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Complaint Investigation

Maclay Healthcare Center

August 28, 2025 · Sylmar, CA · 12831 Maclay Street
Citations 2
CMS Rating 2/5
Beds 141
Provider ID 555583
Healthcare Facility
Maclay Healthcare Center
Sylmar, CA  ·  View full profile →
Inspection Summary

MACLAY HEALTHCARE CENTER in SYLMAR, CA — inspection on August 28, 2025.

Found 2 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.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

During an interview with Resident 2 on 8/28/2025 at 12:10 p.m., Resident 2 stated on 8/23/2025 at 6:30 a.m., his roommate (Resident 1) pressed the call light and CNA 1 came inside the room to answer the call light. Resident 2 stated he (Resident 2) heard Resident 1 told CNA 1 that Resident 1 wanted a different CNA to change Resident 1. Resident 2 stated he (Resident 2) heard CNA 1 yell out obscenities and a derogatory and racial insult at Resident 1. Resident 2 stated CNA 1 should have walked away and called the RN 1, instead of staying in the room and yelling out obscenities at Resident 1.

During an interview with RN 1 on 8/28/2025 at 12:30 p.m., RN 1 stated on 8/23/2025 at 6:30 a.m., Resident 1 called her because he (Resident 1) did not want CNA 1 to change him. RN 1 stated Resident 1 reported to her (RN 1) that CNA 1 called him (Resident 1) a derogatory and racial insult. RN 1 stated she (RN 1) did not report this verbal abuse allegation to anyone because she (RN 1) did not think anything of it. RN 1 stated she (RN 1) realized this was verbal abuse and should have reported to the abuse coordinator within two hours. RN 1 stated she (RN 1) was very sorry for not reporting the verbal abuse right away.

During an interview with the ADMIN and Director of Nurses (DON) on 8/28/2025 at 3:30 p.m., the ADMIN stated Resident 1 reported to her (ADMIN) and the DSD that on 8/23/2025 at 6:30 a.m., CNA 1 went to answer his (Resident 1) call light, and Resident 1 requested for a different CNA.

The ADMIN stated Resident 1 reported that CNA 1 yelled a derogatory and racial insult at him (Resident 1).

The ADMIN stated she (ADMIN) did not know Resident 1 had reported this to RN 1 on 8/23/2025.

The ADMIN and DON stated the facility has no tolerance for any abuse and RN 1 should have reported this right away (facility reported to the State Survey Agency on 8/26/2025).

The ADMIN stated that CNA 1 and RN 1 will be terminated effective immediately. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 4/2021, the policy and procedure indicated Residents have the right to be free from abuse.

This includes but is not limited to verbal abuse.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

MacLay Healthcare Center

12831 MacLay Street Sylmar, CA 91342

SUMMARY STATEMENT OF DEFICIENCIES

During an interview with RN 1 on 8/28/2025 at 12:30 p.m., RN 1 stated on 8/23/2025 at 6:30 a.m., Resident 1 called her because he (Resident 1) did not want CNA 1 to change him. RN 1 stated Resident 1 reported to her (RN 1) that CNA 1 called him (Resident 1) a derogatory and racial insult. RN 1 stated she (RN 1) did not report this verbal abuse allegation to anyone because she (RN 1) did not think anything of it. RN 1 stated she (RN 1) realized this was verbal abuse and should have reported to the abuse coordinator within two hours. RN 1 stated she (RN 1) was very sorry for not reporting the verbal abuse right away.

During an interview with the ADMIN and Director of Nurses (DON) on 8/28/2025 at 3:30 p.m., the ADMIN stated Resident 1 reported to her (ADMIN) and the DSD that on 8/23/2025 at 6:30 a.m., CNA 1 went to answer his (Resident 1) call light, and Resident 1 requested for a different CNA.

The ADMIN stated Resident 1 reported that CNA 1 yelled a derogatory and racial insult at him (Resident 1).

The ADMIN stated she (ADMIN) did not know Resident 1 had reported this to RN 1 on 8/23/2025.

The ADMIN and DON stated the facility has no tolerance for any abuse and RN 1 should have reported this right away (facility reported to the State Survey Agency on 8/26/2025).

The ADMIN stated that CNA 1 and RN 1 will be terminated effective immediately.

During a review of the facility-provided policy and procedure titled, Abuse Investigation and Reporting, revised on 7/2027, the policy and procedure indicated, All reports of resident abuse . shall be promptly reported to local, state and federal agencies (as defined by current regulations).

Reporting 1.

All alleged violations involving abuse . will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a.

The State licensing/\certification agency responsible for surveying/licensing the facility . 2.

An alleged violation of abuse . will be reported immediately, but not later than: a.

Two (2) hours if the alleged violation involves abuse.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SYLMAR, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MACLAY HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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