MacLay Healthcare: Resident Stabbed in Smoking Patio - CA

The March 16 incident at MacLay Healthcare Center left one resident with a three-centimeter laceration on his left thumb and abrasions on both knees after he tried to take a knife away from another resident who pointed it at his face. Video surveillance captured the entire attack, but the weapon has never been found despite facility-wide searches.

Resident 1, who has dementia and schizophrenia and uses a wheelchair, entered the East Smoking Patio at 8:22 a.m. Resident 2, who has schizophrenia and anxiety disorder and also uses a wheelchair, followed two minutes later. Both residents were supposed to be supervised while smoking, according to facility policy.

The confrontation began at 8:26 a.m. when Resident 1 stood up from his wheelchair and walked toward Resident 2. They exchanged words, and Resident 2 attempted to slap Resident 1's hand while Resident 1 pointed at him. At 8:29 a.m., Resident 2 pointed a knife toward Resident 1's face. Thirty-four seconds later, Resident 1 fell to the ground after trying to take the knife away.

Registered Nurse 1 had opened the smoking patio door for an unspecified resident and left it open, allowing both men to enter without staff supervision. He remained at the nursing station during the attack.

Resident 1 approached the nursing station at 8:40 a.m. with blood streaming from his left thumb. He told RN 1 that Resident 2 had cut him while he was trying to take a knife away. RN 1 immediately went to the smoking patio and found Resident 2 about to enter the facility, but saw no knife.

"The guy is waving his knife and I tried to seize it," Resident 1 told RN 1, according to inspection records.

When inspectors interviewed Resident 1 two days later, his left thumb was covered in foam dressing. "He has no respect for anybody, he can't talk like that," Resident 1 said about Resident 2, describing him as disrespectful and using inappropriate words.

RN 1 questioned Resident 2 about having a knife, but Resident 2 denied possession. RN 1 did not search him because of the denial. A body assessment revealed an abrasion on Resident 2's left hand and wrist. Paramedics transferred both residents to separate hospitals for evaluation.

The facility's smoking schedule allows residents to smoke only during specific 30-minute windows five times daily on weekends. Both residents were smoking outside scheduled hours. Resident 1's care plan noted he was "non-compliant with the smoking policy" and had previously been found in the smoking patio during non-smoking times, turning ashtrays upside down to retrieve cigarette butts to chew. His care plan specified he "will not smoke without supervision."

Resident 2's care plan also documented non-compliance with smoking policies and noted he was "at risk for injury from unsafe smoking practices." The plan stated his "risk to smoke without supervision will be minimized" and he would be "monitored for any unsafe smoking practices."

Despite extensive searches, the knife remains missing. Staff searched Resident 2's room, including trash cans, drawers, closets, shoes, under mattresses, and the bathroom. Housekeeping and laundry employees searched trash carts and the laundry area. Department heads searched all residents' rooms and belongings. Maintenance searched the rooftop.

Police arrived at the facility around 11:30 a.m. on March 16 and requested video surveillance footage, but the administrator could not provide it immediately. The footage was delivered to police the next day. On March 18, four officers returned to arrest Resident 2.

The administrator acknowledged the investigation was not thorough and said she should have requested surveillance videos from all cameras to track both residents' movements after the incident. The facility's new administrator, who started in December 2024, had not been given access to review surveillance footage until March 22.

Activity Staff 1 told inspectors that residents smoking in the patio are supposed to be supervised because they occasionally pick up cigarette butts from the floor and try to chew them. She was sitting in the hallway near the smoking patio with doors closed during supervised smoking sessions, but said the entire patio is not visible from behind the doors.

"All residents smoking in the patio should be supervised to prevent resident injury," she told inspectors.

RN 1 acknowledged to inspectors that both residents should have been supervised while smoking and that the physical abuse incident could have been prevented with proper supervision.

The Director of Nursing admitted the facility failed to provide supervision, which led to the altercation and injury. She confirmed there is a possibility the knife is still in the facility or in possession of another resident.

Resident 1's care plan documented a history of physical abuse with another resident, though the name was not specified. He had received a verbal warning in January 2024 for non-compliance with smoking policies.

Resident 2 was diagnosed with psychotic disorder in September 2024, with episodes of delusions and hallucinations documented in his psychiatric evaluation. His personal effects inventory from July 2024 did not list a knife among his belongings.

The facility's abuse prevention policy requires staff to "separate the assailant from the victim" and "isolate the assailant to protect others" when abuse occurs. The smoking policy mandates that "any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking."

Federal inspectors declared an immediate jeopardy situation on March 19, citing the facility's failure to provide supervision that resulted in serious injury. The facility submitted an acceptable removal plan on March 22, and the immediate jeopardy was lifted that evening.

The removal plan included providing one-on-one sitters for both residents, conducting safety checks of all resident rooms for weapons, implementing new supervision protocols for the smoking patio, and posting "No Weapons Allowed" signs throughout the facility. Staff received abuse prevention training, and the facility initiated a new firearms and weapons policy.

Resident 1 returned from the hospital at 9:05 p.m. on March 16 with eight stitches in his thumb laceration. He was monitored for 72 hours for fall complications and emotional distress. A psychiatrist visited him on March 17, and a psychologist saw him on March 19. Social services staff conducted daily wellness visits through March 19.

Resident 2 was readmitted from the psychiatric hospital at 2 a.m. on March 17 with a one-on-one sitter assigned to monitor his aggressive behavior. Police arrested him the following afternoon.

The facility also failed to conduct proper mental health screenings for Resident 2. His admission screening in July 2024 indicated he did not have serious mental diagnoses and did not require specialized mental health evaluation, despite documented diagnoses of schizophrenia, anxiety disorder, depression, and psychosis in his medical records.

Additional violations included physicians failing to conduct required monthly visits for three residents and medical records lacking proper signatures and documentation. Some forms contained nurse practitioner signatures on blank consent forms and worksheets, creating potential for inappropriate care decisions.

The administrator stated there was physical abuse and that Resident 2 "willfully acted on injuring Resident 1." The incident could have been prevented if staff had supervised both residents and immediately separated them when the verbal altercation began, she acknowledged.

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

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