Maclay Healthcare Center
Sylmar, Los Angeles County, California · CCN 555583 · For-profit (LLC) · part of Serrano Group (11 facilities, chain average 1.9 stars)
CMS rates Maclay Healthcare Center 2 of 5 overall as of August 2026. 141 certified beds, 127 residents a day on average. 181 citations on record from the current inspection cycles, 7 at immediate jeopardy; 7 fines totalling $361,118 and 5 payment denials.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
- Special Focus Facility candidate. On CMS’s list of facilities that qualify for the program but are not yet in it.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / 5 of 5 |
Staffing
| Total nurse staffing | 4.09981 hours per resident per day |
|---|---|
| Registered nurses | 0.43141 hours per resident per day |
| Weekend total | 3.71535 hours per resident per day |
| Nursing staff turnover | 43.5% (registered nurses 61.1%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-09 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-29 |
| 2026-06-09 complaint survey |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-29 |
| 2026-06-09 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-29 |
| 2026-04-14 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-24 |
| 2026-04-14 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-24 |
| 2026-04-14 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-24 |
| 2026-04-14 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-24 |
| 2026-04-14 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-24 |
| 2026-03-03 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-27 |
| 2026-03-03 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-27 |
| 2026-03-03 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-27 |
| 2026-01-16 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Nutrition and Dietary Deficiencies · tag F0800 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-25 |
| 2026-01-16 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · tag F0803 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Nutrition and Dietary Deficiencies · tag F0808 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · tag F0809 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · tag F0849 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · tag F0881 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-25 |
| 2026-01-16 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · tag F0693 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2026-01-16 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-02-12 |
| 2025-09-15 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-15 |
| 2025-08-28 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-19 |
| 2025-08-28 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-19 |
| 2025-07-09 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-12 |
| 2025-06-03 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-27 |
| 2025-06-03 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-27 |
| 2025-06-03 complaint survey |
Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · tag F0825 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-27 |
| 2025-06-03 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-27 |
| 2025-04-28 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-05-09 |
| 2025-03-22 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-04-18 |
| 2025-03-22 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-04-18 |
| 2025-03-22 complaint survey |
Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-18 |
| 2025-03-22 complaint survey |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · tag F0712 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-18 |
| 2025-03-22 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-18 |
| 2025-03-22 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-18 |
| 2025-03-22 complaint survey |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · tag F0644 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-18 |
| 2025-01-28 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-28 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-16 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-04 |
| 2024-12-24 complaint survey |
Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-09 |
| 2024-12-24 complaint survey |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · tag F0636 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-09 |
| 2024-12-24 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-09 |
| 2024-12-24 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-09 |
| 2024-12-24 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-09 |
| 2024-12-18 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-30 |
| 2024-10-31 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-11 |
| 2024-10-31 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-11 |
| 2024-10-24 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-11-08 |
| 2024-10-24 complaint survey |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-08 |
| 2024-10-11 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · tag F0700 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · tag F0802 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-06 |
| 2024-10-11 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · tag F0803 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies · tag F0813 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · tag F0814 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · tag F0887 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-10-11 | Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-18 |
| 2024-09-10 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-26 |
| 2024-09-10 complaint survey |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · tag F0626 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-26 |
| 2024-08-21 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-16 |
| 2024-08-05 complaint survey |
Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · tag F0576 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-23 |
| 2024-08-05 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-08-05 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-29 |
| 2024-08-05 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-23 |
| 2024-07-18 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-20 |
| 2024-06-07 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · tag F0712 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · tag F0726 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-15 |
| 2024-06-07 complaint survey |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · tag F0838 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-07-15 |
| 2024-04-10 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-27 |
| 2024-04-10 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-27 |
| 2024-02-23 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-06 |
| 2024-01-25 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-16 |
| 2024-01-25 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-16 |
| 2024-01-25 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-16 |
| 2024-01-25 complaint survey |
Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-16 |
| 2024-01-25 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-16 |
| 2024-01-25 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-16 |
| 2023-12-04 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-12-24 |
| 2023-11-14 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-12-14 |
| 2023-10-25 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-15 |
| 2023-10-06 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · tag F0576 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · tag F0849 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-10-06 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-30 |
| 2023-09-29 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-13 |
| 2023-09-27 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-27 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-27 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-27 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-27 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-22 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-15 |
| 2023-09-07 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-07 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-07 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-07 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-07 complaint survey |
Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-07 complaint survey |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · tag F0712 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-07 complaint survey |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-31 |
| 2023-09-01 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-15 |
| 2023-08-23 complaint survey |
Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-09-08 |
| 2023-08-23 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-08 |
| 2023-08-14 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-21 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-04-29 | Fine | $19,610 |
| 2026-01-16 | Payment denial for 38 days from 2026-02-17 | — |
| 2026-01-16 | Fine | $43,755 |
| 2025-03-22 | Payment denial for 20 days from 2025-04-19 | — |
| 2025-03-22 | Fine | $52,142 |
| 2024-10-11 | Payment denial for 14 days from 2024-11-22 | — |
| 2024-10-11 | Fine | $112,506 |
| 2024-10-11 | Fine | $17,660 |
| 2024-06-07 | Payment denial for 6 days from 2024-07-09 | — |
| 2024-06-07 | Fine | $86,623 |
| 2023-08-23 | Payment denial for 31 days from 2023-11-23 | — |
| 2023-08-23 | Fine | $28,822 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Lory Lynn LLC Organization | 5% or greater direct ownership interest | 17% | 2015-11-01 |
| Maclay Partners LLC Organization | 5% or greater direct ownership interest | 17% | 2015-11-01 |
| Jacobs, Dov Individual | 5% or greater direct ownership interest | 20% | 2015-11-01 |
| Fensterman, Howard Individual | 5% or greater indirect ownership interest | 17% | 2015-11-01 |
| Taub, Judah Individual | 5% or greater indirect ownership interest | 17% | 2015-11-01 |
| Jacobs, Dov Individual | corporate officer | — | 2015-11-01 |
| Landa, Benjamin Individual | corporate officer | — | 2015-11-01 |
| Donohoe, Mark Individual | operational/managerial control | — | 2015-11-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Maclay Healthcare Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Los Angeles County.