survey Agency on 8/26/2025). The ADMIN stated that CNA 1 and RN 1 will be terminated effective immediately. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 4/2021, the policy and procedure indicated Residents have the right to be free from abuse. This includes but is not limited to verbal abuse. Event ID: Facility ID: 555583 If continuation sheet Page 2 of 4 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 08/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) within two hours to the State Survey Agency (SSA). On 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant (CNA) 1 flipped off (describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way) using two middle fingers of both hands, yelled obscenities, and called a derogatory and racial insult at Resident 1. The facility reported the verbal abuse incident on 8/26/2025 to the SSA. This deficient practice resulted in a delay in the investigation and placed Resident 1 at risk for further verbal abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/27/2023 with diagnoses including type 2 diabetes (a group of diseases that result in too much sugar in the blood), polyneuropathy (nerve damage), hypertension (elevated blood pressure), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/3/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) with showering, toileting, and lower body dressing. During a record review of Resident 1's Care Plan, dated 8/27/2025, the Care Plan indicated Resident 1 had potentially a psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being problem due to a verbal incident with staff member (CNA 1). During a record review of Resident 1's Progress Notes, dated 8/28/2025, the Progress Notes indicated on 8/23/2025, at around 5 p.m., Resident 1 went to the Staff Developer (DSD) and the Administrator (ADMIN), and reported that on 8/23/2025, at around 6:30 a.m., CNA 1 called him (Resident 1) a derogatory and racial insult. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/15/2025 with diagnoses including history of falling, acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood, and hypertension (elevated blood pressure). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 required substantial to maximal assistance (helper does more than half the effort) with showering, toileting, and lower body dressing. During an interview with Resident 1 on 8/28/2025 at 10:10 a.m., Resident 1 stated on 8/23/2025, at around 6:30 a.m., Resident 1 pressed the call light because he (Resident 1) wanted to be changed. Resident 1 stated CNA 1 answered his (Resident 1) call light, and he (Resident 1) told CNA 1 he wanted a different CNA to change him (Resident 1). Resident 1 stated CNA 1 flipped off at him (Resident 1) using two middle fingers of both hands. Resident 1 stated CNA 1 called him (Resident 1) a derogatory and racial insult. Resident 1 stated CNA 1 continued to yell obscenities at him (Resident 1). Resident 1 stated he (Resident 1) called the RN Supervisor 1 (RN 1) from his (Resident 1) cell phone to come to his (Resident 1) room to help him (Resident 1). Resident 1 stated he (Resident 1) told RN 1 that CNA 1 was yelling obscenities at him (Resident 1). During an interview with Resident 2 on 8/28/2025 at 12:10 p.m., Resident 2 stated on 8/23/2025 at 6:30 a.m., his roommate (Resident 1) pressed the call light and CNA 1 came inside the room to answer the call light. Resident 2 stated he (Resident 2) heard Resident 1 told CNA 1 that Resident 1 wanted a different CNA to change Resident 1. Resident 2 stated he (Resident 2) heard CNA 1 yell out obscenities and a derogatory and racial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 3 of 4 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 08/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete insult at Resident 1. Resident 2 stated CNA 1 should have walked away and called the RN 1, instead of staying in the room and yelling out obscenities at Resident 1. During an interview with RN 1 on 8/28/2025 at 12:30 p.m., RN 1 stated on 8/23/2025 at 6:30 a.m., Resident 1 called her because he (Resident 1) did not want CNA 1 to change him. RN 1 stated Resident 1 reported to her (RN 1) that CNA 1 called him (Resident 1) a derogatory and racial insult. RN 1 stated she (RN 1) did not report this verbal abuse allegation to anyone because she (RN 1) did not think anything of it. RN 1 stated she (RN 1) realized this was verbal abuse and should have reported to the abuse coordinator within two hours. RN 1 stated she (RN 1) was very sorry for not reporting the verbal abuse right away. During an interview with the ADMIN and Director of Nurses (DON) on 8/28/2025 at 3:30 p.m., the ADMIN stated Resident 1 reported to her (ADMIN) and the DSD that on 8/23/2025 at 6:30 a.m., CNA 1 went to answer his (Resident 1) call light, and Resident 1 requested for a different CNA. The ADMIN stated Resident 1 reported that CNA 1 yelled a derogatory and racial insult at him (Resident 1). The ADMIN stated she (ADMIN) did not know Resident 1 had reported this to RN 1 on 8/23/2025. The ADMIN and DON stated the facility has no tolerance for any abuse and RN 1 should have reported this right away (facility reported to the State Survey Agency on 8/26/2025). The ADMIN stated that CNA 1 and RN 1 will be terminated effective immediately. During a review of the facility-provided policy and procedure titled, Abuse Investigation and Reporting, revised on 7/2027, the policy and procedure indicated, All reports of resident abuse . shall be promptly reported to local, state and federal agencies (as defined by current regulations). Reporting 1. All alleged violations involving abuse . will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/\certification agency responsible for surveying/licensing the facility . 2. An alleged violation of abuse . will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse. Event ID: Facility ID: 555583 If continuation sheet Page 4 of 4