Maclay Healthcare Center
MACLAY HEALTHCARE CENTER in SYLMAR, CA — inspection on April 29, 2026.
Found 4 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
indicated all residents will receive timely, comprehensive, and ongoing nursing assessments to
nursing assessments must be communicated to the Interdisciplinary Team (IDT), reflected in the care
555583 04/29/2026
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
During an interview on 4/29/2026 at 1:26 p.m. and a concurrent record review of Resident 1's Fall Risk Evaluation, dated 2/26/2026, with the Director of Nursing (DON), the DON stated Resident 1 had a total score of ten representing high risk for falls.
The DON stated Resident 1 had history of multiple falls.
The DON stated the Fall Risk Evaluation indicated Resident 1 had no falls in the past 90 days, the Gait Evaluation section was not completed and indicated there was no drop in orthostatic blood pressure between lying and standing.
The DON stated there was no documented evidence of Resident 1's orthostatic blood pressure was taken.
The Diagnosis Review section indicated Resident 1 had one to two present diseases and diagnoses that could contribute to falls.
The DON stated Resident 1 had more than two diseases and diagnoses that could contribute to falls.
The DON stated failure to accurately evaluate Resident 1's risk for falls could cause inadequate interventions required to prevent falls and injuries.
The DON stated there was no documented evidence of monitoring on the identified shifts and Resident 1's orthostatic blood pressures.
The DON stated care not documented was considered not provided.
The DON stated failure to monitor Resident 1 every shift after a COC could result to the resident's missed signs of orthostatic hypotension that could lead to falls and injury.
The DON stated the facility failed to identify, document, and monitor Resident 1's risk for falls.
The DON further stated the facility failed to follow the physician orders to monitor Resident 1 for orthostatic hypotension.
During a review of the facility's policy and procedures (PnP) titled, Nursing Assessment, last reviewed on 4/16/2026, the PnP indicated all residents will receive timely, comprehensive, and ongoing nursing assessments to identify clinical needs, detect changes in condition, and ensure appropriate interventions are implemented in accordance with physician orders and professional standards.
The PnP indicated the purpose to ensure early detection of changes in condition, timely intervention and physician notification, prevention of avoidable decline, accurate and complete clinical documentation.
During a review of the facility's PnP titled, Orthostatic Blood Pressure Monitoring, last reviewed on 4/16/2026, the PnP indicated the purpose is to identify and manage residents at risk for orthostatic hypotension to prevent falls and injury.
The PnP indicated the facility will monitor orthostatic blood pressure (BP) for residents at risk and ensure timely intervention, documentation, and physician notification.
During a review of the facility's PnP titled, Change in Condition, last reviewed on 4/16/2026, the PnP indicated, the facility will promptly recognize, assess, and respond to any changes in a resident's physical, cognitive, or emotional condition to ensure timely medical intervention and maintain resident safety.
The Follow-up section indicated to monitor the resident until the condition stabilizes and adjust care plans and interventions as recommended by physician or Interdisciplinary Team (IDT).
555583 04/29/2026
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
implemented by the Interdisciplinary Team (IDT) that reflects the resident's needs, preferences,
555583 04/29/2026
MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342
document the residents' (Residents 1, 2, and 3) amount of meal intake after the residents (Residents
changes.
The DON further stated the documentation in the resident's medical records should indicate
residents' (Residents 1, 2, and 3) medical records were complete and accurate.During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation Policy, last reviewed on 4/16/2026, the PnP indicated all resident care, assessments, medications, treatments, and changes in condition must be documented in the medical record promptly, accurately, and according to facility and regulatory requirements.
The PnP indicated to document care at the time it is provided of immediately afterward, use clear, legible, and factual entries.
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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.