Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to inform the attending physician (MD) for one of three
sampled residents (Resident 1) when:
1. The Skilled Nursing Facility (SNF) 1, was unable to provide Speech Therapy (ST) on 5/15/2025 when MD
ordered an ST and swallow evaluation (a test done by a Speech-Language Pathologist (SLP) to figure out
why a person is having trouble swallowing).
2. Resident 1 continued to have difficulty swallowing and pocketing (the act of storing food inside the mouth
without swallowing it) after the Change in Condition (COC) on 5/15/2025.
These deficient practices resulted in Resident 1 not receiving the ST evaluation resulting in Resident 1
having a COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing
requiring transfer to General Acute Care Hospital (GACH) 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted
Resident 1 on 1/30/2024 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of
the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body,
often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain attack where
part of the brain's blood supply is blocked or severely reduced) affecting the right dominant side, dysphagia
(difficulty swallowing) oropharyngeal (anything related to the middle part of the throat), dementia (a
progressive state of decline in mental abilities), and depression (a common mental health condition that
causes persistent sadness, loss of interest in activities, and changes in how you think, feel, and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or
potential nutritional problems indicated intervention to monitor, document, and report as needed any sign
and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and to
provide and serve supplements as ordered.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the
MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1
required substantial to maximum assistance (helper does more than half the effort) with toileting,
showering, upper and lower body dressing and putting on and taking off footwear and required partial to
moderate assistance (helper does less than half the effort) with oral hygiene, and personal
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
555583
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
hygiene.
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 1's care plan created on 4/19/2025, the care plan for swallowing problem
related to holding food in mouth and cheeks with intervention to check mouth after meal for pocketing food
and debris and report to nurse, monitor, document, and report as needed any sign or symptoms of
dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow and
refusing to eat.
Residents Affected - Few
During a review of Resident 1's Physician Order Summary Report, dated 4/20/2025, the Physician Order
Summary Report indicated a physician's order for regular diet pureed texture, nectar thickened liquids
consistency, large portion protein per meal.
During a review of Resident 1's COC Evaluation, dated 5/15/2025 at 10:20 p.m., the COC Evaluation
indicated Resident 1pocketing food when eating. Family Member (FM) 1 indicated Resident 1 having
difficulty swallowing his food, Resident 1 pockets the food in his mouth. The MD was notified on 5/15/2025
at 7 p.m. with orders for speech and swallow evaluation, calorie count for seven days.
During a review of Resident 1's Physician Order Summary Report, dated 5/15/2025, the Physician Order
Summary Report indicated a physician's order for Speech and swallow evaluation in the morning.
During a review of Resident 1's care plan created on 5/16/2025, the care plan for difficulty swallowing
indicated interventions of speech and swallow eval, calorie count for seven days and to call MD for changes
in Resident 1's conditions.
During a review of Resident 1's Progress Notes dated 5/16/2025 at 2:17 p.m., the Progress Notes indicated
continued monitoring for difficulty swallowing. Resident 1 is noted with some difficulty swallowing meals.
During a review of Resident 1's Progress Notes dated 5/17/2025 at 1:26 p.m., the Progress Notes indicated
Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's Progress Notes dated 5/18/2025 at 1:23 p.m., the Progress Notes indicated
Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's COC Evaluation dated 5/24/2025 at 10:09 a.m., the COC Evaluation
indicated Resident 1 noted slowly declining in mobility, unable to feed to sit in Resident 1's wheelchair.
During a review of Resident 1's Progress Notes dated 5/24/2025 at 1:13 p.m., the Progress Notes indicated
Resident 1 was transferred to GACH 1 at 12:14 p.m. due to fever, decline in Activities of Daily Living (ADLsactivities such as bathing, dressing and toileting a person performs daily), and unable to eat, coughing and
pocketing food.
During an interview on 6/3/2025 at 12p.m. with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated on
Saturday 5/24/2025 prior to Resident 1 being discharged to GACH 1, RNA 1 attempted to feed Resident 1
pureed eggs and oatmeal and Resident 1 began to choke on the food. RNA 1 stated she reported to the
nurse not sure who the nurse was, but Resident 1 was discharged shortly after that.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 6/3/2025 at 12:31 p.m. with the Director of Rehab (DOR), the DOR stated have not
had an ST in the facility since the beginning of May. The DOR stated if a resident requires ST, we will
downgrade their diet and then send out the resident to the hospital if needed. The DOR stated last day of
ST in the building was 5/5/2025. The DOR stated Resident 1 did not get the ST eval as ordered because
the facility did not have an ST at that time. The DOR stated informed the Director of Nursing (DON), if
Resident 1 was pocketing food or having signs of choking needed to be sent out to hospital this was during
a clinical meeting with all department heads not sure of the date.
During an interview on 6/3/2025 at 12:36 p.m. with the DOR, the DOR stated Resident 1 was ordered to
have ST three times a week for four weeks but since the ST resigned Resident 1 was discharged from ST.
The DOR stated Resident 1 did not meet his goals, Resident 1 was discharged from ST because we could
not provide the ST services for Resident 1. The DOR stated is not sure if the MD was notified that Resident
1 was not able to get ST eval as ordered by MD the one to contact the MD would have been nursing.
During a concurrent interview and record review on 6/3/2025 at 1:22 p.m. of Resident 1's progress notes
with the DON, the DON stated there was no notification to MD regarding not having an ST in the building.
The DON stated based on timesheet the ST's last day was on 5/5/2025 and Resident 1 was ordered an ST
eval on 5/15/2025. The DON stated knowing that Resident 1 needed to transfer out if there was no ST
within seven days. The DON stated Resident was discharged to GACH 1 on 5/24/2025, nine days after ST
eval order, the DON stated does not think Resident 1 had a lot of pocketing of food. The DON reviewed
progress notes dated 5/16/2025 through 5/24/2025 the DON stated the progress notes indicates that
Resident 1 was still pocketing food and had difficulty swallowing. The DON stated there is a potential for
weight loss and potential for aspiration if Resident 1 is pocketing food. The DON stated not sure if nurses
notified MD that Resident 1 was continuing to pocket food. The DON stated it is not documented and
cannot say the MD was notified. The DON stated nurses should have notified MD and/or DON that
Resident 1 was continuing to pocket food. The DON stated can be a risk for resident not to be transferred in
a timely manner. The DON stated there was delay of care. The DON stated as a SNF we should be able to
provide ST, can be potential we cannot provide the right services and treatment and delay in treatment.
During a review of the facility's Policy and Procedure (P&P) titled, Specialized Rehabilitative Services, last
revised on 4/2025, the P&P indicated our facility will provide Rehabilitative Services to residents as
indicated by the MDS.
2. Specialized Rehabilitative Services include the following:
b. Speech Pathology/Audiology;
3. Therapeutic Services are provided only upon the written order of the resident's Attending Physician.
During a review of the facility's P&P titled, Changes in Resident Condition, last revised on 4/2025, the P&P
indicated the resident, attending physician and legal representative or interested family member are notified
when changes in condition or certain events occur. A need to alter treatment significantly (i.e., a need to
discontinue an existing form of treatment due to adverse consequences, or to commence a new form of
treatment).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident
1) received treatment and care in accordance with professional standards of practice when the facility failed
to follow the Registered Dietitian's (RD- a food and nutrition expert who helps people improve their health
through food choices and dietary changes) recommendations.
Residents Affected - Few
This deficient practice had the potential for Resident 1 to have unplanned weight loss.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted
Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia
(total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one
side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain
attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant
side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle part of the throat),
dementia (a progressive state of decline in mental abilities), and depression (a common mental health
condition that causes persistent sadness, loss of interest in activities, and changes in how you think, feel,
and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or
potential nutritional problems indicated intervention to monitor, document, and report as needed any sign
and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and to
provide and serve supplements as ordered.
During a review of Resident 1's Weight Summary, the Weight Summary indicated the following Resident 1's
weights:
- 4/4/2025 154 pounds (lbs.- unit of weight)
- 5/5/2025 151 lbs.
- 5/18/2025 148 lbs.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the
MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1
required substantial to maximum assistance (helper does more than half the effort) with toileting,
showering, upper and lower body dressing and putting on and taking off footwear and required partial to
moderate assistance (helper does less than half the effort) with oral hygiene, and personal hygiene.
During a review of Resident 1's Physician Order Summary Report, dated 4/20/2025, the Physician Order
Summary Report indicated a physician's order for regular diet pureed texture, nectar thickened liquids
consistency, large portion protein per meal.
During a review of Resident 1's Food and Nutrition Progress Notes dated 5/15/2025 at 5:13p.m. indicated
weight loss related to variable oral intake, multiple medical conditions including dysphagia, dementia, and
depression. The plan indicated to provide magic cup (a nutritional supplement designed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
to provide extra calories and protein for individuals who are experiencing involuntary weight loss or have
difficulty consuming enough nutrients through regular meals) daily at lunch for one month.
During an interview on 6/3/2025 at 3:56 p.m. with the Director of Nursing (DON), the DON stated for RD
recommendations the RD comes two times a week, reviews the weights then gives recommendations, the
facility then has three days to follow up on the recommendations including weekends.
During a concurrent interview and record review on 6/3/2025 at 4:25 p.m. of Resident 1's Food and
Nutrition Progress Notes with the DON, the DON stated could not find any recommendations for Resident
1. The DON stated the RD needs to put their recommendations into the Dietary Report. The DON stated
Resident 1 was seen by RD on 5/15/2025. The DON reviewed Resident 1's Food and Nutrition Progress
Notes and the DON stated RD recommended magic cup which was not provided to Resident 1. The DON
stated there is a potential for the interventions not to be done and can lead to a further weight loss.
During a review of the facility's Policy and Procedure (P&P) titled, Weight Assessment and Intervention, last
revised on 4/2025, the P&P indicated undesirable weight change is evaluated by the treatment team
whether or not the criteria for significant weight change has been met. The evaluation includes:
b. the resident's calorie, protein, and other nutrient needs compared with the resident current intake. The
physician and the multidisciplinary team identify conditions and medications that may be causing anorexia,
weight loss or increasing the risk of weight loss for example:
f. increased need for calories and or protein.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to provide Speech Therapy (ST) on 5/15/2025 when
the Medical Doctor (MD) ordered an ST and swallow evaluation (a test done by a Speech-Language
Pathologist (SLP) to figure out why a person is having trouble swallowing) for one of three sampled
residents (Resident 1).
Residents Affected - Few
This deficient practice resulted in Resident 1 not receiving the ST eval resulting in Resident 1 having a
COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing requiring
transfer to General Acute Care Hospital (GACH) 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted
Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia
(total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one
side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain
attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant
side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle part of the throat),
dementia (a progressive state of decline in mental abilities), and depression (a common mental health
condition that causes persistent sadness, loss of interest in activities, and changes in how you think, feel,
and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or
potential nutritional problems indicated interventions including to monitor, document, and report as needed
any sign and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and
to provide and serve supplements as ordered.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the
MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1
required substantial to maximum assistance (helper does more than half the effort) with toileting,
showering, upper and lower body dressing and putting on and taking off footwear and required partial to
moderate assistance (helper does less than half the effort) with oral hygiene, and personal hygiene.
During a review of Resident 1's care plan created on 4/19/2025, the care plan for swallowing problem
related to holding food in mouth and cheeks with intervention to check mouth after meal for pocketing food
and debris and report to nurse, monitor, document, and report as needed any sign or symptoms of
dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow and
refusing to eat.
During a review of Resident 1's Physician Order Summary Report, dated 4/20/2025, the Physician Order
Summary Report indicated a physician's order for regular diet pureed texture, nectar thickened liquids
consistency, large portion protein per meal.
During a review of Resident 1's COC Evaluation, dated 5/15/2025 at 10:20 p.m., the COC Evaluation
indicated Resident 1pocketing food when eating. Family Member (FM) 1 indicated Resident 1 having
difficulty swallowing his food. Resident 1 pockets the food in his mouth. The MD was notified on 5/15/2025
at 7 p.m. with orders for speech and swallow evaluation, calorie count for 7 days.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0825
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a review of Resident 1's Physician Order Summary Report, dated 5/15/2025, the Physician Order
Summary Report indicated a physician's order for Speech and swallow evaluation in the morning.
During a review of Resident 1's care plan created on 5/16/2025, the care plan for difficulty swallowing
indicated interventions of speech and swallow evaluation, calorie count for 7 days and to call MD for
changes in Resident 1's conditions.
During a review of Resident 1's Progress Notes dated 5/16/2025 at 2:17 p.m., the Progress Notes indicated
continued monitoring for difficulty swallowing. Resident 1 is noted with some difficulty swallowing meals.
During a review of Resident 1's Progress Notes dated 5/17/2025 at 1:26 p.m., the Progress Notes indicated
Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's Progress Notes dated 5/18/2025 at 1:23 p.m., the Progress Notes indicated
Resident 1 is on monitoring for difficulty swallowing and pocketing the food in his mouth, still noted.
During a review of Resident 1's COC Evaluation dated 5/24/2025 at 10:09 a.m., the COC Evaluation
indicated Resident 1 noted slowly declining in mobility, unable to feed to sit in Resident 1's wheelchair.
During a review of Resident 1's Progress Notes dated 5/24/2025 at 1:13 p.m., the Progress Notes indicated
Resident 1 was transferred to GACH 1 at 12:14 p.m. due to fever, decline in Activities of Daily Living (ADLsactivities such as bathing, dressing and toileting a person performs daily), and unable to eat, coughing and
pocketing food.
During an interview on 6/3/2025 at 12p.m. with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated on
Saturday 5/24/2025 prior to Resident 1 being discharged to GACH 1, RNA 1 attempted to feed Resident 1
pureed eggs and oatmeal and Resident 1 began to choke on the food. RNA 1 stated she reported to the
nurse not sure who the nurse was, but Resident 1 was discharged shortly after that.
During an interview on 6/3/2025 at 12:31 p.m. with the Director of Rehab (DOR), the DOR stated have not
had an ST in the facility since the beginning of May. The DOR stated if a resident requires ST, we will
downgrade their diet and then send out the resident to the hospital if needed. The DOR stated last day of
ST in the building was 5/5/2025. The DOR stated Resident 1 did not get the ST evaluation as ordered
because the facility did not have an ST at that time. The DOR stated informed the Director of Nursing
(DON), if Resident 1 was pocketing food or having signs of choking needed to be sent out to hospital this
was during a clinical meeting with all department heads not sure of the date.
During an interview on 6/3/2025 at 12:36 p.m. with the DOR, the DOR stated Resident 1 was ordered to
have ST three times a week for four weeks but since the ST resigned Resident 1 was discharged from ST.
The DOR stated Resident 1 did not meet his goals, Resident 1 was discharged from ST because we could
not provide the ST services for Resident 1. The DOR stated is not sure if the MD was notified that Resident
1 was not able to get ST eval as ordered by MD. The DOR stated the one to contact the MD would have
been nursing.
During a concurrent interview and record review on 6/3/2025 at 1:22 p.m. of Resident 1's progress
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0825
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
notes with the DON, the DON stated there was no notification to MD regarding not having an ST in the
building. The DON stated based on timesheet the ST last day was on 5/5/2025 and Resident 1 was ordered
an ST eval on 5/15/2025. The DON stated knew that Resident 1 needed to transfer out if there was no ST
within 7 days. The DON stated Resident was discharged to GACH 1 on 5/24/2025, 9 days after ST eval
order. The DON stated does not think Resident 1 had a lot of pocketing of food. The DON reviewed
progress notes dated 5/16/2025 through 5/24/2025 the DON stated the progress notes indicates that
Resident 1 was still pocketing food and had difficulty swallowing. The DON stated there is a potential for
weight loss and potential for aspiration if Resident 1 is pocketing food. The DON stated as a SNF we should
be able to provide ST and with no ST there is a potential we cannot provide the right services and
treatment and there can be a delay in treatment.
During a review of the facility's Policy and Procedure (P&P) titled, Specialized Rehabilitative Services, last
revised on 4/2025, the P&P indicated our facility will provide Rehabilitative Services to residents as
indicated by the MDS.
2. Specialized Rehabilitative Services include the following:
b. Speech Pathology/Audiology;
3. Therapeutic Services are provided only upon the written order of the resident's Attending Physician.
During a review of the facility's P&P titled, Changes in Resident Condition, last revised on 4/2025, the P&P
indicated the resident, attending physician and legal representative or interested family member are notified
when changes in condition or certain events occur. A need to alter treatment significantly (i.e., a need to
discontinue an existing form of treatment due to adverse consequences, or to commence a new form of
treatment).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on interview and record review, the facility failed to maintain medical records in accordance with
accepted professional standards and practices for one of three sampled residents (Resident 1) when:
Residents Affected - Few
1. The facility failed to accurately document on Resident 1's medication administration Records (MAR - a
daily documentation record used by a licensed nurse to document medications and treatments given to a
resident) for calorie count for seven days.
2. The facility failed to accurately document Resident 1's Calorie Count.
These deficient practices resulted in inaccurate documentation of Resident 1's records.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted
Resident 1 on 1/30/2024 and readmitted the resident on 3/19/2024 with diagnoses including hemiplegia
(total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one
side of the body, often affecting one arm, leg, and sometimes the face) following cerebral infarction (a brain
attack where part of the brain's blood supply is blocked or severely reduced) affecting the right dominant
side, dysphagia (difficulty swallowing) oropharyngeal (anything related to the middle part of the throat),
dementia (a progressive state of decline in mental abilities), and depression (a common mental health
condition that causes persistent sadness, loss of interest in activities, and changes in how you think, feel,
and act).
During a review of Resident 1's care plan created on 3/5/2025, the care plan for nutritional problem or
potential nutritional problems indicated intervention to monitor, document, and report as needed any sign
and or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, and to
provide and serve supplements as ordered.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025, the
MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1
required substantial to maximum assistance (helper does more than half the effort) with toileting,
showering, upper and lower body dressing and putting on and taking off footwear and required partial to
moderate assistance (helper does less than half the effort) with oral hygiene, and personal hygiene.
During a review of Resident 1's Physician Order Summary Report, dated 5/15/2025, the Physician Order
Summary Report indicated a physician's order for calorie count for seven (7) days.
During a review of Resident 1's MAR for 5/2025 for calorie count for seven days, there was no indication of
it being signed off by staff.
During a review of Resident 1's Calorie Count, the Calorie Count indicated on:
- 5/21/2025 for lunch ate 0 percent (%-a way of expressing a number as a fraction of 100).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555583
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MacLay Healthcare Center
12831 MacLay Street
Sylmar, CA 91342
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
- 5/21/2025 for dinner ate 25%
Level of Harm - Minimal harm
or potential for actual harm
- 5/22/2025 for dinner ate 50%
- 5/23/2025 for lunch at 50%
Residents Affected - Few
- 5/23/2025 for dinner was left blank.
During a review of Resident 1's Meal Intake for May 2025, the Meal Intake indicated on:
- 5/21/2025 for lunch ate 26 to 50%
- 5/21/2025 for dinner refused to eat.
- 5/22/2025 for dinner refused to eat.
- 5/23/2025 for lunch ate 76-100%
- 5/23/2025 for dinner at 76-100%
During a concurrent interview and record review of Resident 1's Meal Intake, Calorie Count and MAR with
the Director of Nursing (DON), the DON reviewed the Meal Intake with the Calorie Count and the DON
stated should match and is not accurate. The DON stated for 5/21 it indicates Resident 1 ate 26 to 50% but
the Calorie Count is documented as 0% for lunch and for dinner on 5/21 it indicates Resident refused but
the Calorie Count indicates 25%. The DON reviewed Resident 1's MAR for 5/2025, the DON stated the
calorie count for the seven days was not documented. The DON stated the MAR should have been checked
off and initialed by the license staff, it needs to be signed and checked off indicating staff have done the
task. The DON stated cannot validate the task was done. The DON stated the Meal Intake and Calorie
Count should match for accuracy of records. The DON stated there is a potential for not being able to
provide the right interventions and inconsistency.
During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, last revised
on 4/2025, the P&P indicated the following information is to be documented in the resident medical record:
c. treatments or services performed.
3. Documentation in the medical record will be objective, complete, and accurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555583
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the June 3, 2025 survey of MACLAY HEALTHCARE CENTER?
This was a inspection survey of MACLAY HEALTHCARE CENTER on June 3, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MACLAY HEALTHCARE CENTER on June 3, 2025?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.