Health inspection·September 15, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 2 was independent with ambulating 50 ft and required supervision with ambulating 150 ft. During a review of Resident 2's Care Plan (not titled), initiated on 8/27/2024, the Care Plan indicated Resident 2 had a history of behavioral and emotional challenges such as verbal disagreements with his (Resident 2) roommate (name not indicated). During a review of Resident 2's Care Plan (not titled), initiated on 8/29/2025, the Care Plan indicated Resident 2 was involved in a physical altercation (confrontation or argument that escalates to physical aggression, involving physical force or contact between individuals) with another resident (Resident 1), resulting in the resident (Resident 1) being pushed and found on the floor. During a review of Resident 2's change of condition (COC - when there is a sudden significant change in a resident's health status) form, dated 8/29/2025, the COC form indicated on 8/29/2025 (time not indicated), Resident 2 had an episode of physical altercation with another resident (Resident 1). The COC form indicated that Resident 2 admitted to pushing another resident (Resident 1) that resulted in the other resident (Resident 1) to be found sitting down on the floor on his (Resident 1) right side. c. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 1/18/2025 and readmitted on [DATE] with diagnoses including type 2 DM, muscle weakness, and personal history of other (healed) physical injury and trauma. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive functioning was intact. The MDS indicated Resident 3 was independent and was using a wheelchair. During an interview on 9/15/2025, at 10:40 a.m. with Resident 3, Resident 3 stated on the day of the incident between Resident 1 and Resident 2 (Resident 3 could not recall the exact date but stated it was during the afternoon), Resident 3 was resting in bed in Room B (Resident 3's room that is in front of Room A), when he (Resident 3) heard Resident 2 screamed saying that he (Resident 2) had told him (Resident 1) not to make a mess. Resident 3 stated he (Resident 3) could not recall if Resident 1 replied to Resident 2. Resident 3 stated that approximately two to three minutes after he (Resident 3) heard Resident 2's voice, he (Resident 3) heard a loud noise. Resident 3 stated he (Resident 3) immediately went outside (in a wheelchair) into the hallway in front of Room A and saw Resident 1 lying on the floor, on the side of Resident 1's bed facing the window. Resident 3 stated Resident 1's legs were visible on the floor from the hallway. Resident 3 stated Resident 2 was standing in the middle of the room. Resident 3 stated Resident 2 came out of the room and told Resident 3 that he (Resident 2) pushed Resident 1 to the floor and that he (Resident 2) was worried that he (Resident 2) would get in trouble. During an interview on 9/15/2025 at 11:09 a.m. with Resident 2, Resident 2 stated that on 8/29/2025, at approximately 4:15 p.m., he (Resident 2) pushed Resident 1's back with his three fingers (did not indicate which hand) and Resident 1 fell and sat on the floor. Resident 2 stated that Resident 1 had a bowel movement on his (Resident 1) bed and told Resident 2 that he (Resident 1) would defecate on Resident 2's bed as well. Resident 2 stated that Resident 1 was walking towards Resident 2's bed when he (Resident 2) approached and pushed Resident 1's back between his (Resident 1) shoulder blades. During a concurrent interview and record review on 9/15/2025 at 12:17 p.m. with the Acting Director of Nursing (DON), Resident COC form, initiated on 8/29/2025, at 16:20 p.m., was reviewed. The COC form indicated that on 8/29/2025 (time not indicated) Resident 1's roommate (Resident 2) pushed Resident 1 and Resident 1 fell on his (Resident 1) right side. The Acting DON stated that on 8/29/2025, at approximately 4:30 p.m., the Director of Staff Development asked her (Acting DON) to go to Room A. The Acting DON stated she (Acting DON) immediately went to Room A and saw Resident 1 on the floor next to Resident 1's bed. The Acting DON stated that Resident 2 admitted to pushing Resident 1 because he (Resident 2) was bothered by the smell of Resident 1's bowel movement. During an interview on 9/15/2025 at 1:47p.m. with the Acting DON, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555583 If continuation sheet Page 2 of 3 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 09/15/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the Acting DON stated that the facility failed to keep Resident 1 free from physical abuse. The Acting DON stated the incident of physical altercation on 8/29/2025 between Resident 1 and Resident 2 was an incident of physical abuse and had the potential for Resident 1 to sustain fractures, contusion (an injury that occurs when tissue is damaged by a blunt force causing bleeding under the skin and discoloration), and negatively affect Resident 1's emotional well-being. During an interview on 9/15/2025 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/29/2025, at approximately 4: 10 p.m., Resident 2 approached him (LVN 1) and informed that Resident 1 had a bowel movement and needed assistance. LVN 1 stated that approximately two to three minutes after (approximately 4:15 p.m.) talking to Resident 2, he (LVN 1) went to Room A and found Resident 1 on the floor near the foot of Resident 1's bed, leaning towards his (Resident 1) right side, in a semi-sitting position. LVN 1 stated that he immediately got in between Resident 1 and Resident 2 since Resident 2 was standing too close to Resident 1. LVN 1 stated that Resident 2 said that he (Resident 2) pushed Resident 1. LVN 1 stated that the incident of Resident 2 pushing Resident 1 on 8/29/2025 was an incident of physical abuse and had the potential for Resident 1 to sustain injuries such as fractures, head injury, and bleeding. During an interview on 9/15/2025 at 2:26 p.m. with Registered Nurse (RN) 1, RN 1 stated that on 8/29/2025 she (RN 1) was informed by LVN 1 that Resident 2 pushed Resident 1. RN 1 stated that she (RN 1) could not recall the exact time of the incident but when she (RN 1) entered Room A, Resident 1 was on the floor next to Resident 1's bed, lying towards his (Resident 1) right hip. RN 1 stated Resident 2 told her (RN 1) that he (Resident 2) pushed Resident 1. RN 1 stated that the incident of Resident 2 pushing Resident 1 on 8/29/2025 was an incident of physical abuse and had the potential for Resident 1 to sustain injuries, such as fractures. During a record review of the facility-provided policy and procedure titled, Abuse Prevention and Reporting Policy, last reviewed on 4/2025, the policy and procedure indicated, It is the policy of this facility to maintain a zero tolerance for abuse . All residents have the right to be free from abuse and mistreatment. Purpose - Ensure residents are protected from all forms of abuse (physical .). Definitions - Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment causing physical harm, pain, or mental anguish. Event ID: Facility ID: 555583 If continuation sheet Page 3 of 3