Other·November 21, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint and a facilityreported incident. Complaint: 652349 Facility-reported incident: 652238 Representing the Department: 38487, RN, Health Facilities Evaluator Nurse The inspection was limited to the specific complaint and facility-reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint 652349 and facility-reported incident 652238.

F559 SS=D Choose/Be Notified of Room/Roommate Change CFR(s): 483.10(e)(4)-(6)

F559 §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. §483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement. §483.10(e)(6) The right to receive written notice, including the reason for the change, 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: VZRZ11 Facility ID: CA92000011 If continuation sheet 1 of 7 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 10/24/2019 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 before the resident's room or roommate in the facility is changed. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide one of two samples residents (Resident 1) and the resident's responsible party with written notice of a room change indicating the reason for a facility initiated room change. This deficient practice resulted in the violation of Resident 1's and the responsible party's rights by not providing the opportunity to see the new room, meet the new roommate, and ask questions about the move. Cross-reference F600, F607, F609, and F689. Findings: On 9/10/19, an unannounced visit was made to investigate a complaint regarding quality of care. It was alleged that the facility transferred the resident to a different room despite Resident 1's objections. A review of the Admission Record, dated 8/8/19, indicated Resident 1 was originally admitted to the facility on 10/13/13 and readmitted on 5/8/19. Resident 1 was admitted with diagnoses, that included, epilepsy (nerve cell activity in the brain is disturbed, causing seizures, abnormal electrical activity in the brain), cerebral infarction (stroke - brain damage from interrupted blood flow), dementia (thinking problem that interferes with daily life), hemiplegia and hemiparesis to the right side (muscle weakness or loss of muscle function). A review of Resident 1's Minimum Data Set, an assessment and care-screening tool, dated 7/25/19, indicated Resident 1 had a Brief Interview for Mental Status score of 0, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZRZ11 Facility ID: CA92000011 If continuation sheet 2 of 7 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 10/24/2019 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 indicating the resident was severely impaired with cognition, the process of gaining knowledge and understanding. Resident 1 was totally dependent with bed mobility, dressing, eating, using the bathroom and personal hygiene, and was totally dependent requiring two person assist with transferring from bed to chair. A review Resident 1's History and Physical Examination, dated 5/9/19, indicated the resident did not have the capacity to understand and make decisions. On 9/10/19, at 10:40 a.m., the Administrator in Training (AIT) was interviewed in the presence of the Acting Director of Nursing (ADON). The AIT stated the facility did not know the reasons for Resident 1's room change. The Room Change Notification, dated 8/13/19, was reviewed concurrently. The AIT confirmed Resident 1's reason for room change was an administrative decision, but there was no reasons for the room change documented. The ADON confirmed a written notice of room change was not provided to the responsible party. The ADON also confirmed providing a written notice of room change to the responsible party is not indicated in the facility's policy, Room Change/Roommate Assignment.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZRZ11 Facility ID: CA92000011 If continuation sheet 3 of 7 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 10/24/2019 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 REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to prevent a fall accident for one of two sample residents (Resident 1). Resident 1 required two-person assistance with transfers to and from bed, using a portable total body lift device (used with residents who cannot bear weight, have physical limitations or are very heavy and cannot be safely transferred manually by staff. The lift supports the entire weight of the resident with a sling attached to a stand on wheels that can be freely moved or positioned to allow a transfer to a different surface). On 8/25/19, at around 4:15 p.m., Certified Nursing Assistance 1 (CNA 1) attempted transferring Resident 1 to bed, by herself, using the portable lift device. As a result, Resident 1 fell sustaining swelling and pain on the right shoulder and skin tears on the right forearm and the right lower leg. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) on the same day for further evaluation. Findings: A review of Resident 1's Admission Record (Face Sheet) dated 8/8/19, indicated the facility readmitted Resident 1 on 5/8/19 with diagnoses including, epilepsy (abnormal electrical activity in the brain resulting on seizures), cerebral infarction (brain damage from interrupted blood flow), dementia (thinking problem that interferes with daily life), and right sided hemiplegia and hemiparesis (loss of movement or weakness on one side of the body). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZRZ11 Facility ID: CA92000011 If continuation sheet 4 of 7 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 10/24/2019 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 Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 7/25/19, indicated Resident 1 had severely impaired cognition (the process of gaining knowledge and understanding). Resident 1 was totally dependent with bed mobility, dressing, and personal hygiene, and required two-person assistance with transferring from and to bed. A review of Resident 1's History and Physical (H&P) Examination dated 5/9/19, the physician indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Fall Risk Evaluation indicated Resident 1 had a fall risk score of 14. Total score of 10 or above represented high fall risk. A review of Resident 1's Care Plan developed on 8/8/19 for Resident 1's falls and injury risk, had a goal for Resident 1 to be free from falls and/or injuries. The interventions included to have two-person assistance during transfers to and from bed and Geri-chair (a reclining chair used for positioning). A review of Resident 1's nursing Progress Note dated 8/25/19, indicated on 8/25/19, at around 4:15 p.m., Resident 1 was in the room, on the floor, next to the foot of the bed, complaining of right shoulder pain. Resident 1 had: - Swelling and redness on the right shoulder, - Skin tear on the right forearm measuring seven centimeters (cm - unit of measurement) in length by 10 cm in width with slight bleeding, and - Skin tear on the right lower leg measuring five cm in length by two cm in width with slight bleeding. A review Resident 1's Physician's Order dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZRZ11 Facility ID: CA92000011 If continuation sheet 5 of 7 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 10/24/2019 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 8/25/19, at 4:30 p.m., indicated to transfer Resident 1 via 911 (emergency call for paramedics) to General Acute Care Hospital 1 (GACH 1) for evaluation. A review of Resident 1's the GACH 1 ED (Emergency Department) Provider Notes, dated 8/25/19, indicated Resident 1's diagnoses included right arm and right leg contusion (bruise), and skin tears to right extremities (arm and leg). A review of Resident 1's GACH 1 H&P dated 8/26/19, indicated Resident 1 had pain and new ecchymosis (bruising) to the right shoulder. A review of Resident 1 GACH 1 Orthopedic Progress Note, dated 8/28/19, indicated Resident 1 grimaced (facial expression for pain) with right lower extremity (leg) range of motion (movement). On 9/10/19, at 9:21 a.m., during an interview, Certified Nurse Assistant (CNA 1) stated she was transferring, by herself, Resident 1 from the Geri-chair to the bed using the mechanical lift. CNA 1 stated Resident 1 fell to the ground because the sling hook slipped from the mechanical lift. CNA 1 acknowledged knowing Resident 1 needed two staff when transferring with the use of the mechanical lift. CNA 1 stated she transferred Resident 1 without assistance because, "Everyone was busy." CNA 1 stated Resident 1 could not move her left hand after the fall. On 9/10/19, at 9:57 a.m., the Director of Staff Development (DSD) and Acting Director of Nursing (ADON) were interviewed concurrently. The DSD and ADON, stated CNA 1 should not have transferred Resident 1 without assistance from other staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZRZ11 Facility ID: CA92000011 If continuation sheet 6 of 7 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 10/24/2019 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 policy on Total Mechanical Lift, revised 1/1/2014, indicated at least two people are present while resident is being transferred with the mechanical lift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZRZ11 Facility ID: CA92000011 If continuation sheet 7 of 7