Other·May 3, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA00621971 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 39230 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Four deficiencies were issued for complaint number CA00621971.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 04/30/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 1 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the physician on acute change of condition (COC) for one of three sampled residents (Resident 1). Resident 1 who had a second episode of vomiting on 12/28/18 at 6 p.m. and had an excessive secretion on 12/29/18 at 3:30 a.m. This deficient practice had the potential for resident's condition not treated immediately. Findings: On 1/30/19, at 8:20 a.m., an unannounced visit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 2 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was made to the facility to investigate a complaint regarding quality of care. A review of admission record, indicated Resident 1 was admitted to the facility on 10/12/15 and re-admitted on 12/22/18. Resident 1 diagnoses including sepsis (life threatening infection on the blood), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), dysphagia (difficulty in swallowing), and gastrostomy (surgical creation of external opening into the stomach for administration of food, fluids, and medications). A review of Resident 1's physician (MD) initial history and physical, dated 12/26/18, indicated Resident 1 had no capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 10/25/18, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. The MDS indicated, Resident 1 was totally dependent to staff for activities of daily living (dressing, eating, toilet use, personal hygiene, and bathing) and always incontinent (inability to control) of bowel and had a urinary catheter. A review of Resident 1's physician discharge summary, indicated Resident 1 expired on 12/29/18. No documentation of condition on discharge and/or cause of death. A review of Resident 1's enteral (TF- tube feeding) physician order, dated 12/22/18, indicated TF formula via gastrostomy tube (GTis a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 3 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by pump at 50 milliliters (ml) per hour times twenty hours. Aspiration (sucking in a foreign object into the airway) precaution, monitor every shift. A review of Resident 1's physician order, dated 12/29/18, at 11:45 p.m., indicated may do oral suction as needed for excessive secretions. No documentation of licensed nurse assessment. A review of Resident 1's physician enteral orders form, indicated TF formula at 50 ml per hour, schedule time at 8 a.m. off and at 12 p.m. on. A review of Resident 1's care plan dated 12/22/18, resident on tube feeding related to dysphagia, at risk for aspiration. The goal indicated resident will have no aspiration daily for three months. The interventions included check and maintain placement and patency of GT, keep head of bed (HOB) elevated at 30 degrees, monitor for aspiration, and notify MD of any signs and symptoms of tolerance. A review of Resident 1's nurse's notes, dated 12/27/18 at 1:30 p.m., indicated Resident 1 had small amount of emesis (vomiting) per MD hold feeding for one hour and if no further emesis, re-start GT feeding. No documentation of MD orders and no documentation of continuous assessment from 12/27/18 at 2:30 p.m. to 12/28/18 at 6 p.m. (27.5 hours). A review of Resident 1's nurse's notes, dated 12/28/18 at 6 p.m., indicated Resident 1 had vomiting times one. No documentation of MD notification. A review of Resident 1's nurse's notes, dated 12/29/18 at 3:30 a.m., indicated Resident 1 had excessive secretions. No documentation of MD notification. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 4 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's nurse's notes documented by Registered Nurse 1 (RN 1), dated 12/29/18, at 4:40 a.m., indicated noted Resident 1 in bed with eyes closed, skin warm to touch, no breathing, no vital signs (pulse rate, blood pressure, body temperature and respiratory rate) appreciated at this time, pupils fixed, non-reactive to light. Pronounced dead at this time. A review of Resident 1's nurse's notes entries from 12/27/18 at 1:30 p.m. up to the time of expiration on 12/29/18, indicated 6 entries as follows: 12/27/18 at 1:30 p.m., 12/27/18 at 2:30 p.m., next entry on 12/28/18 at 6 pm (27.5 hours apart), next entry on 12/29/18 at 3 a.m. (9 hours apart), then 12/29/18 at 3:30 a.m., and next entry on 12/29/18 at 4:40 a.m. when Resident 1 expired. During a phone interview with Licensed Vocational Nurse 1 (LVN 1), on 3/4/19, at 9 a.m., LVN 1 stated she worked on 12/28/18 at 11 p.m. to 7 a.m. shift and Resident 1 was her assigned resident. LVN 1 stated on 12/29/18, before she went on break, unable to recall exact time, she heard Resident 1 had secretions then she suctioned and repositioned the resident. LVN 1 stated when she came back from break, she heard a beeping sounds and found out it was Resident 1's TF pump. LVN 1 stopped the machine and noticed Resident 1 had a lot of yellow vomitus on chest. LVN 1 checked Resident 1 and noticed not breathing and called Registered Nurse 1 (RN 1) for help. Informed LVN 1 reviewed clinical record and was unable to find this information. LVN 1 stated she thought she documented it and further stated it should be documented. LVN 1 stated if resident on GT vomited, it was a concern that should be reported to MD, possibly GT not in place. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 5 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a clinical record review and concurrent interview with Director of Nursing (DON), on 3/4/19, at 2:45 p.m., DON stated resident on TF with an episode of vomiting was not normal. DON stated it was a concern that should be reported to MD and find out what's going on to address and provide necessary treatment. DON stated MD order depends on the detailed assessment reported by the licensed nurse (LN) to MD. DON further stated LN should thoroughly report the assessment and condition of the resident to provide proper management and all the details should be documented. DON stated the possible cause of vomiting on resident with TF were obstruction or not tolerating the TF. DON further stated MD might order a diagnostic test, medication, and/or transfer to hospital for further evaluation. DON stated this was a COC that should be assessed and monitored for at least 72 hours. DON stated all MD orders received should be written in the physician's order sheet. DON reviewed clinical record of Resident 1 and was unable to find a documentation on the following: 1. any MD order to address the vomiting, 2. continuous assessment and monitoring for at least 72 hours for COC of vomiting, 3. MD notification for second episode of vomiting and for excessive secretions, and 4. episode of vomiting when Resident 1 was found unresponsive by LVN 1. DON stated resident clinical record should be complete and accurate to reflect resident's condition. During an interview with Attending Physician (AMD), on 3/5/18, at 10:05 a.m., AMD stated the nurse should call MD and report every episodes of vomiting of resident on TF or any COC. AMD stated nurse should assess and monitor the resident and report any changes. AMD stated diagnostic test might be order depends on the condition of the resident, to see FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 6 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE what's going on and to see if there was obstruction or ileus (temporary paralysis of a part of the intestine), and if result was negative then think of another condition that cause the vomiting. AMD further stated the most concern if resident vomiting was the risk for aspiration. AMD stated every episode of vomiting on resident with TF should be managed and addressed. During a clinical record review and concurrent interview with DON, on 3/28/19, at 3:30 p.m., DON stated the MD telephone order on 12/29/18 at 11:45 p.m. for oral suctioning was a wrong entry and it should be 12/28/18. A review of facility's policy and procedure titled "Change of Condition Notification", dated 6/1/17, indicated the purpose is to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. "Clinically important" means a deviation that, without intervention, may result in complications or death. (AMDA 2003). The Attending Physician will be notified timely with a resident's change in condition. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. A Licensed Nurse will document the date, time, pertinent details of the incident and the subsequent assessment in the nursing notes, the time Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. Update the Care Plan to reflect the resident's current status. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 7 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Nurse will document each shift for at least seventy-two hours.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 04/30/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide a services that adhere to acceptable standards of practice for one of three sampled residents (Resident 1). Facility failed to follow own policy on pronouncement of death. This deficient practice had the potential for resident's needs not being provided. Findings: On 1/30/19, at 8:20 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. A review of admission record, indicated Resident 1 was admitted to the facility on 10/12/15 and re-admitted on 12/22/18. Resident 1 diagnoses including sepsis (life threatening infection on the blood), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), dysphagia (difficulty in swallowing), and gastrostomy (surgical creation of external opening into the stomach for administration of food, fluids, and medications). A review of Resident 1's physician (MD) initial history and physical, dated 12/26/18, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 8 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 had no capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 10/25/18, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. The MDS indicated, Resident 1 was totally dependent to staff for activities of daily living (dressing, eating, toilet use, personal hygiene, and bathing) and always incontinent (inability to control) of bowel and had a urinary catheter. A review of Resident 1's physician discharge summary, indicated Resident 1 expired on 12/29/18. No documentation of condition on discharge and/or cause of death. A review of Resident 1's nurse's notes documented by Registered Nurse 1 (RN 1), dated 12/29/18, at 4:40 a.m., indicated noted Resident 1 in bed with eyes closed, skin warm to touch, no breathing, no vital signs (pulse rate, blood pressure, body temperature and respiratory rate) appreciated at this time, pupils fixed, non-reactive to light. Pronounced dead at this time. A review of Resident 1's nurse's notes, dated 12/29/18, at 5 a.m., indicated called and informed primary physician and nurse practitioner, with new order to release the body to funeral. During a phone interview with RN 1, on 3/4/19, at 9:25 a.m., RN 1 stated she worked on 12/28/18 at 11 p.m. to 7 a.m. shift. RN 1 stated it's not normal for resident on GT to vomit and TF should be stopped, assess the resident, and notify the MD. RN 1 stated on 12/29/18, she was called by Licensed Vocational Nurse 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 9 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (LVN 1) to check Resident 1. RN 1 stated Resident 1 was not breathing, no vital signs, skin warm, pupil fixed, do not resuscitate (DNR), and she pronounced Resident 1 dead. RN 1 stated it was the practice in the facility that RN can pronounce dead without calling the MD. During an interview with Director of Nursing (DON), on 3/6/19, at 11:25 a.m., DON stated only licensed physician can pronounce dead per facility policy. A review of facility's policy and procedure titled "Death of a Resident", dated 6/1/17, indicated only a Licensed Physician may declare a resident dead. The Licensed Nurse will notify Attending Physician regarding resident's change in condition. The Resident will be declared dead only by the licensed physician.

F693 SS=G Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 04/30/2019 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 10 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a resident with enteral tube feeding (TF - is the delivery of nutrients through a feeding tube directly into the stomach) and had episodes of vomiting was assessed and monitored continuously for one of three sampled residents (Resident 1) to prevent complications of enteral TF, including; 1. Failure to monitor and assess Resident 1 every shift for at least 72 hours after the first episodes of vomiting on 12/27/18 at 1:30 p.m. 2. Failure to notify Resident 1's attending physician after a second episode of vomiting on 12/28/18, at 6 p.m. in order to evaluate and obtain interventions as needed. 3. Failure to notify the attending physician of Resident 1's episode of excessive secretions (excessive flow of saliva from the mouth) on 12/29/18, at 3:30 a.m. in order to obtain further medical evaluation and intervention. These deficient practices resulted in Resident 1 not receiving immediate medical evaluations and interventions for acute change of condition of two episodes of vomiting and excessive secretions. Resident 1 was found unresponsive on 12/29/18, at 4:40 a.m. and was pronounced dead. Findings: On 1/30/19, at 8:20 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 11 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of admission record indicated Resident 1 was admitted to the facility on 10/12/15 and re-admitted on 12/22/18. Resident 1 diagnoses included sepsis (life threatening infection on the blood), hemiplegia (paralysis of one side of the body), dysphagia (difficulty in swallowing), and had a gastrostomy tube (GT - surgical creation of external opening into the stomach for administration of food, fluids, and medications). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 10/25/18, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. The MDS indicated, Resident 1 was totally dependent on staff for activities of daily living (dressing, eating, toilet use, personal hygiene, and bathing) and always incontinent (inability to control) of bowel and had a urinary catheter (is a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag). A review of Resident 1's care plan dated 12/22/18, resident on tube feeding related to dysphagia, at risk for aspiration (a condition in which foods, stomach contents, or fluids are breathed in through the wind pipe). The goal indicated resident will have no aspiration daily for three months. The interventions included check and maintain placement and patency of GT, keep head of bed (HOB) elevated at 30 degrees, monitor for aspiration, and notify MD of any signs and symptoms of tolerance. A review of Resident 1's physician order dated 12/22/18, indicated Ondansetron (drug use to prevent nausea and vomiting) 4 milligrams via GT as needed (PRN) every six hours for nausea and vomiting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 12 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's physician order, dated 12/22/18, indicated tube feeding (TF) formula via GT pump at 50 milliliters (ml) per hour times twenty hours. Aspiration precaution, monitor every shift. A review of Resident 1's physician order, dated 12/28/18, at 11:45 p.m., indicated may do oral (mouth) suction as needed for excessive secretions. A review of Resident 1's Nurse's Notes, dated 12/27/18 at 1:30 p.m., indicated Resident 1 had small amount of emesis (vomiting). The note indicated that per MD to hold feeding for one hour and if no further emesis, then re-start GT feeding. The Nurse's Note at 2:30 p.m. indicated Resident 1 had no episodes of vomiting, abdomen soft, none distended, and had a small feeding residual. The TF was restarted per MD order. There was no documented evidence of Resident 1 description of vomitus and there was no assessment and monitoring documented after 12/27/18 at 2:30 p.m. A review of Resident 1's Nurse's Notes, dated 12/28/18 at 6 p.m., (28.5 hours after the first episode of Resident 1 vomiting) indicated Resident 1 had vomited times one. There was no documented evidence that the physician was notified that Resident 1 had a second episode of vomiting. A review of Resident 1's Nurse's Notes, dated 12/29/18 at 3:30 a.m., indicated Resident 1 was suctioned for excessive secretions. The note indicated Resident 1 HOB was elevated, aspiration precaution was observed. There was no documentation that Resident 1's MD was notified of excessive secretions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 13 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Nurse's Notes documented by Registered Nurse 1 (RN 1), dated 12/29/18, at 4:40 a.m., indicated Resident 1 in bed with eyes closed, skin warm to touch, no breathing, no vital signs (no sign of life including pulse rate, blood pressure, body temperature and respiratory rate) appreciated at this time, pupils fixed, non-reactive to light. Pronounced dead at this time. A review of Resident 1's Nurse's Notes, dated 12/29/18, at 5 a.m., indicated the primary care physician and the nurse practitioner was called and informed, with new order to release Resident 1's body to funeral. During a phone interview with Licensed Vocational Nurse 1 (LVN 1), on 3/4/19, at 9 a.m., LVN 1 stated she worked on 12/28/18 at 11 p.m. to 7 a.m. shift and Resident 1 was her assigned resident. LVN 1 stated on 12/29/18, before she went on break, unable to recall exact time, she heard Resident 1 had secretions then she suctioned and repositioned the resident. LVN 1 stated when she came back from her break, she heard a beeping sounds and found out it was Resident 1's TF pump. LVN 1 stated she stopped the machine and noticed Resident 1 had a lot of yellow vomitus on chest. LVN 1 stated she checked Resident 1 and noticed that the resident was not breathing, and she called Registered Nurse 1 (RN 1). During a phone interview with RN 1, on 3/4/19, at 9:25 a.m., RN 1 stated she worked on 12/28/18 at 11 p.m. to 7 a.m. shift. RN 1 stated, "It is not normal for resident on GT to vomit and TF should be stopped, assess the resident, and notify the MD." RN 1 stated on 12/29/18, she was called by LVN 1 to check Resident 1. RN 1 stated Resident 1 was not breathing, no vital signs, skin warm, pupil fixed, do not resuscitate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 14 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (DNR - ), and she pronounced Resident 1 dead. RN 1 stated it was the practice in the facility that RN can pronounce dead without calling the MD. During a clinical record review and concurrent interview with Director of Nursing (DON), on 3/4/19, at 2:45 p.m., DON stated resident on TF with an episode of vomiting was not normal. DON stated it was a concern that should be reported to MD to identify the cause and address Resident 1 condition. DON stated MD order depends on the detailed assessment reported by the licensed nurse (LN) to MD. DON further stated LN should thoroughly report the assessment and condition of the resident to provide proper management and all the details should be documented. DON stated the possible cause of vomiting on resident with TF were obstruction or not tolerating the TF. DON further stated MD might order a diagnostic test, medication, and/or transfer to hospital for further evaluation. DON stated this was a COC that should be assessed and monitored for at least 72 hours. DON stated all MD orders received should be written in the physician's order sheet. DON reviewed clinical record of Resident 1 and was unable to provide documented evidence that Resident 1 physician was notified of Resident 1 second episode of vomiting, no assessment and monitoring from 12/27/18 at 2:30 p.m. (initial vomiting) to 12/28/18 at 6 p.m. (second episode of vomiting), and MD notification of resident's excessive secretions. During a clinical record review and concurrent interview with Medical Record Director (MRD), on 3/4/19, at 5:10 p.m., MRD reviewed Resident 1's Physician Discharge Summary and stated Resident 1 expired on 12/29/18. MRD was unable to find a documentation of the cause of death of Resident 1. MRD stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 15 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cause of death should be documented in the physician discharge summary. During an interview with Attending Physician (AMD), on 3/5/19, at 10:05 a.m., AMD stated the nurse should call MD and report every episodes of vomiting of resident on TF or any COC. AMD stated nurse should assess and monitor the resident and report any changes. AMD stated diagnostic test might be order depends on the condition of the resident, to see what is going on and to see if there was obstruction or ileus (temporary paralysis of a part of the intestine), and if result was negative then think of another condition that cause the vomiting. AMD further stated the most concern if resident vomiting was the risk for aspiration. AMD stated every episode of vomiting on resident with TF should be managed and addressed. A review of facility's policy and procedure titled "Change of Condition Notification," dated 6/1/17, indicated the purpose is to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. "Clinically important" means a deviation that, without intervention, may result in complications or death. (AMDA 2003). The Attending Physician will be notified timely with a resident's change in condition. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. A Licensed Nurse will document the date, time, pertinent details of the incident and the subsequent assessment in the nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 16 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notes, the time Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. Update the Care Plan to reflect the resident's current status. Licensed Nurse will document each shift for at least seventy-two hours. A review of facility's policy and procedure titled "Gastrostomy Placement," dated 6/1/17, indicated assess the resident's abdomen for bowel sounds and distention. Check, the placement of the feeding tube externally to be sure it has not slipped out since the last feeding. Document the procedure and any other pertinent clinical information related to the feeding and the resident's tolerance/response to the feeding.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 04/30/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 17 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 18 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain the clinical records of one of three sampled residents (Resident 1) in accordance with accepted professional standards and practices that are complete and accurately documented. 1. Failure to document assessment and monitoring of Resident 1's acute change of condition (COC) for at least 72 hours. 2. Failure to document licensed vocational nurse observation on 12/29/18 when Resident 1 was found unresponsive. 3. Failure to document order received on 12/27/18 in the physician's order sheet. 4. Failure to complete physician discharge summary and document cause of death. These deficient practices had the potential to result in inaccurate resident assessment and delay of treatment. Findings: On 1/30/19, at 8:20 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. A review of admission record, indicated Resident 1 was admitted to the facility on 10/12/15 and re-admitted on 12/22/18. Resident 1 diagnoses including sepsis (life threatening infection on the blood), hemiplegia (paralysis of one side of the body) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 19 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hemiparesis (weakness of one side of the body), dysphagia (difficulty in swallowing), and gastrostomy (surgical creation of external opening into the stomach for administration of food, fluids, and medications). A review of Resident 1's physician (MD) initial history and physical, dated 12/26/18, indicated Resident 1 had no capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 10/25/18, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. The MDS indicated, Resident 1 was totally dependent to staff for activities of daily living (dressing, eating, toilet use, personal hygiene, and bathing) and always incontinent (inability to control) of bowel and had a urinary catheter. A review of Resident 1's physician discharge summary, indicated Resident 1 expired on 12/29/18. No documentation of condition on discharge and/or cause of death. A review of Resident 1's enteral (TF- tube feeding) physician order, dated 12/22/18, indicated TF formula via gastrostomy tube (GTis a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) by pump at 50 milliliters (ml) per hour times twenty hours. Aspiration (sucking in a foreign object into the airway) precaution, monitor every shift. A review of Resident 1's physician order, dated 12/29/18, at 11:45 p.m., indicated may do oral suction as needed for excessive secretions. No documentation of licensed nurse assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 20 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's physician enteral orders form, indicated TF formula at 50 ml per hour, schedule time at 8 a.m. off and at 12 p.m. on. A review of Resident 1's care plan dated 12/22/18, resident on tube feeding related to dysphagia, at risk for aspiration. The goal indicated resident will have no aspiration daily for three months. The interventions included check and maintain placement and patency of GT, keep head of bed (HOB) elevated at 30 degrees, monitor for aspiration, and notify MD of any signs and symptoms of tolerance. A review of Resident 1's nurse's notes, dated 12/27/18 at 1:30 p.m., indicated Resident 1 had small amount of emesis (vomiting) per MD hold feeding for one hour and if no further emesis, re-start GT feeding. No documentation of MD orders and no documentation of continuous assessment from 12/27/18 at 2:30 p.m. to 12/28/18 at 6 p.m. (27.5 hours). A review of Resident 1's nurse's notes, dated 12/28/18 at 6 p.m., indicated Resident 1 had vomiting times one. No documentation of MD notification. A review of Resident 1's nurse's notes, dated 12/29/18 at 3:30 a.m., indicated Resident 1 had excessive secretions. No documentation of MD notification. A review of Resident 1's nurse's notes documented by Registered Nurse 1 (RN 1), dated 12/29/18, at 4:40 a.m., indicated noted Resident 1 in bed with eyes closed, skin warm to touch, no breathing, no vital signs (pulse rate, blood pressure, body temperature and respiratory rate) appreciated at this time, pupils fixed, non-reactive to light. Pronounced dead at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 21 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE this time. A review of Resident 1's nurse's notes entries from 12/27/18 at 1:30 p.m. up to the time of expiration on 12/29/18, indicated 6 entries as follows: 12/27/18 at 1:30 p.m., 12/27/18 at 2:30 p.m., next entry on 12/28/18 at 6 pm (27.5 hours apart), next entry on 12/29/18 at 3 a.m. (9 hours apart), then 12/29/18 at 3:30 a.m., and next entry on 12/29/18 at 4:40 a.m. when Resident 1 expired. A review of Resident 1's nurse's notes, dated 12/29/18, at 5 a.m., indicated called and informed primary physician and nurse practitioner, with new order to release the body to funeral. During a phone interview with Licensed Vocational Nurse 1 (LVN 1), on 3/4/19, at 9 a.m., LVN 1 stated she worked on 12/28/18 at 11 p.m. to 7 a.m. shift and Resident 1 was her assigned resident. LVN 1 stated on 12/29/18, before she went on break, unable to recall exact time, she heard Resident 1 had secretions then she suctioned and repositioned the resident. LVN 1 stated when she came back from break, she heard a beeping sounds and found out it was Resident 1's TF pump. LVN 1 stopped the machine and noticed Resident 1 had a lot of yellow vomitus on chest. LVN 1 checked Resident 1 and noticed not breathing and called Registered Nurse 1 (RN 1) for help. Informed LVN 1 reviewed clinical record and was unable to find this information. LVN 1 stated she thought she documented it and further stated it should be documented. LVN 1 stated if resident on GT vomited, it was a concern that should be reported to MD, possibly GT not in place. During a clinical record review and concurrent interview with Director of Nursing (DON), on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 22 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3/4/19, at 2:45 p.m., DON stated resident on TF with an episode of vomiting was not normal. DON stated it was a concern that should be reported to MD and find out what's going on to address and provide necessary treatment. DON stated MD order depends on the detailed assessment reported by the licensed nurse (LN) to MD. DON further stated LN should thoroughly report the assessment and condition of the resident to provide proper management and all the details should be documented. DON stated the possible cause of vomiting on resident with TF were obstruction or not tolerating the TF. DON further stated MD might order a diagnostic test, medication, and/or transfer to hospital for further evaluation. DON stated this was a COC that should be assessed and monitored for at least 72 hours. DON stated all MD orders received should be written in the physician's order sheet. DON reviewed clinical record of Resident 1 and was unable to find a documentation on the following: 1. any MD order to address the vomiting, 2. continuous assessment and monitoring for at least 72 hours for COC of vomiting, 3. MD notification for second episode of vomiting and for excessive secretions, and 4. episode of vomiting when Resident 1 was found unresponsive by LVN 1. DON stated resident clinical record should be complete and accurate to reflect resident's condition. During a clinical record review and concurrent interview with Medical Record Director (MRD), on 3/4/19, at 5:10 p.m., MRD reviewed Resident 1's clinical record and was unable to find a documentation of the cause of death. MRD stated facility used only one kind of physician discharge summary form for all discharges such as home, transfer, or expire. MRD stated the cause of death should be documented in the physician discharge summary. MRD further stated resident's clinical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 23 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE records should be complete and accurate to reflect the condition of the resident. During a clinical record review and concurrent interview with DON, on 3/28/19, at 3:30 p.m., DON stated the MD telephone order on 12/29/18 at 11:45 p.m. for oral suctioning was a wrong entry and it should be 12/28/18. A review of facility's policy and procedure titled "Medical Record Manual - General", indicated the purpose is to ensure the accurate documentation and maintenance of medical records by the facility. Clinical records, paper or electronic, will be kept for each resident admitted for care. Content will be in compliance with licensing and certifying governmental agency requirements and professional standards. A review of facility's policy and procedure titled "Change of Condition Notification", dated 6/1/17, indicated the purpose is to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. "Clinically important" means a deviation that, without intervention, may result in complications or death. (AMDA 2003). The Attending Physician will be notified timely with a resident's change in condition. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. A Licensed Nurse will document the date, time, pertinent details of the incident and the subsequent assessment in the nursing notes, the time Attending Physician was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 24 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contacted, the method by which he was contacted, the response time, and whether or not orders were received. Update the Care Plan to reflect the resident's current status. Licensed Nurse will document each shift for at least seventy-two hours. A review of facility's policy and procedure titled "Physician Orders and Telephone Orders", dated 11/2017, indicated physician's orders shall be obtained prior to the initiation of any medication or treatment from a person lawfully authorized to prescribed for and treat human illness. All orders must be specific and complete. A review of facility's policy and procedure titled "Discharge/Transfer Note - Physician", dated 11/2017, indicated a Physician Discharge/Transfer Note shall be completed within 30 days of resident discharge. The physician shall document in the resident's health record information at least include the reason for discharge and condition and diagnoses of the resident at the time of discharge or final disposition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT6F11 Facility ID: CA92000011 If continuation sheet 25 of 25