Maclay Healthcare: Racial Slur, Cover-Up - CA
The incident unfolded on August 23 at 6:30 a.m. when Resident 1 activated his call light at Maclay Healthcare Center. CNA 1 responded, but the resident requested a different nursing assistant handle his care.
Instead of leaving, CNA 1 stayed in the room and yelled a "derogatory and racial insult" at the resident, according to inspection records from the California Department of Public Health.
Resident 2, who witnessed the exchange, told state investigators that CNA 1 "should have walked away and called the RN, instead of staying in the room and yelling out obscenities at Resident 1."
The resident immediately called RN 1 to report what happened. But the supervising nurse made a decision that would violate federal abuse reporting requirements and the facility's own policies.
She did nothing.
For three days, RN 1 kept the racial abuse allegation to herself. When state investigators interviewed her on August 28, she admitted knowing about the incident since it occurred but said she "did not report this verbal abuse allegation to anyone because she did not think anything of it."
The nurse's failure to act directly violated Maclay Healthcare's written abuse policy, which requires all alleged violations involving abuse to be reported "immediately, but not later than two hours."
RN 1 eventually acknowledged her mistake to investigators. She "stated she realized this was verbal abuse and should have reported to the abuse coordinator within two hours," according to the inspection report. She told investigators she "was very sorry for not reporting the verbal abuse right away."
But the resident wasn't waiting for an apology.
On August 26, Resident 1 took his complaint directly to facility administrators. He told the administrator and Director of Social Services exactly what had happened three days earlier when CNA 1 responded to his call light.
The administrator was shocked to learn that RN 1 had known about the incident since August 23 but never reported it. "The ADMIN stated she did not know Resident 1 had reported this to RN 1 on 8/23/2025," investigators documented.
When confronted with the cover-up, facility leadership took immediate action. The administrator and Director of Nurses told investigators that "the facility has no tolerance for any abuse and RN 1 should have reported this right away."
Both employees were terminated effective immediately.
The facility finally reported the incident to state survey agencies on August 26, three days after it occurred and only after the resident bypassed the nurse who had buried his complaint.
The delay meant state investigators didn't learn about the racial abuse until nearly 72 hours after it happened, despite federal regulations requiring immediate notification of abuse allegations in nursing homes.
Maclay Healthcare's own policy, revised in July 2027, explicitly states that "all alleged violations involving abuse will be reported immediately, but not later than two hours" to state licensing agencies responsible for surveying the facility.
The policy leaves no room for interpretation about what constitutes reportable abuse or who bears responsibility for reporting it. All reports of resident abuse "shall be promptly reported to local, state and federal agencies," the policy states.
RN 1's decision to sit on the racial abuse allegation for three days represented a fundamental breakdown in the facility's resident protection system. Her admission that she "didn't think anything of it" when a resident reported being subjected to racial slurs raises questions about staff training and cultural competency at the 240-bed facility.
The incident also highlights how nursing home abuse can be compounded when supervisory staff fail to follow mandatory reporting protocols. Had RN 1 reported the incident within two hours as required, state investigators could have begun their review immediately rather than learning about it only when the resident escalated his complaint.
Resident 2's eyewitness account proved crucial in establishing what actually happened in the room that morning. The witness told investigators that CNA 1 should have simply left when the resident requested different care, rather than staying to berate him with racial epithets.
The timing of the incident, occurring during the early morning shift change at 6:30 a.m., suggests the abuse happened during one of the busiest periods in nursing home operations. But facility policies make clear that workload pressures never excuse abusive behavior toward residents.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the racial nature of the abuse and the three-day reporting delay reveal systemic problems in how Maclay Healthcare protects vulnerable residents from mistreatment.
The administrator's statement that the facility "has no tolerance for any abuse" was undermined by the fact that a supervising nurse felt comfortable ignoring a racial abuse complaint for three days without consequence, until the resident himself forced the issue.
The case demonstrates how nursing home residents often must advocate for themselves when staff fail to follow basic protection protocols. Resident 1's persistence in reporting the abuse to multiple facility officials ultimately led to the termination of both employees involved.
But his experience raises troubling questions about how many other abuse incidents might go unreported when residents don't have the capacity or determination to keep pushing for accountability.
The facility's abuse policy, updated just two months before the incident, proved worthless when the very staff members responsible for implementing it chose to ignore clear reporting requirements.
Resident 1 remains at the facility where a nursing assistant called him a racial slur and a supervising nurse thought it wasn't worth reporting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maclay Healthcare Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
MACLAY HEALTHCARE CENTER in SYLMAR, CA was cited for violations during a health inspection on August 28, 2025.
The incident unfolded on August 23 at 6:30 a.m.
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.