Maclay Healthcare Center: PASRR Screening Failure - CA
Inspectors with the Centers for Medicare and Medicaid Services visited the facility at 12831 MacLay Street on March 22, 2025, and documented the lapse for a resident identified in the report only as Resident 2. The resident had shown signs of delusions, which inspectors defined as false or unrealistic beliefs, and hallucinations, sensory experiences that feel real but have no external cause. Those symptoms should have triggered a Level I Pre-Admission Screening and Resident Review, known as a PASRR, under the facility's own written procedures.
Nobody completed it.
PASRR screenings exist to connect nursing home residents who have mental illness or intellectual disabilities to the specialized services and behavioral interventions they may need. A Level I screen is the first step, a determination of whether a resident's psychiatric condition warrants closer evaluation. When a resident's psychiatric diagnosis changes, or when there is a gap between what a PASRR previously documented and what a physician or psychiatrist later finds, the facility's policy, dated September 26, 2023, called for a new screening to be done.
The MDS Specialist at the facility, when interviewed by inspectors, acknowledged the screening should have been completed for Resident 2. The Director of Nursing said the same thing.
She went further. The Director of Nursing told inspectors that the facility's failure to complete the screening "could potentially cause delay in provision of necessary care to Resident 2." That acknowledgment came from the facility's own leadership, not from an outside evaluator or a federal finding imposed over staff objection.
CMS rated the harm level as minimal, with potential for actual harm affecting a small number of residents. That classification reflects the agency's tiered system for deficiency severity, but it does not mean the resident received the interventions the screening was designed to identify. Whether Resident 2 ultimately received appropriate behavioral support, the inspection report does not say.
What the report does say is that the PASRR process carries real consequences when skipped. The screenings are designed to catch residents whose psychiatric needs exceed what a standard nursing facility can provide, and to route them toward the right level of care. A resident experiencing delusions and hallucinations who never gets screened may wait longer for psychiatric follow-up, may not receive targeted behavioral interventions, and may spend days or weeks in a facility that has not formally assessed whether it is equipped to meet their needs.
Maclay Healthcare Center is a licensed skilled nursing facility in the Sylmar neighborhood of Los Angeles. The inspection that turned up this deficiency was completed March 22, 2025, and the report was printed in August 2026.
The facility's own policy was clear. A status change, including a change in psychiatric diagnoses or a discrepancy between what the PASRR previously recorded and what the attending physician or psychiatrist later documented, required a new Level I screen. Inspectors found that discrepancy existed for Resident 2. The screen was not done.
The Director of Nursing did not dispute the finding. She confirmed it, explained its purpose, and described what the failure meant for the resident sitting in the building while the interview was taking place.
Whether Resident 2's hallucinations and delusions were ever formally evaluated under the PASRR process, whether that evaluation led to any change in their care, the inspection report is silent. The screening that was supposed to answer those questions was never started.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maclay Healthcare Center from 2025-03-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 7, 2026 · Our methodology
MACLAY HEALTHCARE CENTER in SYLMAR, CA was cited for violations during a health inspection on March 22, 2025.
Those symptoms should have triggered a Level I Pre-Admission Screening and Resident Review, known as a PASRR, under the facility's own written procedures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.