Other·December 24, 2020

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 complaint CA00707093. Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 38552 Health Facilities Evaluator Nurse ID: 34659 Health Facilities Consultant Pharmacist ID: 40994 Four deficiencies were issued for CA00707093 Highest Severity and Scope: K 1. Administer Resident 1, a total of 69 doses of Rivaroxaban (brand name Xarelto, an anticoagulant medication to prevent blood clots from forming, which usually forms in the legs and can travel to the lungs through the veins. When lodged in the lungs this can cause breathing difficulty and may result in death) 20 milligrams (mg - unit of measure), between 11/4/2019 and 10/4/2020. 2. Administer Resident 2, a total of 11 doses of Advair (Fluticasone-Salmeterol, a purple circular inhaler device that administers medication to a resident to aide in breathing), between 8/25 and 10/4/2020 and a total of eight doses of Spiriva (Tiotropium Bromide, a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs), between 9/21 and 10/4/2020. 3. Administer Resident 3, a total of 18 doses of Lovenox (Enoxaparin, an anticoagulant) between 9/17 and 10/4/2020. 4. Administer Resident 4, one dose of Breo 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: J1LF11 Facility ID: CA92000011 If continuation sheet 1 of 51 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 11/27/2020 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 (Fluticasone Furoate-Vilanterol, to improve symptoms and prevent bronchospasm or asthma attacks), between 9/17 and 10/4/20 and 24 doses of Spiriva between 9/1 and 10/4/2020. 5. Administer Resident 5, a total of 57 doses of Spiriva, between 5/5 and 10/4/2020. 6. Administer Resident 6 a total of 158 doses of Fluticasone Propionate/Salmeterol Diskus Inhalation Powder 100/50 microgram (mcg)/dose, between 12/27/2019 and 10/5/2020. These deficient practices placed Residents 1 and 3 at increased risk to experience serious health complications such as thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation) and pulmonary embolism (clot dislodgement in the lungs), heart attack, or stroke likely resulting in hospitalization or death. Resident 2, 4, 5, and 6 could have experienced serious health complications such as respiratory arrest (the inability to breathe), abnormal heart rhythms such as tachycardia (fast heart rate). On 10/5/2020 at 9:50 p.m., the State Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator (ADM) and the director of nursing (DON). The regulatory requirments not met were: F-755 Failure to provide Residents 1-6 with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 2 of 51 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 11/27/2020 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 pharmaceutical services to meet their needs. F-760 Failure to ensure Residents 1-6 were free from medication errors. On 10/6/2020, at 12:10 p.m., the ADM provided the Department with a Plan of Action (POA, a plan to immediately address non-compliance so that residents are not in danger) which was not accepted as it did not indicate the process to obtain prescribed medications when not found in the medication cart. On 10/6/2020 at 5:05 p.m. the ADM provided the Department with another POA which was not accepted after validation and the ADM was informed on 10/7/2020 at 11:13 a.m. On the same day, by 9:10 p.m., the facility had not provided an accepatable POA. On 10/8/2020 at 9:02 a.m. the DON provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Licensed nurses reassessed Residents 1, 2, 3, 4, 5, and 6 and found the residents condition to be stable with no adverse reactions. Licensed Nurses notified the residents' attending physicians about missing the administration medications. All medications that were not available were reordered from the pharmacy and Resident 1's attending physician (MD 1) ordered lab tests to further assess resident's condition. 2. The DON conducted in-service training to the licensed nurses including process of refills and ordering medications, medication administration, availability of medication, 24hour medication cart check, and ethical standards in medication administrations, medication availability and how to order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 3 of 51 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 11/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Licensed nurses performed a facility-wide, three-way medication cart audit (a check to ensure that the residents' current physician's orders match what is written on their Medication Administration Record [MAR] and that the medication cart contains all of the medications necessary for the residents per physician's orders). On 10/8/2020 at 12:44 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON.

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

F600 §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 observation, interview, and record review, the facility failed to ensure residents have the right to be free from neglect when not provided with the medications needed to treat their serious medical conditions and in accordance with the residents' comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 4 of 51 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 11/27/2020 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 assessment, facility's policies, and physicians' orders for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Administer Resident 1 a total of 69 doses of rivaroxaban (brand name Xarelto, an anticoagulant medication to prevent blood clots from forming, which usually forms in the legs and can travel to the lungs through the veins. When lodged in the lungs this can cause breathing difficulty and may result in death) 20 milligrams (mg - unit of measure), between 11/4/2019 and 10/4/2020. The pharmacy delivered a total of 252 doses of Xarelto between 11/4/19 and 10/4/2020 but the licensed nurses documented giving a total of 321 doses during the same time period. On 10/5/2020, the facility did not have Xarelto for Resident 1. The failure to administer the prescribed Xarelto, placed Resident 1 at increased risk to experience serious health complications such as thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation) and pulmonary embolism (clot dislodgement in the lungs), heart attack, or stroke likely resulting in hospitalization or death. 2.a. Administer Resident 2 a total of 11 doses of Advair (fluticasone-salmeterol, a purple circular inhaler device that administers medication to a resident to aide in breathing), between 8/25 and 10/4/2020 when the pharmacy did not refill the medication. On 10/5/2020, the facility did not have the Advair for Resident 2. Missing the administration of Advair, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 2.b. Administer Resident 2 a total of nine (9) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 5 of 51 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 11/27/2020 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 doses of Spiriva (tiotropium Bromide, a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) 30 capsules supply, between 9/21 and 10/4/2020. The Spiriva box with 30-day supply was opened on 9/21/2020 and on 10/5/2020, there were 24 doses left instead of 15 doses if they were given as ordered. Missing the administration of Spiriva, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 3. Administer Resident 3 a total of 18 doses of Lovenox (enoxaparin, an anticoagulant) between 9/17 and 10/4/2020. Missing the administration of Lovenox, placed Resident 3 at increased risk of experiencing serious health complications such as thromboembolism and pulmonary embolism, heart attack, or stroke likely resulting in hospitalization or death. serious respiratory and heart complications. 4.a. Administer Resident 4 one dose of Breo (fluticasone furoate-vilanterol, to improve symptoms and prevent bronchospasm [when the airways go into spasm and contract] or asthma attacks), between 9/17 and 10/4/2020, based on the amount of 28-day supply delivered by the pharmacy on 9/17/2020 and the amount left in the medication box. On 10/5/2020, there were 11 medications left instead of nine (9) and 24 doses of Spiriva between 9/1 and 10/4/2020. Missing the administration of Breo, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 4.b. Administer Resident 4 a total of 24 doses of Spiriva between 8/21 and 10/4/2020 when the pharmacy did not make deliveries of Spiriva for Resident 4. Missing the administration of Spiriva, placed Resident 4 at increased risk of experiencing serious respiratory and heart FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 6 of 51 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 11/27/2020 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 complications. 5. Administer Resident 5 a total of 57 doses of Spiriva, between 5/6 and 10/4/2020, based on the number of capsules left ungiven (57) from the supplies the pharmacy delivered since 5/5/2020. Missing the administration of Spiriva, placed Resident 5 at increased risk of experiencing serious respiratory and heart complications. 6. Administer Resident 6 a total of 158 doses of fluticasone propionate/salmeterol Diskus Inhalation Powder 100/50 microgram (mcg)/dose, between 12/27/2019 and 10/5/2020, based on the number of capsules left ungiven (158) from the supplies the pharmacy delivered since 5/5/2020. Missing the administration of fluticasone, placed Resident 6 at increased risk of experiencing serious respiratory and heart complications. Cross-reference F-755, F-760, and F-842. Findings: a. A review of Resident 1's Admission Record indicated the facility admitted the resident on 3/16/2018, with diagnoses including stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is blocked by a clot), and atrial fibrillation (is a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications). Resident 1 remained in the facility since admission on 3/16/2018. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and carescreening tool) dated 7/30/2020, indicated Resident 1 was unable to understand and make decisions and required extensive assistance with dressing, eating and personal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 7 of 51 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 11/27/2020 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 hygiene. A review of Resident 1's Physician's Orders, indicated to give Xarelto (rivaroxaban) one tablet 20 mg daily since 4/17/2019. A review of Pharmacy 1's dispensing history indicated it delivered 252 doses of Xarelto 20 mg between 11/4/2019 and 10/4/2020 (14 doses each delivery on: 11/4, 11/15, 11/27, 12/14, 12/28/2019, 1/13, 1/24, 2/10, 2/21, 3/15, 4/8, 4/19, 5/1, 5/28, 6/27, 7/11/7/22, and 10/5/2020). A review of Resident 1's Medication Administration Record (MAR) from 11/4/2019 to 10/4/2020, indicated 321 doses of Xarelto were signed as administered to Resident 1. On 10/5/2020, at 3:20 p.m., during a concurrent observation of Nursing Station 2 Medication and interview, Licensed Vocational Nurse 1 (LVN 1) was signing residents' MARs for medications administered earlier in the day. LVN 1 confirmed Resident 1's Xarelto was not in the medication cart and was not in the medication room or anywhere else in the facility. On 10/5/2020 at 6:46 p.m., during a telephone interview, the Registered Pharmacist 2 (RPH 2) stated the Pharmacy 1 had records of delivering 14-day supply of Xarelto on 10/5/2020. RPH 2 stated Pharmacy 1 did not make other deliveries between 6/18/2020 and 10/4/2020. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 1's MAR was signed indicating 321 doses were given but only 252 doses were dispensed from the pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 8 of 51 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 11/27/2020 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 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on 8/24/2020 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing). A review of Resident 2's MDS dated 9/16/2020 indicated the resident was able to understand and make decisions, and required one-person physical assistance with dressing, toileting, and personal hygiene. A review of Resident 2's Physician's Orders dated 8/24/2020 indicated: a. Advair Diskus Aerosol Powder Breath Activated 150-50 micrograms (mcg)/dose (fluticasone-salmeterol), one puff inhalation orally twice a day for COPD, rinse mouth after each use. b. Spiriva Handihaler (hand-held device) Capsule 18 mcg (tiotropium bromide monohydrate), two inhalations orally once a day for COPD. On 10/5/2020 at 12:10 p.m., during an observation of Nursing Station 2 Medication Cart 1, review of the MAR, and concurrent interview, LVN 1 confirmed Resident 2's Spiriva 30 caplets (30-day supply), with an opened date 9/21/2020, had 24 doses left instead of 15 doses left. Nine (9) doses should have been given. LVN 1 was unable to explain the discrepancy between what was documented as being given and the doses left of Spiriva. LVN 1 stated there was no Advair Diskus in the medication cart or in the facility and it needed to be reordered. The MAR between 8/25/2020 and 10/4/2020 indicated a total of 41 doses of Advair; however, at 6:46 p.m., during a telephone interview, the RPH 2 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 9 of 51 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 11/27/2020 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 Pharmacy 1 had records of delivering on 8/25/2020 a 30-day supply of Advair. RPH 2 stated on 8/25/2020 and on 9/18/2020, the pharmacy delivered a 30-day supply of Spiriva on 8/25/2020. On 10/5/2020 at 1:31 p.m., during an interview, Resident 2 stated he was in the facility for several months and before his admission, he was used to take all his breathing treatment medications such as Spiriva and albuterol. Resident 2 stated he needed those breathing treatments to breathe better but the nurses were not giving them to him, and his breathing problems had not improved. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 2's MAR was signed indicating medications not available were signed as given. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident on 12/27/2019 with diagnoses including malignant neoplasm of brain (brain cancer). A review of Resident 3's MDS dated 10/7/2020 indicated the resident had moderately impaired memory and decision-making and required limited assistance with eating, toileting, and personal hygiene. A review of Resident 3's Physician's Orders indicated an order for Lovenox (enoxaparin sodium) 40 mg/0.4 milliliters (ml), inject 0.4 ml subcutaneously (under the skin) once a day for DVT prophylaxis (prevention), ordered on 9/16/2020 with an end date 10/17/2020. A review of Resident 3's MAR between 9/17 and 10/4/2020 indicated a total of 18 doses of enoxaparin sodium were signed as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 10 of 51 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 11/27/2020 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 administered. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 3's MAR was signed indicating 18 doses of Lovenox were given when there was none received from the pharmacy. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident on 9/13/2020 with diagnoses including COPD and chronic respiratory failure (airways that carry air to your lungs become narrow and damaged). A review of the Census List indicated the resident was at an acute hospital on 9/12/2020 and returned on 9/13/2020. A review of Resident 4's MDS dated 9/17/2020 indicated the resident was able to understand and make decisions and required supervision with bed mobility, dressing, toileting, and personal hygiene. A review of Resident 4's Physician's Orders indicated an order: 1. Breo (fluticasone furoate-vilanterol) Aerosol Powder Breath activated 100-25mcg/inh one puff inhale orally once a day for COPD, rinse mouth with water after treatment and expectorate (spit out by coughing), do not swallow, ordered 9/14/2020. 2. Spiriva, one capsule 18 mcg, inhale orally once a day for COPD ordered 3/6/2020. A review of Resident 4's MAR from 9/17/2020 to 10/4/2020 indicated a total of 18 doses of Breo were signed as administered. A review of Resident 4's MAR from 9/1/2020 to 10/4/2020 indicated a total of 34 doses of Spiriva were signed as administered. A review of Pharmacy 1's dispensing history, a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 11 of 51 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 11/27/2020 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 report indicated Resident 4's Breo was dispensed for 28-day supply on 9/17/2020. Resident 4's Spiriva 5-day supply was delivered on 8/21/2020, 9/17/2020, and 9/21/2020, for a total of 15-day supply of Spiriva. On 10/5/2020 at 5:42 p.m., during a concurrent observation of the medication cart and interview, LVN 10 confirmed Resident 4's Breo had 11 doses left. LVN 10 stated if taken daily, there should be 10 left, one dose was missed. On 10/5/2020 at 6:01 p.m., during an interview, Resident 4 stated he sometimes gets his Breo inhaler and the last time he received Spiriva was about two weeks ago. Resident 4 stated he had not received Breo and Spiriva today. Resident 4 stated he must constantly remind the nurses to give his Breo and Spiriva and does not know why the nurses were not giving him his medications. Resident 4 stated he feels terrible of having to constantly ask the nurses to give his medications. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident on 5/5/2020 with diagnoses including acute respiratory failure and COPD with acute exacerbation. Resident 5 was not transferred to another healthcare facility since admission on 5/5/2020. A review of Resident 5's MDS dated 8/15/2020 indicated the resident was able to understand and make decisions and required supervision with transfers and ambulation. A review of Resident 5's Physician's Orders indicated an order dates 5/5/2020 for Spiriva capsule 18 mcg, one caplet, inhale orally once a day for bronchospasm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 12 of 51 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 11/27/2020 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 10/5/2020 at 3:34 p.m., during an observation of Nursing Station 2 Medication Cart 1 and concurrent interview, LVN 1 confirmed the following: Spiriva (box #1) with 5 caps (5-day supply), filled date 8/13/2020, with an opened date of 8/24/2020 with two caplets left. Spiriva (box #2) with 30 caps (30 day-supply), filled date 9/29/20, sealed and unopened. LVN 1 stated Spiriva (box #1) should have not have any caplet left and Spiriva (box #2) should have a total of 23 doses left. A review of Pharmacy 1's dispensing history indicated that from 5/52020 to 9/29/2020, the pharmacy delivered for Resident 5 a total of 95day supply of Spiriva. The delivery of five-day supply of Spiriva were on the following dates: 5/5, 5/11, 5/25, 6/2, 6/6, 6/12, 6/29, 7/7, 7/13, 7/18, 7/21, 8/5, 8/13. On 9/29, a 30-day supply was delivered. On 10/7/2020 at 12 p.m., during a concurrent interview and a review of Resident 5's 10/2020 MAR, LVN 2 confirmed she signed the MAR for the administration of Spiriva from 10/1/2020 and 10/5/2020. On 10/29/2020 at 3:29 p.m., during a concurrent interview and review of Resident 5's 10/2020 MAR, LVN 6 confirmed she initialed and signed as giving Spiriva to Resident 5 from 5/5/2020 to 10/5/2020, a total of 151 doses. 6. A review of Resident 6's Admission Record indicated the facility re-admitted the resident on 8/31/2012, with diagnoses including COPD. A review of Resident 6's Census List, indicated Resident 6 remained in the facility since readmission on 8/31/2012. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 13 of 51 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 11/27/2020 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 6's MDS, dated 8/26/2020, indicated Resident 6 was able to understand and make decisions and required total care. A review of Resident 6's Physician's Order dated 12/27/2019, indicated Advair Diskus Aerosol Powder Breath Activated 100-50 mcg/dose (fluticasone-salmeterol) one puff inhale orally once a day for difficulty breathing related to COPD. On 10/5/2020 at 3:25 p.m., during an observation of Nursing Station 2 Medication Cart 2 and concurrent interview, the following was observed for Resident 6: 1. Fluticasone Propionate/Salmeterol Diskus Inhalation Powder 100/50 mcg/dose filled date (and in almost all cases delivery date to facility from pharmacy) 8/6/2020, with an unopened package of one inhaler device). 2. Advair Diskus filled date 6/30/2020, with the number "15" on the meter counter, meaning that there are 15 doses left out of 60 doses). A review of Resident 6's pharmacy dispensing history indicated Pharmacy 1 delivered the medication: 1. Fluticasone/Salmeterol 100/50 mcg/dose 60 doses on 11/02/2019, 12/19/2019, 3/3/2020, 6/30/2020 with 15 doses left (in the medication cart), and 8/6/2020 unopened and in the medication cart. A total of 300 doses (75 not used) 2. Advair Diskus 100/50 mcg/dose a total of 125 doses between the dates, 12/27/2019 and 10/5/2020. A review of Resident 6's MAR from 12/27/2019 to 10/5/2020 indicated a total of 283 doses of Advair Diskus were signed as administered but the pharmacy delivered 125 doses. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 14 of 51 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 11/27/2020 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 10/7/2020 at 3:30 p.m., during an interview the DON, stated she was investigating the discrepancies in the medications from what is documented to what is physically present after delivery from the pharmacy. On 10/8/20 at 10:54 a.m., during an interview with the Medical Director (MD), who was also Resident 1's physician, MD stated if the nurses did not administer blood thinners for Resident 1 and 3, and breathing treatments for Resident 2, 4, 5, 6 as ordered, the residents' condition could worsen. A review of the facility's policy and procedure titled, "Abuse and Neglect Prohibition" dated 10/8/2019, indicated deprivation of goods and services by staff, abuse also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In this case is, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s). Neglect is defined as the failure of the facility to provide goods and services to our residents that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

F755 SS=K Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 15 of 51 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 11/27/2020 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 §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide pharmaceutical services by not administering medications in accordance with the facility's policies and the physicians' orders, for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Administer Resident 1 a total of 69 doses of rivaroxaban (brand name Xarelto, an anticoagulant [blood thinner] medication to prevent blood clots from forming, which usually forms in the legs and can travel to the lungs through the veins. When lodged in the lungs this can cause breathing difficulty and may result in death) 20 milligrams (mg - unit of measure), between 11/4/2019 and 10/4/2020. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 16 of 51 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 11/27/2020 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 pharmacy delivered a total of 252 doses of Xarelto between 11/4/19 and 10/4/2020 but the licensed nurses documented giving a total of 321 doses during the same time period. On 10/5/2020, the facility did not have Xarelto for Resident 1. The failure to administer the prescribed Xarelto, placed Resident 1 at increased risk to experience serious health complications such as thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation) and pulmonary embolism (clot dislodgement in the lungs), heart attack, or stroke likely resulting in hospitalization or death. 2.a. Administer Resident 2 a total of 11 doses of Advair (fluticasone-salmeterol, a purple circular inhaler device that administers medication to a resident to aide in breathing), between 8/25 and 10/4/2020 when the pharmacy did not refill the medication. On 10/5/2020, the facility did not have the Advair for Resident 2. Missing the administration of Advair, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 2.b. Administer Resident 2 a total of nine (9) doses of Spiriva (tiotropium Bromide, a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) 30 capsules supply, between 9/21 and 10/4/2020. The Spiriva box with 30-day supply was opened on 9/21/2020 and on 10/5/2020, there were 24 doses left instead of 15 doses if they were given as ordered. Missing the administration of Spiriva, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 3. Administer Resident 3 a total of 18 doses of Lovenox (enoxaparin, an anticoagulant) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 17 of 51 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 11/27/2020 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 between 9/17 and 10/4/2020. Missing the administration of Lovenox, placed Resident 3 at increased risk of experiencing serious health complications such as thromboembolism and pulmonary embolism, heart attack, or stroke likely resulting in hospitalization or death. serious respiratory and heart complications. 4.a. Administer Resident 4 one dose of Breo (fluticasone furoate-vilanterol, to improve symptoms and prevent bronchospasm [when the airways go into spasm and contract] or asthma attacks), between 9/17 and 10/4/2020, based on the amount of 28-day supply delivered by the pharmacy on 9/17/2020 and the amount left in the medication box. On 10/5/2020, there were 11 medications left instead of nine (9) and 24 doses of Spiriva between 9/1/2020 and 10/4/2020. Missing the administration of Breo, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 4.b. Administer Resident 4 a total of 24 doses of Spiriva between 8/21/2020 and 10/4/2020 when the pharmacy did not make deliveries of Spiriva for Resident 4. Missing the administration of Spiriva, placed Resident 4 at increased risk of experiencing serious respiratory and heart complications. 5. Administer Resident 5 a total of 57 doses of Spiriva, between 5/6 and 10/4/2020, based on the number of capsules left ungiven (57) from the supplies the pharmacy delivered since 5/5/2020. Missing the administration of Spiriva, placed Resident 5 at increased risk of experiencing serious respiratory and heart complications. 6. Administer Resident 6 a total of 158 doses of fluticasone propionate/salmeterol Diskus Inhalation Powder 100/50 microgram FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 18 of 51 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 11/27/2020 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 (mcg)/dose, between 12/27/2019 and 10/5/2020, based on the number of capsules left ungiven (158) from the supplies the pharmacy delivered since 5/5/2020. Missing the administration of fluticasone, placed Resident 6 at increased risk of experiencing serious respiratory and heart complications. Because of the serious potential harm related to not administering physician's ordered medications to Residents 1, 2, 3, 4, 5, and 6, who were diagnosed with serious illnesses, on 10/5/2020 at 9:50 p.m., the State Agency (the Department) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under the Code of Federal Regulations (CFR) CFR483.45 (F-755) Pharmacy Services and CFR483.45(f)(2) (F-760) Residents are free of any significant medication with a scope and severity of K (pattern - more than a limited number of residents affected by the same practice) in the presence of the administrator (ADM) and the Director of Nursing (DON). On 10/8/2020 at 12:44 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the State Agency accepted the Plan of Action (POA) and abated the Immediate Jeopardy situation, in the presence of the ADM and the DON. Cross-reference F-600, F760, and F-842. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 3/16/2018, with diagnoses including stroke (occurs when a blood vessel that carries FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 19 of 51 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 11/27/2020 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 oxygen and nutrients to the brain is blocked by a clot), and atrial fibrillation (is a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications). Resident 1 remained in the facility since admission on 3/16/2018. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 7/30/2020, indicated Resident 1 was unable to understand and make decisions and required extensive assistance with dressing, eating and personal hygiene. A review of Resident 1's Physician's Orders since 4/17/2020, indicated to give Xarelto (rivaroxaban) one tablet of 20 mg daily for prevention of deep vein thrombosis (DVT, a serious condition because blood clots can loosen and lodge in the lungs) and atrial fibrillation (abnormal heart beats). A review of Pharmacy 1's dispensing history indicated the delivery of 252 doses of Xarelto 20 mg between 11/4/2019 and 10/4/2020 (the pharmacy delivered 14 doses each delivery on:11/4, 11/15, 11/27, 12/14, 12/28/2019, 1/13, 1/24, 2/10, 2/21, 3/15, 4/8, 4/19, 5/1, 5/28, 6/27, 7/11/7/22, and 10/5/2020). A review of Resident 1's Medication Administration Record (MAR) from 11/4/2019 to 10/4/2020, indicated 321 doses of Xarelto were signed as administered to Resident 1. On 10/5/2020, at 3:20 p.m., during a concurrent observation of Nursing Station 2 Medication and interview, Licensed Vocational Nurse 1 (LVN 1) was signing residents' MAR for medications administered earlier in the day. LVN 1 presented a paper with some medications listed. LVN 1 explained the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 20 of 51 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 11/27/2020 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 documented on the paper were missing or were low in stock and needed to be re-ordered. LVN 1 confirmed Resident 1's Xarelto was not in the medication cart and was not in the medication room or anywhere else in the facility. On 10/5/2020 at 6:46 p.m., during a telephone interview, Registered Pharmacist 2 (RPH 2) stated Pharmacy 1 had records of delivering 14-day supply of Xarelto on 10/5/2020. RPH 2 stated Pharmacy 1 did not make other deliveries between 6/18/2020 and 10/4/2020. On 10/5/2020 at 8:38 p.m., during an interview, the DON stated Residents 1, 2, 3, 4, 5, and 6 had been dispensed medications from Pharmacy 1. The facility did not use other pharmacies to obtain the Xarelto. The DON was unable to explain why Resident 1's MAR was signed indicating 321 doses were given but only 252 doses were dispensed from the pharmacy. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on 8/24/2020 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing). A review of Resident 2's MDS dated 9/16/2020 indicated the resident was able to understand and make decisions, and required one-person physical assistance with dressing, toileting, and personal hygiene. A review of Resident 2's Physician's Orders dated 8/24/2020 indicated: a. Advair Diskus Aerosol Powder Breath Activated 150-50 micrograms (mcg)/dose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 21 of 51 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 11/27/2020 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 (fluticasone-salmeterol), one puff inhalation orally twice a day for COPD, rinse mouth after each use. b. Spiriva Handihaler (hand-held device) Capsule 18 mcg (tiotropium bromide monohydrate), two inhalations orally once a day for COPD. On 10/5/2020 at 12:10 p.m., during an observation of Nursing Station 2 Medication Cart 1, review of the MAR, and concurrent interview, LVN 1 confirmed Resident 2's Spiriva 30 caplets (30-day supply), with an opened date 9/21/2020, had 24 doses left instead of 15 doses left. Nine (9) doses should have been given. LVN 1 was unable to explain the discrepancy between what was documented as being given and the doses left of Spiriva. LVN 1 stated there was no Advair Diskus in the medication cart or in the facility and it needed to be reordered. The MAR between 8/25/2020 and 10/4/2020 indicated a total of 41 doses of Advair; however, at 6:46 p.m., during a telephone interview, the RPH 2 stated Pharmacy 1 had records of delivering on 8/25/2020 a 30-day supply of Advair. RPH 2 stated on 8/25/2020 and on 9/18/2020, the pharmacy delivered a 30-day supply of Spiriva on 8/25/2020. On 10/5/2020 at 1:31 p.m., during an interview, Resident 2 stated he was in the facility for several months and before his admission, he was used to take all his breathing treatment medications such as Spiriva and albuterol. Resident 2 stated he needed those breathing treatments to breathe better but the nurses were not giving them to him, and his breathing problems had not improved. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 2's MAR was signed indicating medications not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 22 of 51 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 11/27/2020 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 available were signed as given. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident on 12/27/2019 with diagnoses including malignant neoplasm of brain (brain cancer). A review of Resident 3's MDS dated 10/7/2020 indicated the resident had moderately impaired memory and decision-making and required limited assistance with eating, toileting, and personal hygiene. A review of Resident 3's Physician's Orders indicated an order for Lovenox (enoxaparin sodium) 40 mg/0.4 milliliters (ml), inject 0.4 ml subcutaneously (under the skin) once a day for DVT prophylaxis, ordered on 9/16/2020 with an end date 10/17/2020. A review of Resident 3's MAR between 9/17/2020 and 10/4/2020 indicated a total of 18 doses of enoxaparin sodium were signed as administered. On 10/5/2020 at 12:16 p.m., during an interview, LVN 1 stated Pharmacy 1 had not sent Resident 3's Lovenox yet. LVN 1 stated she faxed the refill request. LVN 1 stated usually signs the MAR at around 3 p.m. before she leaves for the day. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 3's MAR was signed indicating 18 doses were given but none were dispensed from the pharmacy. On 10/9/2020 at 10:47 a.m., during a telephone interview, RPH 3 stated Pharmacy 1 had records of 4-day supply dispensed on 10/5/2020. There were no other deliveries of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 23 of 51 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 11/27/2020 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 Lovenox between 9/17/2020 and 10/4/2020. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident on 9/13/2020 with diagnoses including COPD and chronic respiratory failure (airways that carry air to your lungs become narrow and damaged). A review of the Census List indicated the resident was at an acute hospital on 9/12/2020 and returned on 9/13/2020. A review of Resident 4's MDS dated 9/17/2020 indicated the resident was able to understand and make decisions and required supervision with bed mobility, dressing, toileting, and personal hygiene. A review of Resident 4's Physician's Orders indicated an order: a. Breo (fluticasone furoate-vilanterol) Aerosol Powder Breath activated 100-25mcg/inh one puff inhale orally once a day for COPD, rinse mouth with water after treatment and expectorate (spit out by coughing), do not swallow, ordered 9/14/2020. b. Spiriva, one capsule 18 mcg, inhale orally once a day for COPD ordered 3/6/2020. A review of Resident 4's MAR from 9/17/2020 to 10/4/2020 indicated a total of 18 doses of Breo were signed as administered. A review of Resident 4's MAR from 9/1/2020 to 10/4/2020 indicated a total of 34 doses of Spiriva were signed as administered. A review of Pharmacy 1's dispensing history, a report indicated Resident 4's Breo was dispensed for 28-day supply on 9/17/2020. Resident 4's Spiriva 5-day supply was delivered on 8/21/2020, 9/17/2020, and 9/21/2020, for a total of 15-day supply of Spiriva. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 24 of 51 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 11/27/2020 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 10/5/2020 at 5:42 p.m., during a concurrent observation of the medication cart and interview, LVN 10 confirmed Resident 4's Breo had 11 doses left. LVN 10 stated if taken daily, there should be 10 left, one dose was missed. On 10/5/2020 at 6:01 p.m., during an interview, Resident 4 stated he sometimes gets his Breo inhaler and the last time he received Spiriva was about two weeks ago. Resident 4 stated he had not received Breo and Spiriva today. Resident 4 stated he must constantly remind the nurses to give his Breo and Spiriva and does not know why the nurses were not giving him his medications. Resident 4 stated he feels terrible of having to constantly ask the nurses to give his medications. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident on 5/5/2020 with diagnoses including acute respiratory failure and COPD. Resident 5 remained at the facility since admission on 5/5/2020. A review of Resident 5's MDS dated 8/15/2020 indicated the resident was able to understand and make decisions and required supervision with transfers and ambulation. A review of Resident 5's Physician's Orders dated 5/5/2020 for Spiriva 18 mcg, one caplet, inhale orally once a day for bronchospasm. On 10/5/2020 at 3:34 p.m., during an observation of Nursing Station 2 Medication Cart 1 and concurrent interview, LVN 1 confirmed the following: Spiriva (box #1) with 5 caps (5-day supply), filled date 8/13/2020, with an opened date of 8/24/2020 with two caplets left. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 25 of 51 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 11/27/2020 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 Spiriva (box #2) with 30 caps (30 day-supply), filled date 9/29/20, sealed and unopened. LVN 1 stated Spiriva (box #1) should have not have any caplet left and Spiriva (box #2) should have a total of 23 doses left. A review of Pharmacy 1's dispensing history indicated from 5/52020 to 9/29/2020, the pharmacy delivered for Resident 5 a total of 95day supply of Spiriva. The delivery of five-day supply of Spiriva were on the following dates: 5/5, 5/11, 5/25, 6/2, 6/6, 6/12, 6/29, 7/7, 7/13, 7/18, 7/21, 8/5, 8/13. On 9/29, a 30-day supply was delivered. On 10/7/2020 at 12 p.m., during a concurrent interview and a review of Resident 5's 10/2020 MAR, LVN 2 confirmed she signed the MAR for the administration of Spiriva from 10/1/2020 and 10/5/2020. On 10/29/2020 at 3:29 p.m., during a concurrent interview and review of Resident 5's 10/2020 MAR, LVN 6 confirmed she initialed and signed as giving Spiriva to Resident 5 from 5/5/2020 to 10/5/2020, a total of 151 doses, 57 caplets over the amount the pharmacy delivered. 6. A review of Resident 6's Admission Record indicated the facility re-admitted the resident on 8/31/2012, with diagnoses including COPD. A review of the Census List, indicated Resident 6 remained in the facility since re-admission on 8/31/2012. A review of Resident 6's MDS, dated 8/26/2020, indicated Resident 6 was able to understand and make decisions and required total care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 26 of 51 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 11/27/2020 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 6's Physician's Order dated 12/27/2019, indicated Advair Diskus Aerosol Powder Breath Activated 100-50 mcg/dose (fluticasone-salmeterol) one puff inhale orally once a day for difficulty breathing related to COPD. On 10/5/2020 at 3:25 p.m., during an observation of Nursing Station 2 Medication Cart 2 and concurrent interview, the following was observed for Resident 6: a. Fluticasone Propionate/Salmeterol Diskus Inhalation Powder 100/50 mcg/dose filled date (and in almost all cases delivery date to facility from pharmacy) 8/6/2020, with an unopened package of one inhaler device). b. Advair Diskus filled date 6/30/2020, with the number "15" on the meter counter, meaning that there are 15 doses left out of 60 doses). A review of Pharmacy 1's dispensing history indicated delivering: a. Fluticasone/Salmeterol 100/50 mcg/dose 60 doses on 11/02/2019, 12/19/2019, 3/3/2020, 6/30/2020 with 15 doses left (in the medication cart), and 8/6/2020 unopened and in the medication cart. A total of 300 doses (75 not used) b. Advair Diskus 100/50 mcg/dose a total of 125 doses between the dates, 12/27/2019 and 10/5/2020. A review of Resident 6's MAR from 12/27/2019 to 10/5/2020 indicated a total of 283 doses of Advair Diskus were signed as administered but the pharmacy delivered 125 doses. On 10/7/2020 at 3:30 p.m., during an interview the DON, stated she was investigating the discrepancies in the medications from what is documented to what is physically present after delivery from the pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 27 of 51 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 11/27/2020 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 10/8/20 at 10:54 a.m., during an interview with the Medical Director (MD), who was also Resident 1's physician, MD stated if the nurses did not administer blood thinners for Resident 1 and 3, and breathing treatments for Resident 2, 4, 5, 6 as ordered, the residents' condition could worsen. A review of the facility's policy on Preparation and General Guidelines, approved on 10/8/2019, indicated the charge nurse is notified if supplies are inadequate or equipment fails to work properly. The charge nurse reports equipment and supply deficiencies to the DON. A review of the facility's policy on Medication Orders, indicated "The prescriber is contacted for direction when delivery of a medication will be delayed, or the medication is not or will not be available. Documentation of the medication order number one each medication order is documented in the residence medical record with the date, time, and signature of the persons receiving the order. The order is recorded on the position order sheet or the telephone order sheet if it is a verbal order, and on the MAR or Treatment Administration Record (TAR)." G. Receiving medications from the Pharmacy: 1) A licensed nurse: a. Receives medications delivered to the facility and documents that the delivery was received and was secure (on the medication delivery receipt) r. Verifies medications received and directions for use with a medication order form. s. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse or supervisor. t. Immediately delivers the medications to the appropriate secure storage area (or a designee under the direct supervision of the license nurse). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 28 of 51 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 11/27/2020 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 u. Assures medications are incorporated into the resident specific allocation prior to the next medication pass. Document titled "Anticoagulation Therapy Management", indicated that it is the policy of this facility to ensure that anticoagulants are given as ordered and monitored as ordered by physicians. 1. Document the administration of medication on the resident's medication sheets. 2. Indicate any communication with physician and responsible party on the nurse's progress notes.

F760 SS=K Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure it is free of any medication errors of not giving medications as per facility's policies and as prescribed by the physician for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Administer Resident 1 a total of 69 doses of rivaroxaban (brand name Xarelto, an anticoagulant medication [blood thinner] to prevent blood clots from forming, which usually forms in the legs and can travel to the lungs through the veins. When lodged in the lungs this can cause breathing difficulty and may result in death) 20 milligrams (mg - unit of measure), between 11/4/2019 and 10/4/2020. The pharmacy delivered a total of 252 doses of Xarelto between 11/4/19 and 10/4/2020 but the licensed nurses documented giving a total of 321 doses during the same time period. On FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 29 of 51 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 11/27/2020 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 10/5/2020, the facility did not have Xarelto for Resident 1. The failure to administer the prescribed Xarelto, placed Resident 1 at increased risk to experience serious health complications such as thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation) and pulmonary embolism (clot dislodgement in the lungs), heart attack, or stroke likely resulting in hospitalization or death. 2.a. Administer Resident 2 a total of 11 doses of Advair (fluticasone-salmeterol, a purple circular inhaler device that administers medication to a resident to aide in breathing), between 8/25 and 10/4/2020 when the pharmacy did not refill the medication. On 10/5/2020, the facility did not have the Advair for Resident 2. Missing the administration of Advair, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 2.b. Administer Resident 2 a total of nine (9) doses of Spiriva (tiotropium Bromide, a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) 30 capsules supply, between 9/21 and 10/4/2020. The Spiriva box with 30-day supply was opened on 9/21/2020 and on 10/5/2020, there were 24 doses left instead of 15 doses if they were given as ordered. Missing the administration of Spiriva, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 3. Administer Resident 3 a total of 18 doses of Lovenox (enoxaparin, an anticoagulant) between 9/17 and 10/4/2020. Missing the administration of Lovenox, placed Resident 3 at increased risk of experiencing serious health complications such as thromboembolism and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 30 of 51 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 11/27/2020 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 pulmonary embolism, heart attack, or stroke likely resulting in hospitalization or death. serious respiratory and heart complications. 4.a. Administer Resident 4 one dose of Breo (fluticasone furoate-vilanterol, to improve symptoms and prevent bronchospasm [when the airways go into spasm and contract] or asthma attacks), between 9/17/2020 and 10/4/2020, based on the amount of 28-day supply delivered by the pharmacy on 9/17/2020 and the amount left in the medication box. On 10/5/2020, there were 11 medications left instead of nine (9) and 24 doses of Spiriva between 9/1 and 10/4/2020. Missing the administration of Breo, placed Resident 2 at increased risk of experiencing serious respiratory and heart complications. 4.b. Administer Resident 4 a total of 24 doses of Spiriva between 8/21 and 10/4/2020 when the pharmacy did not make deliveries of Spiriva for Resident 4. Missing the administration of Spiriva, placed Resident 4 at increased risk of experiencing serious respiratory and heart complications. 5. Administer Resident 5 a total of 57 doses of Spiriva, between 5/6 and 10/4/2020, based on the number of capsules left ungiven (57) from the supplies the pharmacy delivered since 5/5/2020. Missing the administration of Spiriva, placed Resident 5 at increased risk of experiencing serious respiratory and heart complications. 6. Administer Resident 6 a total of 158 doses of fluticasone propionate/salmeterol Diskus Inhalation Powder 100/50 microgram (mcg)/dose, between 12/27/2019 and 10/5/2020, based on the number of capsules left ungiven (158) from the supplies the pharmacy delivered since 5/5/2020. Missing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 31 of 51 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 11/27/2020 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 administration of fluticasone, placed Resident 6 at increased risk of experiencing serious respiratory and heart complications. Because of the serious potential harm related to not administering physician's ordered medications to Residents 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12, who were diagnosed with serious illnesses, on 10/5/2020 at 9:50 p.m., the State Agency (the Department) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under the Code of Federal Regulations (CFR) CFR483.45 (F-755) Pharmacy Services and CFR483.45(f)(2) (F-760) Residents are free of any significant medication with a scope and severity of K (pattern - more than a limited number of residents affected by the same practice) in the presence of the administrator (ADM) and the Director of Nursing (DON). On 10/8/2020 at 12:44 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the State Agency accepted the Plan of Action (POA) and abated the Immediate Jeopardy situation, in the presence of the ADM and the DON. Cross-reference F-600, F-755, and F-842. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 3/16/2018, with diagnoses including stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is blocked by a clot), and atrial fibrillation (is a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 32 of 51 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 11/27/2020 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 complications). A review of the Census List (an account of residents activity in the facility such as, admission, discharge to hospital, and readmissions), indicated Resident 1 has remained in the facility since admission on 3/16/2018. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 7/30/2020, indicated Resident 1 was unable to understand and make decisions and required extensive assistance with dressing, eating and personal hygiene. A review of Resident 1's Physician's Orders since 4/17/2020, indicated to give Xarelto (rivaroxaban) one tablet of 20 mg daily for prevention of deep vein thrombosis (DVT, a serious condition because blood clots can loosen and lodge in the lungs) and atrial fibrillation (abnormal heart beats). A review of Pharmacy 1's dispensing history, indicated the delivery of 252 doses of Xarelto 20 mg between 11/4/2019 and 10/4/2020 (the pharmacy delivered 14 doses each delivery on:11/4, 11/15, 11/27, 12/14, 12/28/2019, 1/13, 1/24, 2/10, 2/21, 3/15, 4/8, 4/19, 5/1, 5/28, 6/27, 7/11/7/22, and 10/5/2020). A review of Resident 1's Medication Administration Record (MAR) from 11/4/2019 to 10/4/2020, indicated 321 doses of Xarelto were signed as administered to Resident 1. On 10/5/2020, at 3:20 p.m., during a concurrent observation of Nursing Station 2 Medication and interview, Licensed Vocational Nurse 1 (LVN 1) was signing residents' MARs for medications administered earlier in the day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 33 of 51 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 11/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 1 had a paper with some medications listed. LVN 1 explained the medications documented on the paper were missing or were low in stock and needed to be re-ordered. LVN 1 confirmed Resident 1's Xarelto was not in the medication cart and was not in the medication room or anywhere else in the facility. On 10/5/2020 at 6:46 p.m., during a telephone interview, the Registered Pharmacist 2 (RPH 2) stated Pharmacy 1 had records of delivering 14-day supply of Xarelto on 10/5/2020. RPH 2 stated Pharmacy 1 did not make other deliveries between 6/18/2020 and 10/4/2020. On 10/5/2020 at 8:38 p.m., during an interview, the DON stated Residents 1, 2, 3, 4, 5, and 6 had been dispensed medications only from Pharmacy 1. The facility did not use other pharmacies to obtain the Xarelto. The DON was unable to explain why Resident 1's MAR was signed indicating 321 doses were given but only 252 doses were dispensed from the pharmacy. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on 8/24/2020 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing). A review of Resident 2's MDS dated 9/16/2020 indicated the resident was able to understand and make decisions, and required one-person physical assistance with dressing, toileting, and personal hygiene. A review of Resident 2's Physician's Orders dated 8/24/2020 indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 34 of 51 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 11/27/2020 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. Advair Diskus Aerosol Powder Breath Activated 150-50 micrograms (mcg)/dose (fluticasone-salmeterol), one puff inhalation orally twice a day for COPD, rinse mouth after each use. b. Spiriva Handihaler (hand-held device) caplets 18 mcg (tiotropium bromide monohydrate), two inhalations orally once a day for COPD. On 10/5/2020 at 12:10 p.m., during an observation of Nursing Station 2 Medication Cart 1, review of the MAR, and concurrent interview, LVN 1 confirmed Resident 2's Spiriva 30 caplets (30-day supply), with an opened date 9/21/2020, had 24 doses left instead of 15 doses left. Nine doses should have been given. LVN 1 was unable to explain the discrepancy between what was documented as being given and the doses left of Spiriva. LVN 1 stated there was no Advair Diskus in the medication cart or in the facility and it needed to be reordered. The MAR between 8/25/2020 and 10/4/2020 indicated a total of 41 doses of Advair; however, at 6:46 p.m., during a telephone interview, the RPH 2 stated Pharmacy 1 had records of delivering on 8/25/2020 a 30-day supply of Advair. RPH 2 stated on 8/25/2020 and on 9/18/2020, the pharmacy delivered a 30-day supply of Spiriva on 8/25/2020. On 10/5/2020 at 1:31 p.m., during an interview, Resident 2 stated he was in the facility for several months and before his admission, he was used to take all his breathing treatment medications such as Spiriva and albuterol. Resident 2 stated he needed those breathing treatments to breathe better but the nurses were not giving them to him, and his breathing problems had not improved. On 10/5/2020 at 8:38 p.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 35 of 51 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 11/27/2020 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 DON was unable to explain why Resident 2's MAR was signed indicating medications not available were signed as given. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident on 12/27/2019 with diagnoses including malignant neoplasm of brain (brain cancer). A review of Resident 3's MDS dated 10/7/2020 indicated the resident had moderately impaired memory and decision-making and required limited assistance with eating, toileting, and personal hygiene. A review of Resident 3's Physician's Orders indicated Lovenox (enoxaparin sodium) 40 mg/0.4 milliliters (ml), inject 0.4 ml subcutaneously (under the skin) once a day for DVT prophylaxis (prevention), ordered on 9/16/2020 with an end date 10/17/2020. A review of Resident 3's MAR between 9/17/2020 and 10/4/2020 indicated a total of 18 doses of enoxaparin sodium were signed as administered. On 10/5/2020 at 12:16 p.m., during an interview, LVN 1 stated Pharmacy 1 had not sent Resident 3's Lovenox yet. LVN 1 stated she faxed the refill request. LVN 1 stated usually signs the MAR at around 3 p.m. before she leaves for the day. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 3's MAR was signed indicating 18 doses were given but none were dispensed from the pharmacy. 4. A review of Resident 4's Admission Record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 36 of 51 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 11/27/2020 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 the facility admitted the resident on 9/13/2020 with diagnoses including COPD and chronic respiratory failure (airways that carry air to your lungs become narrow and damaged). A review of the Census List indicated the resident was at an acute care hospital on 9/12/2020 and returned on 9/13/2020. A review of Resident 4's MDS dated 9/17/2020 indicated the resident was able to understand and make decisions and required supervision with bed mobility, dressing, toileting, and personal hygiene. A review of Resident 4's Physician's Orders indicated an order: a. Breo (fluticasone furoate-vilanterol) Aerosol Powder Breath activated 100-25mcg/inh one puff inhale orally once a day for COPD, rinse mouth with water after treatment and expectorate (spit out by coughing), do not swallow, ordered 9/14/2020. b. Spiriva, one capsule 18 mcg, inhale orally once a day for COPD ordered 3/6/2020. A review of Resident 4's MAR from 9/17/2020 to 10/4/2020 indicated a total of 18 doses of Breo were signed as administered. A review of Resident 4's MAR from 9/1/2020 to 10/4/2020 indicated a total of 34 doses of Spiriva were signed as administered. A review of Pharmacy 1's dispensing history, a report indicated Resident 4's Breo was dispensed for 28-day supply on 9/17/2020. Resident 4's Spiriva 5-day supply was delivered on 8/21/2020, 9/17/2020, and 9/21/2020, for a total of 15-day supply of Spiriva. On 10/5/2020 at 5:42 p.m., during a concurrent observation of the medication cart and interview, LVN 10 confirmed Resident 4's Breo FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 37 of 51 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 11/27/2020 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 had 11 doses left. LVN 10 stated if taken daily, there should be 10 left, one dose was missed. On 10/5/2020 at 6:01 p.m., during an interview, Resident 4 stated he sometimes gets his Breo inhaler and the last time he received Spiriva was about two weeks ago. Resident 4 stated he had not received Breo and Spiriva today. Resident 4 stated he must constantly remind the nurses to give his Breo and Spiriva and does not know why the nurses were not giving him his medications. Resident 4 stated he feels terrible of having to constantly ask the nurses to give his medications. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident on 5/5/2020 with diagnoses including acute respiratory failure and COPD with acute exacerbation. Resident 5 was not transferred to another healthcare facility since admission on 5/5/2020. A review of Resident 5's MDS dated 8/15/2020 indicated the resident was able to understand and make decisions and required supervision with transfers and ambulation. A review of Resident 5's Physician's Orders indicated an order dates 5/5/2020 for Spiriva capsule 18 mcg, one caplet, inhale orally once a day for bronchospasm. On 10/5/2020 at 3:34 p.m., during an observation of Nursing Station 2 Medication Cart 1 and concurrent interview, LVN 1 confirmed the following: Spiriva (box #1) with 5 caps (5-day supply), filled date 8/13/2020, with an opened date of 8/24/2020 with two caplets left. Spiriva (box #2) with 30 caps (30 day-supply), filled date 9/29/20, sealed and unopened. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 38 of 51 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 11/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 1 stated Spiriva (box #1) should have not have any caplet left and Spiriva (box #2) should have a total of 23 doses left. A review of Pharmacy 1's dispensing history indicated from 5/52020 to 9/29/2020, the pharmacy delivered a total of 95-day supply of Spiriva for Resident 5. The delivery of five-day supply of Spiriva were on the following dates: 5/5, 5/11, 5/25, 6/2, 6/6, 6/12, 6/29, 7/7, 7/13, 7/18, 7/21, 8/5, 8/13. On 9/29, a 30-day supply was delivered. On 10/7/2020 at 12 p.m., during a concurrent interview and a review of Resident 5's 10/2020 MAR, LVN 2 confirmed she signed the MAR for the administration of Spiriva from 10/1/2020 and 10/5/2020. On 10/29/2020 at 3:29 p.m., during a concurrent interview and review of Resident 5's 10/2020 MAR, LVN 6 confirmed she initialed and signed as giving Spiriva to Resident 5 from 5/5/2020 to 10/5/2020, a total of 151 doses, 57 caplets over the amount the pharmacy delivered. 6. A review of Resident 6's Admission Record indicated the facility re-admitted the resident on 8/31/2012, with diagnoses including COPD. Resident 6 remained in the facility since readmission on 8/31/2012. A review of Resident 6's MDS, dated 8/26/2020, indicated Resident 6 was able to understand and make decisions and required total care. A review of Resident 6's Physician's Order dated 12/27/2019, indicated Advair Diskus Aerosol Powder Breath Activated 100-50 mcg/dose (fluticasone-salmeterol) one puff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 39 of 51 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 11/27/2020 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 inhale orally once a day for difficulty breathing related to COPD. On 10/5/2020 at 3:25 p.m., during an observation of Nursing Station 2 Medication Cart 2 and concurrent interview, the following was observed for Resident 6: a. Fluticasone Propionate/Salmeterol Diskus Inhalation Powder 100/50 mcg/dose filled date (and in almost all cases delivery date to facility from pharmacy) 8/6/2020, with an unopened package of one inhaler device). b. Advair Diskus filled date 6/30/2020, with the number "15" on the meter counter, meaning that there are 15 doses left out of 60 doses). A review of Resident 6's pharmacy dispensing history indicated Pharmacy 1 delivered the medication: a. Fluticasone/Salmeterol 100/50 mcg/dose 60 doses on 11/02/2019, 12/19/2019, 3/3/2020, 6/30/2020 with 15 doses left (in the medication cart), and 8/6/2020 unopened and in the medication cart. A total of 300 doses (75 not used) b. Advair Diskus 100/50 mcg/dose a total of 125 doses between the dates, 12/27/2019 and 10/5/2020. A review of Resident 6's MAR from 12/27/2019 to 10/5/2020 indicated a total of 283 doses of Advair Diskus were signed as administered but the pharmacy delivered 125 doses. On 10/7/2020 at 3:30 p.m., during an interview the DON, stated she was investigating the discrepancies in the medications from what is documented to what is physically present after delivery from the pharmacy. On 10/8/20 at 10:54 a.m., during an interview with the Medical Director (MD), who was also Resident 1's physician, MD stated if the nurses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 40 of 51 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 11/27/2020 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 did not administer blood thinners for Resident 1 and 3, and breathing treatments for Resident 2, 4, 5, 6 as ordered, the residents' condition could worsen. A review of the facility's policy on Preparation and General Guidelines, approved on 10/8/2019, indicated the charge nurse is notified if supplies are inadequate or equipment fails to work properly. The charge nurse reports equipment and supply deficiencies to the DON. A review of the facility's policy on Medication Orders, indicated "The prescriber is contacted for direction when delivery of a medication will be delayed, or the medication is not or will not be available. Documentation of the medication order number one each medication order is documented in the residence medical record with the date, time, and signature of the persons receiving the order. The order is recorded on the position order sheet or the telephone order sheet if it is a verbal order, and on the MAR or Treatment Administration Record (TAR)." G. Receiving medications from the Pharmacy: 1) A licensed nurse: a. Receives medications delivered to the facility and documents that the delivery was received and was secure (on the medication delivery receipt) r. Verifies medications received and directions for use with a medication order form. s. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse or supervisor. t. Immediately delivers the medications to the appropriate secure storage area (or a designee under the direct supervision of the license nurse). u. Assures medications are incorporated into the resident specific allocation prior to the next medication pass. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 41 of 51 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 11/27/2020 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 Document titled "Anticoagulation Therapy Management", indicated that it is the policy of this facility to ensure that anticoagulants are given as ordered and monitored as ordered by physicians. 1. Document the administration of medication on the resident's medication sheets. 2. Indicate any communication with physician and responsible party on the nurse's progress notes.

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

F842 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 42 of 51 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 11/27/2020 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 with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (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 observation, interview, and record review, the facility failed to keep medical records in accordance with accepted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 43 of 51 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 11/27/2020 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 professional standards and facility's policy and procedures to ensure records are accurately documented for six of six residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Document accurately the administration of Resident 1's rivaroxaban (Xarelto, an anticoagulant medication to prevent blood clots from forming). The pharmacy delivered a total of 252 doses of Xarelto between 11/4/19 and 10/4/2020 but the licensed nurses documented giving a total of 321 doses during the same time period. A total of 69 doses of Xarelto not given were documented as given. 2.a. Document accurately the administration of Resident 2's Advair (fluticasone-salmeterol, a purple circular inhaler device that administers medication to a resident to aide in breathing). A total of 11 doses were documented as administered between 8/25/ and 10/4/2020 when the pharmacy did not refill the medication. 2.b. Document accurately the administration of Resident 2's Spiriva (tiotropium Bromide, a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs). A total of nine (9) doses were documented as administered, when the Spiriva box with 30-day supply opened on 9/21/2020, had 24 doses left instead of 15. 3. Document accurately the administration of Resident 3's Lovenox (enoxaparin, a blood thinner) between 9/17/2020 and 10/4/2020. A total of 18 doses of Lovenox that were not delivered by the pharmacy, were documented as given to Resident 3. 4. Document accurately the administration of Resident 4's Spiriva. A total of 24 doses of Spiriva were documented as given to Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 44 of 51 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 11/27/2020 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 between 8/21/2020 and 10/4/2020 when the pharmacy did not deliver the medication. 5. Document accurately the administration of Resident 5's Spiriva. Between 5/6/2020 and 10/4/2020, 57 doses of Spiriva were documented as given but were left in the box. 6. Document accurately the administration of Resident 6's fluticasone propionate/salmeterol Diskus Inhalation Powder between 12/27/2019 and 10/5/2020. A total of 158 doses of fluticasone propionate/salmeterol Diskus Inhalation Powder were documented as administered to Resident 6, but were still left unused. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 3/16/2018, with diagnoses including stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is blocked by a clot), and atrial fibrillation (is a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications). A review of Resident 1's Physician's Orders since 4/17/2019, indicated to give daily Xarelto (rivaroxaban) tablet 20 mg for prevention of deep vein thrombosis (DVT, a serious condition because blood clots can loosen and lodge in the lungs) and atrial fibrillation (irregular heart beats). A review of the pharmacy's history Report indicated Pharmacy 1 delivered 252 doses of Xarelto 20 mg between 11/4/2019 and 10/4/2020 (the pharmacy delivered 14 doses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 45 of 51 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 11/27/2020 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 each delivery on:11/4, 11/15, 11/27, 12/14, 12/28/2019, 1/13, 1/24, 2/10, 2/21, 3/15, 4/8, 4/19, 5/1, 5/28, 6/27, 7/11/7/22, and 10/5/2020). A review of Resident 1's Medication Administration Record (MAR) from 11/4/2019 to 10/4/2020, indicated 321 doses of Xarelto were signed as administered to Resident 1. On 10/5/2020, at 3:20 p.m., during a concurrent observation of Nursing Station 2 Medication and interview, Licensed Vocational Nurse 1 (LVN 1) was signing residents' MAR for medications administered earlier in the day. LVN 1 confirmed Resident 1's Xarelto was not in the medication cart and was not in the medication room or anywhere else in the facility. On 10/5/2020 at 6:46 p.m., during a telephone interview, the RPH 2 stated Pharmacy 1 had records of delivering a 14-day supply of Xarelto on 10/5/2020. RPH 2 stated there were no other deliveries between 6/18/2020 and 10/4/2020. On 10/5/2020 at 8:38 p.m., during an interview, the DON stated Residents 1, 2, 3, 4, 5, and 6 had been dispensed medications only from Pharmacy 1. The facility did not use other pharmacies to obtain the Xarelto. The DON was unable to explain why Resident 1's MAR was signed indicating 321 doses were given but only 252 doses were dispensed from the pharmacy. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on 8/24/2020 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, lung disease characterized by chronic obstruction of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 46 of 51 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 11/27/2020 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 lung airflow that interferes with normal breathing). A review of Resident 2's Physician's Orders dated 8/24/2020 indicated: a. Advair Diskus Aerosol Powder Breath Activated 150-50 micrograms (mcg)/dose (fluticasone-salmeterol), one puff inhalation orally twice a day for COPD, rinse mouth after each use. b. Spiriva Handihaler (hand-held device) Capsule 18 mcg (tiotropium bromide monohydrate), two inhalations orally once a day for COPD. On 10/5/2020 at 12:10 p.m., during an observation of Nursing Station 2 Medication Cart 1, review of the MAR, and concurrent interview, LVN 1 confirmed Resident 2's Spiriva 30 caplets (30-day supply), with an opened date 9/21/2020, had 24 doses left instead of 15 doses left. Nine (9) doses should have been given. LVN 1 was unable to explain the discrepancy between what was documented as being given and the doses left of Spiriva. LVN 1 stated there was no Advair Diskus in the medication cart or in the facility and it needed to be reordered. The MAR between 8/25/2020 and 10/4/2020 indicated a total of 41 doses of Advair; however, at 6:46 p.m., during a telephone interview, the RPH 2 stated Pharmacy 1 had records of delivering on 8/25/2020 a 30-day supply of Advair. RPH 2 stated on 8/25/2020 and on 9/18/2020, the pharmacy delivered a 30-day supply of Spiriva on 8/25/2020. On 10/5/2020 at 1:31 p.m., during an interview, Resident 2 stated he was in the facility for several months and before his admission, he was used to take all his breathing treatment medications such as Spiriva and albuterol. Resident 2 stated he needed those breathing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 47 of 51 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 11/27/2020 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 treatments to breathe better but the nurses were not giving them to him, and his breathing problems had not improved. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 2's MAR was signed indicating medications not available were signed as given. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident on 12/27/2019 with diagnoses including malignant neoplasm of brain (brain cancer). A review of Resident 3's Physician's Orders indicated an order for Lovenox (enoxaparin sodium) 40 mg/0.4 milliliters (ml), inject 0.4 ml subcutaneously (under the skin) once a day for DVT prophylaxis, ordered on 9/16/2020 with an end date 10/17/2020. A review of Resident 3's MAR between 9/17 and 10/4/2020 indicated a total of 18 doses of enoxaparin sodium were signed as administered. On 10/5/2020 at 12:16 p.m., during an interview, LVN 1 stated Pharmacy 1 had not sent Resident 3's Lovenox yet. LVN 1 stated she faxed the refill request. LVN 1 stated usually signs the MAR at around 3 p.m. before she leaves for the day. On 10/5/2020 at 8:38 p.m., during an interview, the DON was unable to explain why Resident 3's MAR was signed indicating 18 doses were given but none were dispensed from the pharmacy. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 48 of 51 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 11/27/2020 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 9/13/2020 with diagnoses including COPD and chronic respiratory failure (airways that carry air to your lungs become narrow and damaged). A review of Resident 4's Physician's Orders indicated Spiriva, one capsule 18 mcg, inhale orally once a day for COPD ordered 3/6/2020. A review of Resident 4's MAR from 9/1/2020 to 10/4/2020 indicated a total of 34 doses of Spiriva were signed as administered but according to Pharmacy 1's dispensing history indicated a total of 15-day supply of Spiriva was delivered between 8/21/2020 and 9/21/2020. On 10/5/2020 at 6:01 p.m., during an interview, Resident 4 stated the last time he received Spiriva was about two weeks ago. Resident 4 stated he had not received Spiriva today. Resident 4 stated he must constantly remind the nurses to give his Spiriva and does not know why the nurses were not giving him his medications. Resident 4 stated he feels terrible of having to constantly ask the nurses to give his medications. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident on 5/5/2020 with diagnoses including acute respiratory failure and COPD. A review of Resident 5's Physician's Orders dated 5/5/2020 for Spiriva capsule 18 mcg, one caplet, inhale orally once a day for bronchospasm. On 10/5/2020 at 3:34 p.m., during an observation of Nursing Station 2 Medication Cart 1 and concurrent interview, LVN 1 confirmed the following: Spiriva (box #1) with 5 caps (5-day supply), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 49 of 51 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 11/27/2020 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 filled date 8/13/2020, with an opened date of 8/24/2020 with two caplets left. Spiriva (box #2) with 30 caps (30 day-supply), filled date 9/29/20, sealed and unopened. LVN 1 stated Spiriva (box #1) should have not have any caplet left and Spiriva (box #2) should have a total of 23 doses left. A review of Pharmacy 1's dispensing history indicated that from 5/52020 to 9/29/2020, the pharmacy delivered for Resident 5 a total of 95day supply of Spiriva. The delivery of five-day supply of Spiriva were on the following dates: 5/5, 5/11, 5/25, 6/2, 6/6, 6/12, 6/29, 7/7, 7/13, 7/18, 7/21, 8/5, 8/13. On 9/29, a 30-day supply was delivered. On 10/7/2020 at 12 p.m., during a concurrent interview and a review of Resident 5's 10/2020 MAR, LVN 2 confirmed she signed the MAR for the administration of Spiriva from 10/1/2020 and 10/5/2020. On 10/29/2020 at 3:29 p.m., during a concurrent interview and review of Resident 5's 10/2020 MAR, LVN 6 confirmed she initialed and signed as giving Spiriva to Resident 5 from 5/5/2020 to 10/5/2020, a total of 151 doses, 57 caplets over the amount the pharmacy delivered. 6. A review of Resident 6's Admission Record indicated the facility re-admitted the resident on 8/31/2012, with diagnoses including COPD. A review of Resident 6's Physician's Order dated 12/27/2019, indicated Advair Diskus Aerosol Powder Breath Activated 100-50 mcg/dose (fluticasone-salmeterol) one puff inhale orally once a day for difficulty breathing related to COPD. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 50 of 51 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 11/27/2020 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 10/5/2020 at 3:25 p.m., during an observation of Nursing Station 2 Medication Cart 2 and concurrent interview, the following was observed for Resident 6: a. Fluticasone Propionate/Salmeterol Diskus Inhalation Powder 100/50 mcg/dose filled date (and in almost all cases delivery date to facility from pharmacy) 8/6/2020, with an unopened package of one inhaler device). b. Advair Diskus filled date 6/30/2020, with the number "15" on the meter counter, meaning that there are 15 doses left out of 60 doses). A review of Resident 6's pharmacy dispensing history indicated Pharmacy 1 delivered the medication: a. Fluticasone/Salmeterol 100/50 mcg/dose 60 doses on 11/02/2019, 12/19/2019, 3/3/2020, 6/30/2020 with 15 doses left (in the medication cart), and 8/6/2020 unopened and in the medication cart. A total of 300 doses (75 not used) b. Advair Diskus 100/50 mcg/dose a total of 125 doses between the dates, 12/27/2019 and 10/5/2020. A review of Resident 6's MAR from 12/27/2019 to 10/5/2020 indicated a total of 283 doses of Advair Diskus were signed as administered but the pharmacy delivered 125 doses. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J1LF11 Facility ID: CA92000011 If continuation sheet 51 of 51