MacLay Healthcare: Racial Slur, Cover-Up Exposed - CA
The incident occurred at MacLay Healthcare Center on August 23 at 6:30 a.m. when Resident 1 pressed his call light. CNA 1 responded to the call, and the resident requested that a different nursing assistant help change him instead.
CNA 1 responded by yelling obscenities and "a derogatory and racial insult" at the resident, according to federal inspection records. The resident's roommate witnessed the entire exchange.
"CNA 1 should have walked away and called the RN, instead of staying in the room and yelling out obscenities," Resident 2 told inspectors on August 28.
The resident immediately called RN Supervisor 1 on his cell phone from his room, asking her to come help him. He reported that CNA 1 had used obscenities and a racial slur against him.
The supervisor came to the room but made a decision that would extend the resident's exposure to potential retaliation for three more days.
"RN 1 stated she did not report this verbal abuse allegation to anyone because she did not think anything of it," inspectors wrote.
Federal regulations require nursing homes to report suspected abuse to designated coordinators within two hours. The supervisor knew this requirement existed.
"RN 1 stated she realized this was verbal abuse and should have reported to the abuse coordinator within two hours," according to the inspection report. "RN 1 stated she was very sorry for not reporting the verbal abuse right away."
The facility's administration learned about the incident only when the resident reported it directly to the administrator and director of social services three days later on August 26.
"The ADMIN stated she did not know Resident 1 had reported this to RN 1 on 8/23/2025," inspectors documented.
Both the administrator and director of nurses told inspectors that "the facility has no tolerance for any abuse and RN 1 should have reported this right away."
The facility reported the incident to state survey officials on August 26, the same day administrators learned of it from the resident's direct complaint.
By the time federal inspectors arrived on August 28 to investigate, facility leadership had made their decision about consequences.
"The ADMIN stated that CNA 1 and RN 1 will be terminated effective immediately," the inspection report states.
The case illustrates how reporting failures can compound the original abuse. While CNA 1's verbal assault lasted minutes, the supervisor's decision not to report it meant the resident remained in potential danger from retaliation for 72 additional hours.
The resident who witnessed the incident understood immediately what should have happened. He told inspectors that CNA 1 should have simply walked away and contacted the supervising nurse rather than remaining in the room to berate his roommate.
Instead, when the supervising nurse did arrive, she failed to recognize verbal abuse that included racial slurs as reportable misconduct.
The facility's own policies contradicted the supervisor's inaction. MacLay Healthcare Center's abuse prevention procedures, dated April 2021, explicitly state that "Residents have the right to be free from abuse. This includes but is not limited to verbal abuse."
The inspection found the facility violated federal regulations requiring residents to be free from abuse and neglect. Inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
However, the classification system doesn't capture the specific impact on Resident 1, who experienced both the original verbal assault and three additional days of potential vulnerability while the incident remained unreported through official channels.
The roommate's account provided crucial corroboration for the resident's complaint. Without Resident 2's testimony, the incident might have remained a he-said-she-said dispute between the resident and nursing assistant.
The supervisor's explanation to inspectors revealed a troubling gap in recognizing abuse. Her statement that she "did not think anything of it" when a resident reported being subjected to racial slurs and obscenities suggests either inadequate training or willful disregard for resident protection requirements.
Federal inspectors completed their investigation on August 28, five days after the original incident and two days after the facility's internal investigation began.
The terminations of both employees represented the facility's attempt to demonstrate zero tolerance for abuse, but the delayed reporting meant Resident 1 remained potentially exposed to retaliation during the three-day gap between the incident and official reporting.
MacLay Healthcare Center operates at 12831 MacLay Street in Sylmar, serving residents who depend on staff for basic care needs including personal hygiene assistance. The facility's abuse prevention policies acknowledge that verbal abuse violates residents' fundamental rights, making the supervisor's failure to report particularly significant.
The case demonstrates how quickly abuse incidents can escalate from individual misconduct to systemic failures when proper reporting protocols aren't followed. What began as one nursing assistant's verbal assault became a facility-wide compliance violation due to supervisory inaction.
Resident 1's decision to use his personal cell phone to immediately contact the supervisor showed his understanding of proper escalation procedures. His subsequent direct report to administration three days later ultimately triggered the official investigation that the supervisor should have initiated within two hours of the original incident.
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 20, 2026 · Our methodology
MACLAY HEALTHCARE CENTER in SYLMAR, CA was cited for violations during a health inspection on August 28, 2025.
The incident occurred at MacLay Healthcare Center 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.