Other·August 15, 2019

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 Department of Public Health during the investigation of one facility-reported incident (FRI) during an annual recertification visit. FRI number: CA00643057 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 40354 Health Facilities Evaluator Nurse ID: 39664 Health Facilities Evaluator Nurse ID: 39550 Health Facilities Evaluator Nurse ID: 36862 Health Facilities Evaluator Nurse ID: 36332 Health Facilities Evaluator Nurse ID: 35004 Three deficiencies were issued for FRI number: CA00643057 (F600, F609 and F689). Highest Severity and Scope: E Total Resident Census: 153 Resident Sample Size: 32

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 07/31/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of 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: B8R211 Facility ID: CA92000011 If continuation sheet 1 of 59 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 07/01/2019 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 his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to treat one of four residents (Resident 125) with respect and dignity who was yelling for food during scheduled meal times by not giving his meal tray on scheduled times. This deficient practice resulted to Resident 125 constantly yelling until food was served. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 2 of 59 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 07/01/2019 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 the Admission Record dated 7/1/2019 indicated that Resident 125 was originally admitted on 5/18/18 with diagnoses that included diabetes mellitus (abnormal sugar regulation), hypertension (high blood pressure), and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). The Minimum Data Set (MDS, an assessment and care screening tool) dated 5/21/19 indicated Resident 125's cognition (a mental process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated that Resident 125 needed extensive assistance and one-person physical assist on eating and personal hygiene. During an observation on 6/28/19 at 5:45 p.m., Resident 125 was lying down in his bed shouting for his food. Resident 125 stopped shouting when food was given at 5:47 p.m. Resident 125 again yelled for soup and stopped yelling when soup was given. During an observation on 6/30/19 at 7:36 a.m., Resident 125 was lying down in his bed and was yelling for his breakfast. Resident 125 stopped yelling when breakfast was given at 7:54 a.m. During a concurrent interview with the Registered Nurse Supervisor 1 (RNS 1) and record review on 6/30/19 at 9:56 a.m., RNS 1 stated that meal trays of Resident 125 should be given earlier. RNS 1 stated that Resident 125's care plan for yelling for food did not include an intervention of serving meal trays earlier. RNS 1 stated that Resident 125's care plan for yelling for food should be revised. A review of the facility's undated policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 3 of 59 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 07/01/2019 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 procedure titled "Meal Service Times" indicated "meal times are typically at 7:00 a.m., 12:00 a.m., and 5:00 p.m." A review of the facility's policy and procedure titled "Resident Dignity & Personal Privacy" with release date on December 2016, indicated "Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff ... must focus on assisting the resident in maintaining and enhancing his or her self-esteem and selfworth and incorporating the resident's goals, preferences, and choices."

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 07/31/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain an environment free from resident-to resident physical abuse, for two of two sampled residents (Resident 89 and 120), as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 4 of 59 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 07/01/2019 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 On June 17, 2019, Resident 89 was passing by Resident 120's room and both residents had a disagreement about Resident 120's door being left closed. The facility failed to implement interventions until June 23, 2019, when Resident 120 hit Resident 89 on the left side of his neck with a man-made weapon. This failure has the potential for major injury for Residents 120 and 89, if there were no interventions in place after their disputes. Findings: On June 29, 2019, at 11:16 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 89 and 120 were both involved in a physical altercation with each other in Station 2 hallway. The DON stated Resident 120 hit Resident 89 with a black sock that contained his wallet with some coins. The DON stated that this incident was witnessed by staff members. The DON further stated that prior to that incident, Resident 120 was in the dining room and saw Resident 89 checking out his room. Resident 89 told Resident 120 that he could go there whenever he wanted to. Resident 120 got upset and they started an argument. The DON stated that Resident 89 provoked Resident 120 to hit him and there were other incidents before with them. A review of Resident 89's record indicated, Resident 89 was admitted to the facility on April 25, 2018, with diagnoses that included heart failure and chronic obstructive pulmonary disease (lung disease causing shortness of breath). A review of Resident 89's progress notes indicated the following incidents: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 5 of 59 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 07/01/2019 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 - June 17, 2019, at 10:10 p.m., indicated Resident 89 was requesting to speak to the Nurse Supervisor. Upon arrival to Resident 89's room, Resident 89 started asking why Resident 120 had his door closed to his room. Resident 89 was notified that the issue would be investigated. Resident 89 insisted that we check on Resident 120's room. On the way out to check on Resident 120's room, Resident 89 followed behind and started yelling, "I told you the door was closed. Let him open the door because he is a man!" Resident 89 continued yelling and he was advised to stop. Resident 120 opened the door to see what was going on but Resident 89 continued to use foul language. Resident 89 was advised to calm down and stop the disruption but continued yelling as he wheeled himself to his room. Will continue frequent visual monitoring. - June 20, 2019, at 11:33 p.m., Resident 89's progress notes indicated, Resident went up to another nurse and began yelling about a resident's door being closed. Resident 89 became more aggravated as their conversation continued. Resident became louder and ambulated over to Resident 120's room where he began arguing loudly with that resident about leaving his door completely open. The nurse effectively brought the resident back towards his own room to prevent further arguing. There was no documented evidence of any interventions in Resident 89's record to prevent further resident-to-resident altercation. - June 23, 2019, at 3:05 a.m., Resident 89's progress notes indicated, At 12 a.m. Charge nurse called the supervisor, went to Station 2, Resident 120 and 89 were having an argument. Tried to separate both of them but of Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 6 of 59 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 07/01/2019 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 120 hit Resident 89 on his left side back of the neck with a sock filled with his wallet and some coins. Staff tried to separate them but Resident 89 tried to hit Resident 120 by swinging at him twice. Residents were separated but Resident 89 still aggressive and staff could not control him. At 12:30 a.m., 9-1-1 was called and got transferred to Police department. At 12:45 a.m., two police men came and took report and left. Resident 89 still aggressive towards staff and other residents. Kept both residents separated, while interviewing Resident 120 stated, "If he comes back to me again I will hurt him very bad." Resident 89 is still aggressive towards staff and residents. Resident 120 seems more calm and resting in his room. On June 29, 2019, at 6:17 p.m., Resident 89 was interviewed in his room. Resident 89 stated he was wheeling himself with his wheelchair to go outside and saw Resident 120 coming out of the dining room. Resident 89 stated after passing by, Resident 120 had a weapon in his hand and struck him to the left side of his neck. Resident 89 stated that the weapon was made up of a sock with heavy stuff in it. Resident 89 stated he felt dizzy, weak, with his ears were buzzing after the attack. Resident 89 stated that he was so upset that he screamed. On June 30, 2019, at 3:05 p.m., Resident 120 was interviewed in his room. Resident 120 stated that Resident 89 stared at him and gave an attitude. Resident 120 stated that the staff was too busy and did not do anything about the abuse. Resident 120 stated that he used a sock for protection. Resident 120 stated that he was aggressive and would hurt Resident 89 eventually. On June 30, 2019, at 7:56 p.m., the Administrator was interviewed. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 7 of 59 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 07/01/2019 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 Administrator stated Resident 89 provoked Resident 120 with continuous behavior of following him and accusations. The Administrator stated that Resident 89 kept visiting Resident 120's room for no reason to determine if the room was closed or not. A review of the facility's policy titled "Abuse Prevention and Prohibition Program," revised November 1, 2017, indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. Cross reference F609

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 07/31/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 8 of 59 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 07/01/2019 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 §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to report resident-toresident physical altercation as indicated in the facility's policy and procedure. On June 20, 2019, Resident 120 allegedly grabbed Resident 89's neck. This failure resulted in another resident-to resident physical altercation. On June 23, 2019, Resident 120 hit Resident 89 with a man-made weapon in the hallway. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 9 of 59 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 07/01/2019 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 On June 29, 2019, at 11:48 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 89 and 120 were both involved in a physical altercation with each other in Station 2 hallway. The DON stated Resident 120 hit Resident 89 with a black sock that contained his wallet with some coins. The DON stated that this incident was witnessed by staff members and was reported to the state agencies. The DON stated that there were other resident-to resident altercation incidents with Resident 89 and 120. A review of Resident 89's record indicated, Resident 89 was admitted to the facility on April 25, 2018, with diagnoses that included heart failure and chronic obstructive pulmonary disease (lung disease causing shortness of breath). A review of Resident 89's record titled "Interdisciplinary (IDT - interdisciplinary teamhealth professionals work together and collaboratively to communicate to impact residents' care) Progress Notes," dated June 21, 2019, indicated, IDT met to discuss the incident happened on 6/20/19. Resident 89 mentioned another incident happened allegedly. He was attacked by another resident (Resident 120). Resident 89 was touched inappropriately by Resident 120 holding his neck. Resident 89 stated that his needs were not met. Resident 89 talked about the incident that happened on 6/20/2019. On June 23, 2019, at 3:05 a.m., Resident 89's progress notes indicated, at 12 a.m. Charge nurse called the supervisor, went to Station 2, Resident 120 and 89 were having an argument. Tried to separate both of them but Resident 120 hit Resident 89 on his left side back of the neck with a sock filled with his wallet and some coins. Staff tried to separate them but Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 10 of 59 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 07/01/2019 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 89 tried to hit Resident 120 by swinging at him twice. Residents were separated but Resident 89 still aggressive and staff could not control him. At 12:30 a.m., 9-1-1 (emergency number) was called. At 12:45 a.m., two police men came and took report and left. Resident 89 still aggressive towards staff and other residents. Kept both residents separated, while interviewing Resident 120 stated, "If he comes back to me again I will hurt him very bad." Resident 89 is still aggressive towards staff and residents. Resident 120 seems more calm and resting in his room. On June 29, 2019, at 6:17 p.m., Resident 89 was interviewed in his room. Resident 89 stated that he called the Administrator a couple times and did not respond. Resident 89 stated that Resident 120 was holding him from behind. Resident 89 stated that while Resident 120 was standing, Resident 89 was yelling and asked for help. Resident 89 stated that he told the Administrator and he stated Resident 120 never touched him. Resident 89 stated that he interviewed everybody about the incident but he mentioned only one person. Resident 89 stated that Resident 120 held him on the shoulder and this was not the first time he got assaulted by him. Resident 89 stated the choking incident happened a week ago and was not reported. On June 30, 2019, at 3:05 p.m., Resident 120 was interviewed in his room. Resident 120 stated that Resident 89 stared at him and gave an attitude. Resident 120 stated that the staff was too busy and did not do anything about the abuse. Resident 120 stated that he only pushed him away but did not choke him. On June 30, 2019, at 6:23 p.m., the Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she knew that Resident 89 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 11 of 59 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 07/01/2019 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 120 were fighting. One time she was here when it happened. Resident 89 was upset and screaming at hallway telling Resident 120 to come out of the room. This happened maybe 2 weeks ago. LVN 1 stated she heard do not know if the incident was reported. On June 30, 2019, at 7:56 p.m., the Administrator was interviewed. The Administrator stated Resident 89 provoked Resident 120 with continuous behavior of following him and accusations. The Administrator stated that Resident 89 kept visiting Resident 120's room for no reason to determine if the room was closed or not. The Administrator stated that he could not remember when Resident 120 grabbed him on the neck but he filed a grievance and it was unsubstantiated. On July 1, 2019, at 3:13 pm, the DON stated they both refused to change rooms. Resident 89's record was reviewed with the DON. The DON stated that the incident on June 20, 2019, was not reported and it was missed. The DON stated that only grievance was filed. A review of the facility's policy titled "Abuse Prevention and Prohibition Program," revised November 1, 2017, indicated, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility will report known or suspended instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or thorough a confidential internet reporting tool as required by state and federal regulations. If the reportable events results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than two (2) hours of the observation, knowledge or suspicion of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 12 of 59 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 07/01/2019 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 physical abuse. If the reportable event does not result in serious bodily injury, the Administrator, or his/her designee, will make a telephone report to the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of the physical abuse. Cross Reference F600

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 07/31/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 13 of 59 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 07/01/2019 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 (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop/implement a comprehensive person-centered care plan for three of 32 sampled residents (Residents 100, 125, and 144) by: 1. Failed to develop complete care plan for Resident 100 who have vascular/diabetic ulcer and actual skin breakdown. 2. Failed to develop a plan of care for Resident 125 who yells for his food to include in his care plan serving of meal trays on scheduled times. 3. Failed to implement Resident 144 care plan to assist resident in bathing twice a week and as needed as indicated in the care plan. These deficient practices have the potential for the missed implementation of relevant interventions and a decline in physical and psychosocial well-being. Findings: a. A review of admission record indicated Resident 100 was admitted to the facility on 8/1/18, with diagnoses that included nonpressure chronic ulcer lower leg, generalized edema, and chronic obstructive pulmonary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 14 of 59 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 07/01/2019 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 disease (a lung disease characterized by longterm poor airflow). A review of Resident 100's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 5/15/19 indicated the resident is cognitively intact, and independent for bed mobility, transfer, and dressing. During an observation on 6/29/19 at 8:08 AM, Resident 100 was sitting in her bed with bilateral leg edema. A review of Resident 100's care plans in the presence of the Medical Record Director (MRD) and Registered Nurse Supervisor 2 (RNS 2) on 6/30/19 at 2:07 PM, the following care plans have incomplete approaches or intervention by not having frequency for monitoring weight and frequency for turning and repositioning. 1. Care Plan for vascular/diabetic ulcer for left lower venous stasis ulcer, dated 3/13/19. 2. Care Plan for vascular/diabetic ulcer for right lower venous stasis ulcer, dated 3/13/19. 3. Undated Care plan for Actual Skin Breakdown of the left posterior thigh. 4. Care Plan for Actual Skin Breakdown of the coccyx (tailbone) dated 6/9/19. 5. Care Plan for Actual Skin Breakdown of the perineal area due to Moisture-associated skin damage (MASD - is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). On current interview with RNS 2, she stated that the care plans were incomplete and should be completed. A review of facility's policy titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 15 of 59 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 07/01/2019 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 "Comprehensive Plan of Care," dated December 2016, indicated, It is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment. Re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly, and with significant change in status assessment. b. A review of the Admission Record dated 7/1/2019 indicated that Resident 125 was originally admitted to the facility on 5/18/18 with diagnoses that included diabetes mellitus (abnormal sugar regulation), hypertension (high blood pressure), and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). The Minimum Data Set (MDS, an assessment and care screening tool) dated 5/21/19 indicated Resident 125's cognition (a mental process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated that Resident 125 needed extensive assistance and one-person physical assist on eating and personal hygiene. During an observation made on 6/28/19 at 5:45 p.m., Resident 125 was lying down in his bed shouting for his food. Resident 125 stopped shouting when food was served at 5:47 p.m. Resident 125 again yelled for soup and stopped yelling when soup was served. During an observation made on 6/30/19 at 7:36 a.m., Resident 125 lying down in his bed was yelling for his breakfast. Resident 125 stopped yelling when breakfast was served at 7:54 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 16 of 59 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 07/01/2019 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 concurrent interview with the Registered Nurse Supervisor 1 (RNS 1) and record review on 6/30/19 at 9:56 a.m., RNS 1 stated that Resident 125's care plan for yelling for food should be revised and should include serving of meal trays earlier. A review of the facility's undated policy and procedure titled "Meal Service Times" indicated "meal times are typically at 7:00 a.m., 12:00 a.m., and 5:00 p.m. A review of the facility's policy and procedure titled "Comprehensive Care Plan" with release date on December 2016 indicated "The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .... The comprehensive plan of care will include: Reflect interventions to meet both short and long-term goals .... Develop goals and approaches for each problem and/or condition that are realistic, specific, measurable, and include interventions/approaches that relate to each stated long or short-term goal." c. A review of the Admission Record dated 7/1/2019 indicated Resident 144 was originally admitted to the facility on 11/22/18 with diagnoses that included encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) and persistent vegetative state (completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function, being kept alive only by medical intervention). The Minimum Data Set (MDS, an assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 17 of 59 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 07/01/2019 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 and care screening tool) dated 5/31/19 indicated Resident 144 was totally dependent and one-person physical assist on bed mobility, dressing, toilet use, and personal hygiene. A review of the neurologic status of Resident 144 in his History and Physical dated 1/1/19 indicated, "The patient is awake, not alert, not oriented, (and) not responding to yes/no questions appropriately ...." During an observation on 6/29/19 at 8:51 a.m., Resident 144 was lying down in his bed with a bad smell coming from his head. During an interview with the Licensed Vocational Nurse (LVN) 5 on 6/29/19 at 8:58 a.m., LVN 5 stated that the bad smell was coming from Resident 144's head. During an interview with Certified Nurse Assistant 5 (CNA 5) on 6/29/19 at 9:01 a.m., CNA 5 stated that bad smell was coming from Resident 144's head. During an interview with the Registered Nurse Supervisor 1 (RNS) 1 on 6/29/19 at 9:06 a.m., RNS 1 stated that there was an unpleasant smell coming from Resident 144's head. RNS1 stated that the unpleasant smell might spread in the room and other residents inside the room might get affected. During an interview with CNA 6 on 6/30/19 at 8:27 a.m., CNA 6 stated that she was assigned to Resident 144 on 6/28/19 (Friday). CNA 6 stated she did not give Resident 144 a shower. CNA 6 stated she gave Resident 144 a bed bath that did not include washing the head. During an interview with LVN 5 on 6/30/19 at 8:31, LVN 5 stated that on 6/28/19, she gave oral care to Resident 144 and she smelled the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 18 of 59 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 07/01/2019 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 head of Resident 144. LVN 5 stated that she was expecting CNA 6 to give Resident 144 a shower because it was his shower day. LVN 5 stated that at the end of the shift on 6/28/19, CNA 6 made her sign a document of what CNA 6 had done for the day. LVN 5 stated that she saw in the document that Resident 144 was not given a shower. LVN 5 stated that she told CNA 6 to inform her next time if resident missed his shower. LVN 5 stated that CNA 6 only did bed bath and no shower. LVN 5 stated that she could not remember endorsing to the next shift that Resident 144 was not given a shower. During a concurrent interview with the RNS 1 and record review of the care plan on ADLs on 6/30/19 at 9:00 a.m., RNS 1 stated that Resident 144's care plan intervention included assistance with bathing twice a week and as needed. RNS 1 stated that Resident 144 needed a care plan for the head smelling bad and sweating a lot. A review of the facility's undated policy and procedure titled "Care Standards" revised on 6/1/17 indicated "All residents shall receive necessary care and services to assist them in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. Care is documented in the medical record according to state and/or federal regulations." Cross Reference F677

F657 SS=E Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 07/31/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 19 of 59 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 07/01/2019 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 the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to 1. Revise Resident 89's care plan after a resident-to-resident altercation on June 17, 2019 and June 20, 2019. 2. Update the care plan for Resident 100's bilateral edema on her lower leg. 3. Revise Resident 152's care plan to reflect the current order for tube feeding. 4. Revise Resident 115's care plan to reflect the scheduled of hospice licensed nurse visit. These failures resulted in the occurrence of another resident-to-resident altercation on June 23, 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 20 of 59 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 07/01/2019 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 Findings: a. A review of Resident 89's record indicated, Resident 89 was admitted to the facility on April 25, 2018, with diagnoses that included heart failure and chronic obstructive pulmonary disease (lung disease causing shortness of breath). A review of Resident 89's care plan titled "Resident has episodes of resisting care and striking out staff, resident-to-resident altercation with no physical injury, verbally aggressive with other residents, refused room change," initiated on June 23, 2019, indicated to monitor Resident 89's whereabouts, report to law enforcement, try to find out the cause of the behavior, and one to one monitoring. A review of Resident 89's progress notes indicated the following resident-to-resident altercation: - June 17, 2019, at 10:10 p.m., indicated, Resident 89 requesting to speak to the Nurse Supervisor. Upon arrival to Resident 89's room, Resident 89 started asking why Resident 120 had his door closed to his room. Resident 89 was notified that the issue would be investigated. Resident 89 insisted to check Resident 120's room. On the way out to check on Resident 120's room, Resident 89 followed behind and started yelling, "I told you the door was closed. Let him open the door because he is a man!" Resident 89 continued yelling and he was advised to stop. Resident 120 opened the door to see what was going on but Resident 89 continued to use foul language. Resident 89 was advised to calm down and stop the disruption but continued yelling as he wheeled himself to his room. Will continue frequent visual monitoring. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 21 of 59 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 07/01/2019 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 - June 20, 2019, at 11:33 p.m., Resident 89's progress notes indicated, resident went up to another nurse and began yelling about a resident's door being closed. Resident 89 became more aggravated as their conversation continued. Resident 89 became louder and ambulated over to Resident 120's room where he began arguing loudly with that resident about leaving his door completely open. The nurse effectively brought the resident back towards his own room to prevent further arguing. - June 23, 2019, at 3:05 a.m., Resident 89's progress notes indicated, At 12 a.m. Charge nurse called the supervisor, went to Station 2, Resident 120 and 89 were having an argument. There was no documented evidence of any revised interventions regarding Resident 89 and 120's dispute. On June 23, 2019, at 6:23 p.m., the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she have been hearing they were fighting (Resident 89 and 120). One time she was here and it happened. Resident 89 was upset and screaming at hallway telling Resident 120 to come out of the room. LVN 1 stated the nurses were required to initiate care plan. The facility's policy titled "Comprehensive Plan of Care," dated December 2016, indicated, It is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment. Reevaluate and modify care plans as necessary to reflect changes in care, service and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 22 of 59 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 07/01/2019 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 treatment, quarterly, and with significant change in status assessment. Cross Reference F600 and F609 b. A review of admission record indicated Resident 100 was admitted to the facility on 8/1/18, with diagnoses that included nonpressure chronic ulcer lower leg, generalized edema, and chronic obstructive pulmonary disease (a lung disease characterized by longterm poor airflow). A review of Resident 100's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 5/15/19, indicated the resident is cognitively intact, and independent for bed mobility, transfer, and dressing. During observation on 6/29/19 8:08 AM, Resident 100 was sitting in her bed with bilateral leg edema. On 06/30/19 at 2:07 PM, during Resident 100's record review and interview, Medical Record Director (MRD) and Licensed Vocational Nurse 6 (LVN 6) was asked to provide plan of care lower edema. MRD presented a Care Plan for Edema dated 8/1/18 with target date 11/2018. MRD and LVN 6 stated no available updated care plan for edema in residents' medical record for both paper chart and computer chart. LVN 6 stated the care plan should have been updated. c. A review of admission record indicated Resident 152 was readmitted to the facility on 5/31/17, with diagnoses that included high blood pressure, cerebral infraction (stroke), and gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or bile FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 23 of 59 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 07/01/2019 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 irritates the food pipe lining). A review of Resident 152's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 6/5/19, indicated the resident rarely make self-understood and rarely had the ability to understand others, and total dependence for bed mobility, transfer, and dressing. A review of Resident 152's Physician order dated 3/7/19 indicated enteral feeding of Jevity 1.2 formula via gastrostomy tube (GT- a surgical procedure for inserting a tube directly into the stomach through the abdomen wall incision for administration of food, fluids, and medications) at 60 millimeter (ml) per hour times 20 hours. On 6/29/19 at 2:33 PM, during observation, Resident 152 was on his bed with GT feeding of Jevity 1.2 at 60 ml/hr. During a review of Resident 152's Tube Feeding Care Plan with revision date of 4/18/19, indicated Jevity 1.2 at 75 cc/hr. times 20 hours to yield at 1500 cc/1800 kcal. On 6/30/19 at 11:27 AM, during an interview, Registered Nurse Supervisor 2 (RNS 2) stated the care plan was not updated or revised. She further stated the care plan should have been revised to reflect the current order of the tube feeding. d. A review of admission record indicated Resident 115 was readmitted to the facility on 2/27/19, with diagnoses that included high blood pressure, COPD, and chronic atrial fibrillation (irregular heartbeat). A review of Resident 115's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 24 of 59 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 07/01/2019 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 (MDS- a comprehensive assessment and screening tool) dated 5/18/19, indicated resident cognitive skills for daily decisionmaking was severely impaired, and extensive assistance for bed mobility, transfer, and dressing. During a review of Resident 115's Hospice Care Plan dated of 2/27/19, indicated hospice staff to render care during visits, licensed nurse three times a week. During a review of Resident 115's Hospice Visit Calendar from April 1, 2019 to June 1, 2019, indicated licensed nurses are scheduled to visit the resident three times and twice a week alternately. On 6/30/19 at 3:01 PM, during an interview, Registered Nurse Supervisor 2 (RNS 2) stated the care plan was not updated. A review of facility's policy titled "Comprehensive Plan of Care," dated December 2016, indicated, It is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment. Re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly, and with significant change in status assessment.

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

F658 07/31/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 25 of 59 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 07/01/2019 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 (i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the licensed nursing staff failed to meet professional standards of quality for one of four sampled residents (Resident 51) by failing to provide water flushes (cleansing of water) between each medication given via gastrostomy tube (G-tube - a medical tube inserted through the stomach that delivers nutrition and medication) This deficient practice placed the resident at risk for drug incompatibility (undesirable reaction that occurs between drugs that should not be mixed) and tube occlusion (blockage). Findings: A review of Resident 51's Admission Record indicated the resident was admitted to the facility on February 26, 2009 and readmitted April 9, 2013 with diagnosis of, but not limited to encounter for attention to gastrostomy (surgical operation for making an opening in the stomach). A review of Resident 51's Minimum Data Set (MDS [a standardized assessment and screening tool] dated April 8, 2019, indicated the resident has a feeding tube and requires total dependence for eating. During a medication administration observation for Resident 51 on June 28, 2019 at 8:25 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed not providing water flushes in between each medication being given to Resident 51 via G-tube. During an interview with LVN 1 on June 28, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 26 of 59 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 07/01/2019 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 2019 at 8:40 a.m., LVN 1 stated that when administering medications via G-tube, he lets each medication drain entirely before administering the next medication. He stated he does not flush with water in between each medication. During an interview with the Director of Nursing (DON) on June 28, 2019 at 12:08 p.m., DON stated that between each medication given via G-tube, nursing staff is to flush with water. DON stated that LVN 1 should have flushed with water in between administering each medication. A review of the facilities policy and procedure titled "Feeding Tube-Administration of Medication" revised June 1, 2017, indicates that when administering medication, mediation must be given separately and to flush with 5 cubic centimeter (cc) of warm water in between each medication. According to the American Society for Parenteral and Enteral Nutrition, Patient safety initiatives, safe practice recommendation is that the tube should be flushed with at least 15 milliliters (ml) of water before and after each medication is given.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 07/31/2019 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 144) who was totally dependent on staff with activities of daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 27 of 59 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 07/01/2019 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 living (ADL) was given a shower on 6/28/19. This deficient practice resulted to an unpleasant odor that can be smelled from Resident 144's head. Findings: A review of the Admission Record dated 7/1/2019 indicated that Resident 144 was originally admitted to the facility on 11/22/18 with diagnoses that included encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) and persistent vegetative state (completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function, being kept alive only by medical intervention). The Minimum Data Set (MDS, an assessment and care screening tool) dated 5/31/19 indicated Resident 144 was totally dependent and one-person physical assist on bed mobility, dressing, toilet use, and personal hygiene. A review of the neurologic status of Resident 144 in his History and Physical dated 1/1/19 indicated "The patient is awake, not alert, not oriented, (and) not responding to yes/no questions appropriately ...." During an observation on 6/29/19 at 8:51 a.m., Resident 144 was lying down in his bed with a bad smell coming from his head. On 6/29/19 at 8:58 a.m., during an interview with the Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated that the bad smell was coming from Resident 144's head. On 6/29/19 at 9:01 a.m., during an interview with the Certified Nurse Assistant 5 (CNA 5) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 28 of 59 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 07/01/2019 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 CNA 5 stated that bad smell was coming from Resident 144's head. On 6/29/19 at 9:06 a.m., during an interview with the Registered Nurse Supervisor 1 (RNS 1) RNS 1 stated that there was an unpleasant smell coming from Resident 144's head. RNS 1 stated that the unpleasant smell might spread in the room and other residents inside the room might get affected. During an interview with CNA 6 on 6/30/19 at 8:27 a.m., CNA 6 stated that she was assigned to Resident 144 on 6/28/19 (Friday). CNA 6 stated she did not give Resident 144 a shower. CNA 6 stated she gave Resident 144 a bed bath that did not include washing the head. During an interview with LVN 5 on 6/30/19 at 8:31, LVN 5 stated that on 6/28/19 she gave oral care to Resident 144 and she smelled the head of Resident 144. LVN 5 stated that she was expecting CNA 6 to give Resident 144 a shower because it was his shower day. LVN 5 stated that at the end of the shift on 6/28/19, CNA 6 made her sign a document of what CNA 6 had done for the day. LVN 5 stated that she saw in the document that Resident 144 was not given a shower. LVN 5 stated that she told CNA 6 to inform her next time if resident missed his shower. LVN 5 stated that CNA 6 only did the bed bath and no shower. LVN 5 stated that she cannot remember endorsing to the next shift that Resident 144 was not given a shower. A review of facility's policy and procedure titled "Routine Nursing Care" released on February 2017 indicated "Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .... Showers, tub baths, and shampoos are scheduled at least twice weekly and more often FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 29 of 59 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 07/01/2019 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 as needed ...." Cross Reference F656

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/31/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an environment that was free from accident hazards and resident receives adequate supervision and assistance devices to prevent accidents for five of thirty-two sampled residents (Residents 89, 4, 115, 54, and 86), by failing to: 1. Ensure tab alarm was provided for Resident 4 who was assessed high risk for fall as indicated in Falling Star Program Care Plan. 2. Ensure to conduct root cause analysis for the accident happened on June 23, 2019, where Resident 89's left lower leg was scraped from a wheelchair after the resident-to-resident altercation. 3. Ensure to provide functioning pressure pad alarm and bilateral floor mats for Resident 115 who was assessed high risk for fall as indicated in the physician order and Falling Star Care Plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 30 of 59 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 07/01/2019 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 4. Ensure to provide bilateral side rails padding to prevent injury secondary to seizure disorder for Resident 54 as indicated in the physician order and Seizure Disorder Care Plan. 5. Ensure to provide full size floor mats for Resident 86 who was assessed high risk for fall. These deficient practices have the potential for further injury if the facility did not conduct a root cause analysis after accidental injuries (Resident 89) and have the potential to result in serious injuries in the event the resident has fall incident (Resident 4, 115, 54, and 86). Findings: a. On June 29, 2019, at 6:17 p.m., Resident 89 was interviewed in his room. Resident 89 was observed with a white bandage to the left lower leg. Resident 89 stated, "After Resident 120 tried to attack him, he got injured with red scratches in his leg." Resident 89 stated he did not know how it happened. Resident 89 stated that the nurses never asked him if he wanted to go to the hospital. A review of Resident 89's record indicated, Resident 89 was admitted to the facility on April 25, 2018, with diagnoses that included heart failure and chronic obstructive pulmonary disease (lung disease causing shortness of breath). A review of Resident 89's care plan titled "Resident is at risk for falls/injury related to impaired cognition, poor safety awareness, use of medications," initiated on February 18, 2019, indicated Resident 89 would be free from injury by the next three months. The care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 31 of 59 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 07/01/2019 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 indicated for the facility staff to visibly observe the resident frequently, provide a safe and clutter-free environment, and provide safety instruction to resident regarding ambulation, transfers, and ADLs (activities of daily living) when appropriate. On June 23, 2019, at 3 p.m., Resident 89's progress notes indicated, received new orders for right lower leg abrasion secondary to resident attempting to get out of the wheelchair. On July 1, 2019, at 3:13 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility was required to conduct a root cause analysis of accidental injuries that occurred. The DON stated if the resident was interview, they should know the cause but the nurses would check root cause. b. A review of admission record indicated Resident 4 was admitted to the facility on 1/4/19, with diagnoses that included Alzheimer's disease, high blood pressure, and osteoarthritis A review of Resident 4's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 4/22/19, indicated the resident cognitive skills for daily decisionmaking was severely impaired, and extensively assistance for bed mobility, transfer, toilet use, and dressing. A review of Resident 4's Fall Risk Evaluation dated 5/3/19 indicated high risk for potential falls. A review of Resident 4's Physician Order dated 2/7/19, indicated to utilize tab alarm while in bed or up in a wheel chair to assist in notifying nursing of resident unassisted mobility. Monitor placement and function use every shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 32 of 59 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 07/01/2019 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 4's Falling Star Program Care Plan with onset date of 2/6/19 and revised 5/3/19, indicated tab alarm to remind resident to stop and ask for assistance. During observation on 6/29/19 at 7:45 AM 8:08 AM, Resident 4's room door has a yellow star beside her name. Resident 4's was lying on her bed with no tab alarm. During the concurrent interview with Certified Nursing Assistant 7 (CNA 7), stated she does not know if the resident should have tab alarm. c. A review of admission record indicated Resident 115 was readmitted to the facility on 2/27/19, with diagnoses that included high blood pressure, COPD, and chronic atrial fibrillation (irregular heartbeat). A review of Resident 115's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 5/18/19, indicated resident cognitive skills for daily decisionmaking was severely impaired, and required extensive assistance on staff for bed mobility, transfer, and dressing. A review of Resident 115's Fall Risk Evaluation dated 5/30/19 indicated high risk for potential falls. A review of Resident 115's Physician Order dated 5/3/19, indicated to utilize tab alarm while in bed or up in a wheel chair to assist in notifying nursing of resident unassisted mobility. Monitor placement and function use every shift. A review of Resident 115's Falling Star Care Plan dated 3/8/19 and revised 5/3/19, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 33 of 59 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 07/01/2019 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 pressure pad alarm to remind resident to stop and ask for assistance, floor mats at bed side, and bed alarm During observation on 6/29/19 at 7:08 AM, Resident 115 was lying on her bed. Floor mats was observed on her left side of the bed, no floor mat on her right side. On 06/29/19 at 7:23 AM, during the interview and concurrent observation, Licensed Vocational Nurse 7 (LVN 7) stated she does not know why there was only one floor mat. She further stated there should be floor mats on both side of the bed. On 6/29/19 at 7:29 AM, during the interview and concurrent observation, Certified Nursing Assistant 7 (CNA 7) stated resident is very impulsive and usually stand up without waiting for the staff. She also stated Resident 115 had a bed alarm. When CNA 7 was asked to show the bed alarm, the resident had only pressure pad alarm but no device connected the pad. CNA 7 stated she does not regularly check the bed alarm. On 6/29/19 at 7:35 AM, during the interview and concurrent observation, LVN 7 stated there should be a device connected to the pad alarm to work. On 6/30/19 at 7:05 AM, during observation Resident 115 was sleeping on her low position bed and 1/2 floor mat was on her right side no floor mat on her left side. d. A review of admission record Resident 54 was readmitted to the facility on 5/1/18, with diagnoses that included high blood pressure, COPD, and convulsion (seizure) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 34 of 59 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 07/01/2019 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 54's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 4/9/19, indicated resident cognitive skills for daily decision-making was intact and required extensive assistance on staff for bed mobility, toilet, and dressing. A review of Resident 54's Physician order dated 5/1/18 indicated bilateral side rails padding to prevent injury secondary to seizure disorder. A review of Resident 54's Fall Risk Evaluation dated 4/23/19 indicated high risk for potential falls. A review of Resident 54's Seizure Disorder Care Plan dated 5/1/18 and revised 1/18/19, indicated bilateral side rails up with padding to prevent injury. A review of Resident 54's Medical Administration Record for June 2019 indicated licensed nurses are checking every shift the bilateral side rails padding to prevent injury secondary to seizure disorder. During observation on 6/29/19 at 08:57 AM, Resident was lying on his bed, bilateral 1/2 side rails up but no padding on the side rails. During observation and interview on 6/30/19 at 08:36 AM, Resident 54 was lying on his bed, bilateral 1/2 side rails up but no padding on the side rails. Resident 54 stated the facility did not put any padding on his side rails. During observation and interview on 6/30/19 at 10:11 AM, Registered Nurse Supervisor (RNS 2) stated siderails should be padded for prevention of accident. Resident 54 stated he has no problem if the facility put padding in his side rails. RNS 2 stated she would call the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 35 of 59 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 07/01/2019 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 maintenance to put padding on the side rails. e. A review of admission record indicated Resident 86 was readmitted to the facility on 8/12/12, with diagnoses that included high blood pressure, hemiplegia, and convulsion (seizure) A review of Resident 86's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 4/22/19, indicated resident cognitive skills for daily decisionmaking was severely impaired, and required limited assistance on staff for transfer, and dressing. A review of Resident 86's Fall Risk Evaluation dated 6/24/19, indicated high risk for potential falls. A review of Resident 86's Falls Care Plan dated 6/24/19, indicated floor mats. During observation on 6/30/19 at 7:08 AM, resident was sleeping in low position bed with bilateral half size floor mats. During observation and interview on 6/30/19 at 7:10 AM, CNA 7 identified Resident 86's floor mats is only half size. When asked if there was any reason why the floor mats was only half size, she stated, "We don't have enough floor mats." During the concurrent interview, LVN 6 stated the floor mats should be full size, same as the size of the bed. She further stated she would ask the maintenance to provide full size floor mats.

F732 SS=B Posted Nurse Staffing Information CFR(s): 483.35(g)(1)-(4) FORM CMS-2567(02-99) Previous Versions Obsolete

F732 Event ID: B8R211 07/31/2019 Facility ID: CA92000011 If continuation sheet 36 of 59 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 07/01/2019 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 §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure posting of staffing information was updated on a daily basis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 37 of 59 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 07/01/2019 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 deficient practice had the potential of not having the information available to the residents and public in a timely manner. Findings: On 06/29/19, at 4 PM and on 06/30/19, at 6:12 PM, the staffing information posted in the hallway for skilled nursing was dated June 28, 2019, and the resident census was 102. During the concurrent interview with Registered Nurse 3 (RN 3) stated the staffing information posted was not updated. She stated the staffing information should be updated every day. RN 3 further stated she overlooked updating the information and she will update the information.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 07/31/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 38 of 59 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 07/01/2019 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 drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to discontinue a psychotropic medication given as needed after 14 days for one of six sampled residents (Resident 145) reviewed for unnecessary medication. This deficient practice has the potential for Resident 145 to be given unnecessary medications and has the potential for an adverse outcome. Findings: A review of the Admission Record dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 39 of 59 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 07/01/2019 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 7/1/2019 indicated Resident 145 was originally admitted to the facility on 12/16/10. Resident 145 diagnoses included altered mental status (disruption in how the brain works that causes a change in behavior), schizoaffective disorder (mental condition that causes both a loss of contact with reality and mood disorders), major depressive disorder (serious medical illness that negatively affects how you feel, the way you think, and how you act), and generalized anxiety disorder (characterized by persistent and excessive worry about a number of different things). The Minimum Data Set (MDS, an assessment and care screening tool) dated 6/1/19 indicated Resident 145's cognition (a mental process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 145 needed extensive assistance and one-person physical assist on bed mobility, dressing, and personal hygiene. On 7/1/19 at 3:58 p.m., during a concurrent interview and record review with the Director of Nursing (DON), DON stated that physician ordered on 4/22/19 Chlordiazepoxide (medication which acts on the brain and nerves to produce a calming effect, used to treat anxiety) 25 milligrams (mg) 1 tablet by mouth every eight hours as needed for Resident 145. DON stated that upon the recommendation of the Pharmacist, physician ordered Chlordiazepoxide to be discontinued on 5/20/19. DON stated that it was more than 14 days and that there was no order from physician in the medical record of Resident 145 that Chlordiazepoxide was renewed. On 7/1/19 at 5:09 p.m., during a telephone interview with facility's Pharmacist, Pharmacist stated that Chlordiazepoxide, unfortunately, exceeded 14 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 40 of 59 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 07/01/2019 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 the facility's policy and procedure titled "Psychoactive Medication Physician's order" released on July 2017 indicated that " ... PRN (as needed) orders for psychotropic drugs are limited to 14 days."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 07/31/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 41 of 59 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 07/01/2019 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 1. Failed to properly store Humulin (medication used to treat high sugar levels in the blood) according to manufacturer specification. 2. Failed to ensure that an open date was not written on an unopened vial of Humulin found inside a medication cart. 3. Failed to monitor and document the refrigerator temperature and the medication room temperature for one of three medication rooms (Station 2). These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medication or cause medication errors and lead to unsafe nursing practice. Findings: a. During an observation on June 28, 2019 at 10:05 a.m. of medication cart 3 for the Subacute unit (a unit for complete inpatient care for someone suffering from an illness or injury), an unopened vial of Humulin was found inside the medication cart. The label on the container for the Humulin vial indicated that the medication needed to be refrigerated. During an interview with Licensed Vocational Nurse 3 (LVN 3) on June 28, 2019 at 10:20 a.m., LVN 3 stated that the unopened vial of Humulin should have been stored in the refrigerator until it is opened. A review of the manufacturers recommended guideline for proper storage of Humulin states to store new (unopened) vials in the refrigerator between 36 and 46 degrees F (Fahrenheit). Do not freeze. The facility's policy and procedures titled "Storage of Medication" undated, states that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 42 of 59 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 07/01/2019 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 medications and biologicals are stored safely, securely, and properly, following manufactures' recommendations or those of the supplier. Medication requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring. b. During an observation on June 28, 2019 at 10:05 a.m. of medication cart 3 for the Subacute unit, an unopened vial of Humulin was found inside the medication cart. On the label of the Humulin vial, there was an open date documented as June 28, 2019. During an interview and concurrent observation with Licensed Vocational Nurse 2 (LVN 2) on June 28, 2019 at 10:05 a.m. LVN 2 confirmed that the vial of Humulin was not opened. LVN 2 stated that open dates of medications are filled out when the medications are opened. During an interview and concurrent observation with Licensed Vocational Nurse 3 (LVN 3) on June 28, 2019 at 10:22 a.m., LVN 3 stated that the open date on medications should only be filled out when the medication has been used. LVN 3 confirmed that the vial of Humulin was not opened as the cap was still intact. The facility's policy and procedures titled "Documentation-Nursing" revised June 01, 2017, states that nursing documentation will be concise, clear, pertinent, and accurate. c. During an observation and record review on 6/28/19 at 10:35 a.m. in Station 2 medication room, the refrigerator temperature log for 6/19/19 11:00 p.m to 7:00 a.m. shift was blank. Further review of the refrigerator temperature log indicated the refrigerator temperature must be checked and documented every shift. If the temperature is not within acceptable ranges (36°F to 46°F) to report to the maintenance supervisor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 43 of 59 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 07/01/2019 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 an observation and record review on 6/28/19 at 10:38 a.m. in Station 2 medication room, the medication room temperature log for 6/13/19 11:00 p.m. to 7:00 a.m. shift was blank. Further review of the medication room temperature log indicated the temperature must be checked and documented every shift. If the temperature is not within acceptable ranges (59°F to 86°F) to report to the maintenance supervisor. During an interview with Licensed Vocational Nurse 6 (LVN 6) on 6/28/19 at 10:40 a.m. she stated it was missed. LVN 6 stated it should have been checked every shift and documented the refrigerator temperature and medication room temperature in the appropriate log upon start of shift. During an interview with the DON on 6/28/19 at 10:55 a.m. she stated it is the responsibility of the registered nurses to monitor and log the refrigerator temperatures and medication room temperature in their assigned medication rooms every shift. The facility's policy and procedure titled "Medication Storage in the Facility" undated indicated it is the policy of the facility to safely, securely and properly store medications and biologicals following manufacturer's recommendations or those of the supplier. Medications requiring storage at room temperature are kept at temperatures ranging from 59°F to 86°F. Medications requiring "refrigeration" or temperatures between 36°F to 46°F are kept in a refrigerator with a thermometer to allow temperature monitoring.

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

F842 07/31/2019 §483.20(f)(5) Resident-identifiable information. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 44 of 59 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 07/01/2019 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 (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 (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, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 45 of 59 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 07/01/2019 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 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; (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 ensure one of one resident (Resident 60) medical record reflect an accurate updated information of resident whereabouts. Resident 60 went for a fistulagram appointment (special x-ray procedure using a contrast to look at the blood flow of a dialysis access that takes around 15 to 30 minutes) on 6/26/19, as of 6/29/19, Resident 60 has not return to the facility. . This deficient practice has the potential for Resident 60's health status to be unknown and needs not addressed. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 46 of 59 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 07/01/2019 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 the Admission Record dated 7/1/2019 indicated that Resident 60 was originally admitted on 7/12/19 with diagnoses that included end stage renal disease (ESRD, kidney failure), hypotension (low blood pressure), and anemia (low blood count). The Minimum Data Set (MDS, an assessment and care screening tool) dated 4/11/19 indicated Resident 60's cognition (a mental process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 60 was totally dependent and one-person physical assist on locomotion (movement) on and off unit, dressing, eating, toilet use, and personal hygiene. During an observation dated 6/29/19 at 10:36 a.m., Resident 60's bed was empty and there was no name label outside the room. During an interview on 6/29/19 at 10:36 a.m. with Certified Nursing Assistant 4 (CNA 4) who was inside the room of Resident 60 said that Resident 60 was out of the facility doing dialysis. During an interview on 6/29/19 at 10:54 a.m. with the Director of Nursing (DON), DON stated that Resident 60 went for a fistulagram on 6/26/19. DON stated that facility has not received any word from the hospital. DON stated the staff were should have call the hospital. During an interview on 6/29/19 at 11:12 a.m., DON stated that she called the doctor doing the fistulagram and doctor said that Resident 60 had low blood pressure and tachycardic (rapid heart rate) during the fistulagram procedure. DON stated Resident 60 had no clearance yet to leave the hospital. DON stated that there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 47 of 59 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 07/01/2019 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 no documentation in the medical record that staff made a follow up on Resident 60's whereabouts. DON stated that if there was no follow up, the facility will not know what happened to Resident 60. A review of the facility's policy and procedure titled "Documentation - Nursing" indicated that the purpose is "To provide documentation of resident status and care given by nursing staff."

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 07/31/2019 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 48 of 59 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 07/01/2019 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) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 49 of 59 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 07/01/2019 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 and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 50 of 59 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 07/01/2019 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 residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 51 of 59 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 07/01/2019 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 and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the hospice services (program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) meet professional standards, and necessary care was provided consistently to a resident who was receiving hospice services for two of three sampled residents (Resident 113 and 100 ) by failing to: 1. Collaborate with hospice representatives in the hospice care planning process for those residents receiving hospice services. 2. Ensure Resident 100's hospice agency provided a calendar as means of communicating with the facility when the projected visits are scheduled. These deficient practices had the potential to negatively affect residents' physical comfort and psychosocial well-being and had the potential to result in a delay or lack of coordination in delivery of hospice services to the resident. Findings: a. A review of admission record Resident 113 was admitted to the facility on 5/13/19, with diagnoses that included Parkinson's disease (a disease of the nervous system that mostly affects older people), diabetes, and high blood pressure. A review of Resident 113's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 52 of 59 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 07/01/2019 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 [MDS- a comprehensive assessment and screening tool] dated 5/13/19, indicated resident cognitive skills for daily decisionmaking was intact, and extensive assistance for bed mobility, dressing, and personal hygiene. On 6/29/19 at 11:31 AM, during an interview, Licensed Vocational Nurse (LVN 7) stated Resident 113 is a hospice resident. On 6/29/19 at 4:46 PM, during record review and interview, the Medical Record Director (MRD) stated he cannot find any documentation or evidence that the hospice agency and the nursing home collaborated in the development of a coordinated plan of care for Resident 113 who is receiving hospice services. On concurrent interview, Minimum Data Set Coordinator (MDS) stated documentation should be found in the Interdisciplinary Team (IDT) notes and the Hospice care plan is signed by the hospice agency. No IDT notes was provided. A review of the Hospice Care plan dated 5/24/19, showed no signature of the Hospice agency representative. During a review of Resident 113's Hospice Care Plan dated of 5/24/19, indicated hospice staff to render care during visits, Licensed Nurse three times a week. During a review of Resident 113's Hospice Visit Calendar from May 1, 2019 to June 30, 2019, indicated licensed nurses are scheduled to visit the resident twice a week. On 6/29/19 at 5:22 PM, during an interview, the Director of Nursing (DON) stated she will call the Hospice agency to coordinate with them for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 53 of 59 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 07/01/2019 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 the care plan and schedule of visit. b. A review of admission record Resident 100 was admitted to the facility on 8/1/18, with diagnoses that included non-pressure chronic ulcer lower leg, generalized edema, and chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow). A review of Resident 100's Minimum Data Set dated 5/15/19, indicated the resident is cognitively intact, and independent for bed mobility, transfer, and dressing. During an observation on 6/29/19 8:08 AM, Resident 100 was sitting in her bed with bilateral leg edema. On 6/29/19 at 12:15 PM, during record review and interview, the Medical Record Director (MRD) cannot find Hospice Visit Calendar for June 2019. He stated he will inform the DON to follow up for the calendar. On 6/29/19 at 5:22 PM, during an interview, the Director of Nursing (DON) stated there should be a calendar for the proposed visit of the Hospice Agency. A review of the facility's policy and procedure titled "Hospice Care," dated August 2017, indicated to develop a plan of care that reflects the participation of the hospice agency, the facility, and the resident and family to the extent possible.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 07/31/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 54 of 59 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 07/01/2019 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 designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 55 of 59 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 07/01/2019 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 (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to observe infection control measures by failing to store clean linens in a method that ensure cleanliness for two of three clean linen storage rooms. These deficient practices caused the potential for the development and the spread of infection. Findings: On 06/30/19, at 7:33 AM, during an observation and inspection of the Station 2 clean linen storage room with the presence of Registered Nurse 3 (RN 3) and Licensed Vocational Nurse 7 the linen storage room was stocked with disarray clean linens. The linens in the lower shelves was touching the dusty floor. The antiFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 56 of 59 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 07/01/2019 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 skid socks was stored touching the floor. During the concurrent interview, RN 3 stated linens, towels, gowns, and sock should not be stored touching the floor to prevent contamination and infection. On 06/30/19, at 7:39 AM, during an observation of the Station 3 clean linen storage room with RN 3, the linen storage room was stocked with disarray clean linens. Plastics are found in the floor and abduction pillows are found on top of the linen shelves. During the concurrent interview, RN 3 stated she will tell the housekeeping to clean the storage room because it is a concern for infection control. She further stated clean linen storage room should be organized and clean to prevent infection.

F919 SS=D Resident Call System CFR(s): 483.90(g)(2)

F919 §483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. §483.90(g)(2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the breath call cord (device that allows emergency calls to be sent using simple air/breath activation) was functional which was used by one of two residents (Resident 24) who cannot use the facility's call light button. This deficient practice has the potential for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 57 of 59 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 07/01/2019 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 24's calls not being answered and needs not being met. Findings: A review of the Admission Record dated 7/1/2019 indicated that Resident 24 was originally admitted to the facility on 3/27/18 with diagnoses that included contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of muscle for right and left upper arms and quadriplegia (paralysis of all four limbs). The Minimum Data Set (MDS, an assessment and care screening tool) dated 6/11/19 indicated Resident 24's cognition (a mental process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 24 needed total dependence on bed mobility, eating, toilet use, and personal hygiene. During an observation on 6/30/19 at 5:36 p.m., with the Director of Nursing (DON) and Director of Maintenance (DOM), the breath call cord of Resident 24 did not trigger the call light when Resident 24 blew air into the device. The DOM changed the device and this time Resident 24 blew air into the breath call cord triggering the call light to turn on. During an interview with the DON on 6/30/19 at 6:40 p.m., DON stated that nobody knew that the breath call cord was not functioning. During an interview with the DOM on 6/30/19 at 6:15 p.m., the DOM indicated that the breath call cord of Resident 24 was functioning the last time he checked on 6/26/19. A review of the facility's undated policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 58 of 59 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 07/01/2019 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 procedure titled "Resident Rights Accommodation of Needs" indicated that "Facility staff helps to keep hearing aids, glasses and other adaptive devices clean and in working order for the resident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8R211 Facility ID: CA92000011 If continuation sheet 59 of 59