Maclay Healthcare Center
MACLAY HEALTHCARE CENTER in SYLMAR, CA — inspection on March 22, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a record review of Resident 10 ' s MDS, dated [DATE], the MDS indicated Resident 10 ' s
During a record review of Resident 11 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/21/2025 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness.
During a record review of Resident 11 ' s MDS, dated [DATE], the MDS indicated Resident 11 ' s cognitive skills for daily decision making was intact.
During a record review of Resident 12 ' s admission Record, the admission Record indicated the facility admitted the resident on 11/28/2023 with diagnoses including type 2 diabetes mellitus, essential hypertension, and muscle weakness.
During a record review of Resident 12 ' s MDS, dated [DATE], the MDS indicated Resident 12 ' s cognitive skills for daily decision making was moderately impaired.
During a concurrent observation and interview on 3/21/2025 at 9:04 a.m. with RN 2, observed nurse station 3 ' s computer had Resident 10, Resident 11, and Resident 12 ' s clinical records on the screen. RN 2 stated the nurse station 3 computer screen indicated the access belonged to Licensed Vocational Nurse (LVN) 4, an 11 p.m. to 7 a.m. shift nursing staff. RN 2 stated Residents 10, 11, and 12 ' s clinical information was left unattended and had the potential for unauthorized access from other facility staff that were not involved on the residents ' care, visitors, and other outside agencies.
RN 2 stated the facility failed to ensure Residents 10, 11, and 12 ' s right for privacy was protected.
During a record review of the facility ' s Policy and Procedure (PnP) titled, Electronic Medical Records, last reviewed on 4/2025, the PnP indicated only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system.
The PnP indicated the medical records system safeguards the prevent unauthorized access of electronic protected health information (e-PHI).
These safeguards included administrative, technical, and physical safeguards.
555583 03/22/2025
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices 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.
During a review of the current facility-provided policy and procedure titled, Abuse Policy, last reviewed on 4/2024, the policy and procedure indicated, Communities does not condone (accept and allow) resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including . other residents Residents have the right to be free from abuse 1.
Providing a safe environment for the resident is one of the most basic and essential duties of our facility 4.
Identification of abuse shall be the responsibility of every employee Resident abuse is defined as the willful infliction of injury, unreasonable . resulting in physical harm or pain, mental anguish Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability.
Examples of verbal abuse include, but are not limited to: threats of harm Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking . and willful neglect of the resident ' s basic needs If abuse happens: 1.
Separate the assailant from the victim. 2.
Isolate the assailant to protect others.
555583 03/22/2025
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
During a review of facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last reviewed on 4/2024, the P&P indicated, All allegations are thoroughly investigated.
The administrator initiates investigations The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation.
555583 03/22/2025
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
During a review of the current facility-provided policy and procedure (P&P) titled, Subject: PASRR, dated 9/26/23, the P&P indicated status change Level I PASRR screening should be completed for a resident if there is a change in psychiatric diagnoses or if there is a discrepancy between PASRR diagnoses and diagnoses given by the attending physician or psychiatrist.
555583 03/22/2025
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
During an interview on 3/19/2025 at 1:36 p.m. with the DON, the DON stated the facility failed to provide supervision to Resident 1 and Resident 2 on 3/16/2025 in the smoking patio, which led to a physical altercation between the two residents (Resident 1 and Resident 2) and Resident 1 sustaining an injury.
The DON stated the facility has not found the knife used by Resident 2.
The DON stated there is a possibility that the knife is still in the facility or in the possession of another resident.
During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated Resident 1 had informed the Administrator that Resident 2 was using inappropriate words towards Resident 1.
The administrator also stated the physical altercation between Resident 1 and Resident 2 could have been prevented if the two residents (Resident 1 and Resident 2) were supervised in the smoking patio.
During an interview on 3/20/2025 at 2:45 p.m. with the Administrator, the Administrator stated the knife used by Resident 2 to injure Resident 1 was not found.
The Administrator also stated body inspection was not done on Resident 2 since Resident 2 refused.
The Administrator stated there was a possibility Resident 2 ' s knife is still in the facility.
During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, last reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices 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.
During a review of the current facility-provided policy and procedure titled, Safety and Supervision of Residents, last reviewed on 4/2024, the policy and procedure indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Individualized, Resident-Centered Approach to Safety: 1.
Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents 3.
The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision Systems Approach to Safety: . 2.
Resident supervision is a core component of the systems approach to safety.
The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. 3.
The type and frequency of resident supervision may vary among residents and over time for the same resident.
For example, resident supervision may need to be increased when there are temporary hazards in the environment of if there is a change in the resident ' s condition.
555583 03/22/2025
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
During a record review of Resident 8 ' s MDS, dated [DATE], the MDS indicated Resident 8 ' s
During a record review of Resident 8 ' s H&P, dated 12/20/2024 and 3/7/2025, the H&P indicated MD 1 and NP 2 visited and assessed the resident.
There was no documented H&P or Attending Progress Note in Resident 8 ' s EHR and printed medical records for 1/2025 and 2/2025.
During an interview on 3/21/2025 at 9:04 a.m. and a concurrent record review of Resident 5, Resident 6, and Resident 8 ' s H&Ps and Attending Physician Notes, reviewed with Registered Nurse (RN) 2, RN 2 stated there were no documented evidence that Resident 8 ' s MD visited the resident on 1/2025 and 2/2025. RN 2 stated a physician ' s progress notes should be in the residents ' medical records.
RN 2 stated no documented physician progress notes indicated the MD did not assess the resident.
RN 2 stated the residents ' condition had the potential to worsen. RN 2 stated the facility failed to ensure the attending physicians visited the residents and documented the visit according to the facility ' s policy and procedure.
During an interview on 3/21/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated the physician progress notes were proof that the MD assessed the residents and verified the residents ' medications were accurate.
The DON stated the staff involved in the residents ' care had the potential to make inconsistent or inaccurate medical decisions that had the potential to cause harm to the residents.
During a record review of the facility ' s Policy and Procedure (PnP) titled, Physician Visits, last reviewed on 4/2024, the PnP indicated the attending physician must visit his/her patients at least once every 30 days for the first 90 days following the resident ' s admission and then at least every 60 days thereafter.
The policy indicated that after the first 90 days, if the attending physician determines that a resident need not be seen by him every 30 days, an alternate schedule of visits may be established, but not to exceed every 60 days. A physician assistant or NP may make alternate visits after the initial 90 days following admission.
During a record review of the facility ' s PnP titled, Attending Physician Responsibilities, last reviewed on 4/2024, the PnP indicated the Attending Physician will visit the residents in an timely The PnP indicated the MD will provide progress notes in a timely manner for placement in the medical record.
The PnP indicated the note should either be written of entered at the time of the visit or should be returned to the facility for placement on the chart within one week.
555583 03/22/2025
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
they are given and will authenticate, co-sign, and date them in a timely manner no later than the next
During a review of Resident 1 ' s Admission Record (undated), the Admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
555583
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555583 B.
Wing 03/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.