Maclay Healthcare Center
Sylmar, California
Skilled nursing facility in Sylmar, CA with 141 certified beds and a 2-star CMS overall rating.
Maclay Healthcare Center is a skilled nursing facility in Sylmar, California (Los Angeles County), with 141 Medicare/Medicaid-certified beds.
Address: 12831 Maclay Street, Sylmar, CA 91342. Phone: (818) 361-4455.
Ownership: For profit - Limited Liability company. Certified for Medicare and Medicaid. Automatic sprinkler systems in all required areas. Has a resident council. Part of the Serrano Group chain.
CMS Five-Star ratings (source: Medicare Care Compare): overall 2 of 5, health inspections 1, staffing 3, quality measures 5.
Levels of care
- Skilled nursing
Facility details
- Street address
- 12831 Maclay Street
- City
- Sylmar
- State
- California
- ZIP code
- 91342
- Phone
- (818) 361-4455
- Levels of care
- Skilled nursing
- Payment options accepted
- Medicare, Medicaid
- Cms Ccn
- 555583
- County
- Los Angeles
- Ownership Type
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Certified Beds
- 141
- Avg Daily Residents
- 127.1
- Continuing Care Community
- No
- Resident Family Council
- Resident
- Sprinklers All Areas
- Yes
- Medicare Medicaid Approved Date
- 1993-12-01
- Chain Name
- Serrano Group
- Overall Rating
- 2
- Health Inspection Rating
- 1
- Staffing Rating
- 3
- Quality Measure Rating
- 5
- Special Focus Facility
- SFF Candidate
- Total Nurse Hours Per Resident Day
- 4.09981
- Rn Hours Per Resident Day
- 0.43141
- Latitude
- 34.299
- Longitude
- -118.42
Medicare & Medicaid quality data
Published by the Centers for Medicare & Medicaid Services (CMS) [1] , data as of October 1, 2026. CMS ID 555583. Ratings compare this home with other nursing homes; they are not a pass or fail.
CMS overall rating
2 / 5
Below average- Certified beds
- 141
- Residents per day
- 128
- Ownership
- For profit - Limited Liability company
- Health citations (latest)
- 50
- Fines
- 7 ($349,023)
Star ratings
CMS rates every certified nursing home from 1 to 5 stars in three areas and combines them into an overall rating. The ratings compare homes with each other: 5 is much above average, 3 is average, 1 is much below average.
Overall rating
Below averageThe headline score, from 1 to 5 stars.
✗ Worse than the state average. State 3.2 · National 3.0
How is this scored?
Three steps: start with the health inspection stars; add one star if staffing is 5 stars (subtract one if it is 1 star); then add one star if quality measures are 5 stars (subtract one if 1 star). It never goes above 5 or below 1, and a home with 1 health inspection star can gain at most one star from the other two. It compares homes with each other; it is not a pass/fail grade. [11]
Health inspections
Much below averageHow the home did in recent state inspections and complaint investigations.
✗ Worse than the state average. State 2.8 · National 2.8
How is this scored?
Based on the two most recent annual inspections plus 36 months of complaint and infection-control inspections, and on how many revisits were needed to confirm fixes. Each citation is weighted by scope and severity. Homes are then ranked within their own state: the best 10% (lowest scores) earn 5 stars, the middle 70% earn 2, 3 or 4 stars in equal shares, and the worst 20% earn 1 star. [11]
Staffing
AverageHow many nurses care for each resident, and how stable the nursing team is.
✗ Worse than the state average. State 3.3 · National 3.0
How is this scored?
Six measures: three of staffing level (total nurse, registered nurse and weekend nurse hours per resident per day, adjusted for how much care residents need) and three of turnover (nursing staff, RNs and administrators). The hours come from payroll records submitted to CMS each quarter; turnover uses six quarters of that data. [11]
Quality measures
Much above averageHow residents are actually doing.
✓ Better than the state average. State 4.2 · National 3.7
How is this scored?
Scores 15 quality measures drawn from resident assessments (the Minimum Data Set) and Medicare claims, such as falls with major injury, pressure ulcers, rehospitalizations and medication use. Long-stay and short-stay residents are rated separately and combined. [11]
This home State average National average
- Long-stay quality
- Residents who live in the home: outcomes such as falls, pressure ulcers and medication use.
- Short-stay quality
- Residents staying for rehab or recovery: outcomes such as rehospitalization and regaining function.
Flags CMS attaches to this home
- ⚑ Special Focus Facility: SFF Candidate. CMS's program for homes with a history of serious quality problems. Homes currently in it get no star ratings; candidates are rated but may be added to the program. [11]
How to read the numbers on this page
- Star ratings — 1 to 5 (no stars = not rated)
- 5 is much above average and 1 is much below average, compared with other nursing homes. A home with too little data may have no rating.
- Health inspection score — 0 and up, lower is better
- Points added up from citations (see the scope and severity grid) and revisits. 0 means a clean record; the state table shows which scores earn which stars.
- Quality measure percentages — 0 to 100%
- The share of residents with an outcome, such as a fall with major injury. For most measures a lower percentage is better; for vaccination measures a higher percentage is better.
- Nurse hours per resident per day — Hours, higher is better
- Paid nursing time divided by residents. For example 4.0 means each resident gets about four hours of nursing care a day, shared across all shifts.
- Staff turnover — 0 to 100%, lower is better
- The share of nursing staff who left during the year. High turnover can mean less continuity of care.
- Case-mix index — Around 1.0 is typical
- How much care the residents need. Above 1 means sicker or more dependent residents who need more staff time.
- Fines — Dollars; payment denials in days
- Penalties CMS imposed for serious or repeated problems. A payment denial stops Medicare/Medicaid payment for new admissions.
Sources: Nursing Home Provider Information [1] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Staffing & turnover
More nursing time per resident and a steadier team are both signs of better care. Hours come from payroll records the home submits to CMS each quarter.
Nurse hours per resident per day, by role
A resident's day is 24 hours; this is how much paid nursing time each resident gets, shared across all shifts.
RN 0.39 · LPN 1.13 · Nurse aide 2.48. What the home's payroll records show.
RN 0.73 · LPN 0.91 · Nurse aide 2.47. What CMS predicts a home with these residents' needs would staff.
RN 0.37 · LPN 1.07 · Nurse aide 2.33. The reported hours rescaled so homes with sicker or healthier residents can be compared fairly.
Compared with CA and the nation
This home State average National average
- Total nurse hours (hrs/resident/day, higher is better)
- 4.00
✗ Worse than the state average. State 4.54 · National 3.90
- Registered nurse (RN) hours (hrs/resident/day, higher is better)
- 0.39
✗ Worse than the state average. State 0.68 · National 0.69
- Licensed nurse hours (RN + LPN) (hrs/resident/day, higher is better)
- 1.52
✗ Worse than the state average. State 1.88 · National 1.55
- Nurse aide hours (hrs/resident/day, higher is better)
- 2.48
✗ Worse than the state average. State 2.66 · National 2.35
- Weekend total nurse hours (hrs/resident/day, higher is better)
- 3.76
✗ Worse than the state average. State 4.10 · National 3.43
- Weekend RN hours (hrs/resident/day, higher is better)
- 0.28
✗ Worse than the state average. State 0.52 · National 0.48
- Physical therapist hours (hrs/resident/day, higher is better)
- 0.02
✗ Worse than the state average. State 0.10 · National 0.07
- Nursing staff turnover (%, lower is better)
- 36.4%
≈ About the state average. State 36.6% · National 45.3%
- RN turnover (%, lower is better)
- 47.1%
✗ Worse than the state average. State 37.8% · National 42.5%
- Administrators who left (people, lower is better)
- 0
✓ Better than the state average. State 0 · National 1
- Nursing case-mix index (index)
- 1.49
State 1.51 · National 1.41
Turnover is the share of nursing staff who left over the year. The case-mix index shows how much care residents need: about 1.0 is typical, higher means more dependent residents.
Sources: Nursing Home Provider Information [1] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Inspections
State inspectors visit each home about once a year and investigate complaints. Every problem they cite is a deficiency, lettered A to L by how serious and how widespread it was.
Health inspection score
781.3 points — in CA that earns (Much below average).
Lower is better. The score adds up points for every citation (more for serious, widespread problems) and for revisits needed to confirm fixes, then weights recent inspections most. [11]
Score needed for each star in CA [10]
- 5 ★
- 0.000-33.000
- 4 ★
- 33.001-66.000
- 3 ★
- 66.001-96.000
- 2 ★
- 96.001-146.000
- 1 ★ (this home)
- >146.000
| Period | Inspection | Citations (complaint) | Citation points | Revisits | Revisit points | Total |
|---|---|---|---|---|---|---|
| Most recent cycle | Jan 16, 2026 | 50 (16) | 436 | 2 | 218 | 654 |
| Prior cycles (2 and 3) | Oct 11, 2024 | 90 (60) | 775 | 2 | 388 | 1163 |
Health citations per inspection
Jan 16, 2026
Oct 11, 2024
Oct 6, 2023
State average for that cycle. Fewer is better.
Fire-safety citations per inspection
Jan 16, 2026
Oct 11, 2024
Oct 6, 2023
State average for that cycle. Fewer is better.
What the latest health inspection cited
- Quality of Life and Care 11
- Resident Assessment and Care Planning 9
- Resident Rights 7
- Nutrition and Dietary 7
- Pharmacy Service 7
- Freedom from Abuse and Neglect and Exploitation 3
- Infection Control 3
- Environmental 2
- Administration 1
What the latest fire-safety inspection cited
- Smoke 5
- Gas and Vacuum and Electrical Systems 2
- Services 1
- Egress 1
- Miscellaneous 1
How serious were the citations?
Each health citation gets a letter. The number in each cell is how many of this home's citations got that letter; the points show what each letter adds to the health inspection score. Citations where care was substandard score higher than shown. [11]
| Isolated (a few residents) | Pattern (some residents) | Widespread (many residents) | |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J · 50 pts 4 | K · 100 pts 1 | L · 150 pts 0 |
| Actual harm, not immediate jeopardy | G · 20 pts 5 | H · 35 pts 0 | I · 45 pts 0 |
| No actual harm, potential for more than minimal harm | D · 4 pts 91 | E · 8 pts 66 | F · 16 pts 0 |
| No actual harm, potential for minimal harm only | A · 0 pts 0 | B · 0 pts 0 | C · 0 pts 1 |
Darker cells mean more citations. Counts cover every health citation CMS lists for this home.
All health citations (168) [2]
Inspection on Jul 21, 2026 · 1 citation
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Aug 12, 2026) · From a complaint
Inspection on Jun 9, 2026 · 3 citations
-
D
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Jun 29, 2026) · From a complaint
-
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jun 29, 2026) · From a complaint
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Jun 29, 2026) · From a complaint
Inspection on Apr 29, 2026 · 4 citations
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jul 2, 2026) · From a complaint
-
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jun 3, 2026) · From a complaint
-
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jul 2, 2026) · From a complaint
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (May 26, 2026) · From a complaint
Inspection on Apr 14, 2026 · 5 citations
-
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Apr 24, 2026) · From a complaint
-
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Apr 24, 2026) · From a complaint
-
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Apr 24, 2026) · From a complaint
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Apr 24, 2026) · From a complaint
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Apr 24, 2026) · From a complaint
Inspection on Mar 3, 2026 · 3 citations
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Mar 27, 2026) · From a complaint
-
E
Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Mar 27, 2026) · From a complaint
-
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Mar 27, 2026) · From a complaint
Inspection on Jan 16, 2026 · 34 citations
-
E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F0605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
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.
F0578 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
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.
F0803 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F0925 · Environmental Deficiencies · Deficient, Provider has date of correction (Mar 25, 2026)
-
E
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.
F0809 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
F0800 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Mar 25, 2026)
-
K
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Implement a program that monitors antibiotic use.
F0881 · Infection Control Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F0604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
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.
F0808 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
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.
F0693 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Provide safe, appropriate pain management for a resident who requires such services.
F0697 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F0921 · Environmental Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F0804 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
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.
F0849 · Administration Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
E
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.
F0584 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
-
D
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 12, 2026)
Inspection on Sep 15, 2025 · 1 citation
-
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Oct 15, 2025) · From a complaint
Inspection on Aug 28, 2025 · 2 citations
-
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Sep 19, 2025) · From a complaint
-
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Sep 19, 2025) · From a complaint
Inspection on Jul 9, 2025 · 1 citation
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Aug 12, 2025) · From a complaint
Inspection on Jun 3, 2025 · 4 citations
-
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jun 27, 2025) · From a complaint
-
D
Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jun 27, 2025) · From a complaint
-
D
Provide or get specialized rehabilitative services as required for a resident.
F0825 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jun 27, 2025) · From a complaint
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Jun 27, 2025) · From a complaint
Inspection on Apr 28, 2025 · 1 citation
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (May 9, 2025) · From a complaint
Inspection on Mar 22, 2025 · 7 citations
-
D
Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Apr 18, 2025) · From a complaint
-
E
Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Apr 18, 2025) · From a complaint
-
E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
F0712 · Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction (Apr 18, 2025) · From a complaint
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Apr 18, 2025) · From a complaint
-
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Apr 18, 2025) · From a complaint
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Apr 18, 2025) · From a complaint
-
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F0644 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Apr 18, 2025) · From a complaint
Inspection on Jan 28, 2025 · 2 citations
-
D
Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 12, 2025) · From a complaint
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 12, 2025) · From a complaint
Inspection on Jan 16, 2025 · 1 citation
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 4, 2025) · From a complaint
Inspection on Dec 24, 2024 · 5 citations
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jan 9, 2025) · From a complaint
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jan 9, 2025) · From a complaint
-
D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F0636 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jan 9, 2025) · From a complaint
-
D
Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Jan 9, 2025) · From a complaint
-
D
Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Jan 9, 2025) · From a complaint
Inspection on Dec 18, 2024 · 1 citation
-
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Dec 30, 2024) · From a complaint
Inspection on Oct 31, 2024 · 2 citations
-
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Nov 11, 2024) · From a complaint
-
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 11, 2024) · From a complaint
Inspection on Oct 24, 2024 · 2 citations
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Nov 8, 2024) · From a complaint
-
E
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.
F0584 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 8, 2024) · From a complaint
Inspection on Oct 11, 2024 · 30 citations
-
D
Assist a resident in gaining access to vision and hearing services.
F0685 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F0925 · Environmental Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
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.
F0700 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
J
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F0806 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Dispose of garbage and refuse properly.
F0814 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
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.
F0758 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F0802 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Dec 6, 2024)
-
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
Keep all essential equipment working safely.
F0908 · Environmental Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F0804 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F0561 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
D
Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
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.
F0887 · Infection Control Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F0813 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
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.
F0803 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
-
E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F0604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Nov 18, 2024)
Inspection on Sep 10, 2024 · 2 citations
-
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Sep 26, 2024) · From a complaint
-
D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
F0626 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Sep 26, 2024) · From a complaint
Inspection on Aug 21, 2024 · 1 citation
-
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Sep 16, 2024) · From a complaint
Inspection on Aug 5, 2024 · 4 citations
-
D
Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Aug 29, 2024) · From a complaint
-
D
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Sep 23, 2024) · From a complaint
-
D
Ensure residents have reasonable access to and privacy in their use of communication methods.
F0576 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Sep 23, 2024) · From a complaint
-
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Aug 29, 2024) · From a complaint
Inspection on Jul 18, 2024 · 1 citation
-
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Aug 20, 2024) · From a complaint
Inspection on Jun 7, 2024 · 10 citations
-
E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
F0712 · Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
C
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.
F0838 · Administration Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
D
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
D
Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
E
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.
F0726 · Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
-
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jul 15, 2024) · From a complaint
Inspection on Apr 10, 2024 · 2 citations
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Apr 27, 2024) · From a complaint
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Apr 27, 2024) · From a complaint
Inspection on Feb 23, 2024 · 1 citation
-
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Mar 6, 2024) · From a complaint
Inspection on Jan 25, 2024 · 6 citations
-
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 16, 2024) · From a complaint
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 16, 2024) · From a complaint
-
D
Provide safe, appropriate pain management for a resident who requires such services.
F0697 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 16, 2024) · From a complaint
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 16, 2024) · From a complaint
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Feb 16, 2024) · From a complaint
-
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 16, 2024) · From a complaint
Inspection on Dec 4, 2023 · 1 citation
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 24, 2023) · From a complaint
Inspection on Nov 14, 2023 · 1 citation
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 14, 2023) · From a complaint
Inspection on Oct 25, 2023 · 1 citation
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 15, 2023) · From a complaint
Inspection on Oct 6, 2023 · 29 citations
-
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F0925 · Environmental Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F0657 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F0676 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F0804 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Ensure residents have reasonable access to and privacy in their use of communication methods.
F0576 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
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.
F0578 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
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.
F0758 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
PASARR screening for Mental disorders or Intellectual Disabilities
F0645 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
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.
F0849 · Administration Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
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.
F0584 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
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.
F0688 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023) · From a complaint
-
E
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 30, 2023)
All fire-safety citations (19) [3]
Inspection on Aug 13, 2026 · 1 citation
-
D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K0211 · Egress Deficiencies · Deficient, Provider has date of correction (Sep 4, 2026) · From a complaint
Inspection on Jan 16, 2026 · 9 citations
-
E
Inspect, test, and maintain automatic sprinkler systems.
K0353 · Smoke Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
D
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K0926 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
D
Provide properly protected cooking facilities.
K0324 · Smoke Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
E
Properly select, install, inspect, or maintain portable fire extinguishes.
K0355 · Smoke Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
F
Have approved installation, maintenance and testing program for fire alarm systems.
K0345 · Smoke Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
D
Install corridor and hallway doors that block smoke.
K0363 · Smoke Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
F
Have properly installed electrical wiring and gas equipment.
K0511 · Services Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
F
Have simulated fire drills held at unexpected times.
K0712 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
-
E
Ensure proper usage of power strips and extension cords.
K0920 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Jan 19, 2026)
Inspection on Oct 11, 2024 · 6 citations
-
D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K0321 · Smoke Deficiencies · Deficient, Provider has date of correction (Oct 25, 2024)
-
D
Have properly installed electrical wiring and gas equipment.
K0511 · Services Deficiencies · Deficient, Provider has date of correction (Oct 25, 2024)
-
E
Inspect, test, and maintain automatic sprinkler systems.
K0353 · Smoke Deficiencies · Deficient, Provider has date of correction (Oct 25, 2024)
-
D
Ensure proper usage of power strips and extension cords.
K0920 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Oct 25, 2024)
-
E
Have simulated fire drills held at unexpected times.
K0712 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Oct 25, 2024)
-
C
Provide emergency officials' contact information.
E0031 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Oct 25, 2024)
Inspection on Oct 6, 2023 · 3 citations
-
D
Inspect, test, and maintain automatic sprinkler systems.
K0353 · Smoke Deficiencies · Deficient, Provider has date of correction (Oct 31, 2023)
-
D
Have properly located and lighted "Exit" signs.
K0293 · Egress Deficiencies · Deficient, Provider has date of correction (Oct 31, 2023)
-
E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K0211 · Egress Deficiencies · Deficient, Provider has date of correction (Oct 31, 2023)
Sources: Nursing Home Provider Information [1] ; Nursing Home Survey Summary [4] ; Nursing Home Health Deficiencies [2] ; Nursing Home Fire Safety Deficiencies [3] ; Nursing Home Health Inspection Cut Points [10] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Fines & penalties
CMS can fine a home or stop Medicare and Medicaid payments for new admissions when problems are serious or keep recurring. Most homes have none.
- Fines
- 7 State avg 0.8 · National 0.9
- Total fined
- $349,023 State avg 23,366 · National 30,351
- Payment denials
- 4 Periods with no Medicare/Medicaid payment for new admissions
Fines by year
| Date | Type | Amount | Payment denial |
|---|---|---|---|
| Jul 21, 2026 | Fine | $22,895 | — |
| Apr 29, 2026 | Fine | $12,747 | — |
| Jan 16, 2026 | Fine | $44,450 | — |
| Jan 16, 2026 | Payment Denial | — | 38 days from Feb 17, 2026 |
| Mar 22, 2025 | Fine | $52,142 | — |
| Mar 22, 2025 | Payment Denial | — | 20 days from Apr 19, 2025 |
| Oct 11, 2024 | Fine | $17,660 | — |
| Oct 11, 2024 | Fine | $112,506 | — |
| Oct 11, 2024 | Payment Denial | — | 14 days from Nov 22, 2024 |
| Jun 7, 2024 | Payment Denial | — | 6 days from Jul 9, 2024 |
| Jun 7, 2024 | Fine | $86,623 | — |
Sources: Nursing Home Provider Information [1] ; Nursing Home Penalties [5] ; Nursing Home State & National Averages [9]
Resident quality measures
These measure what actually happens to residents, as a percentage from 0 to 100 (or events per 1,000 resident days). For almost all of them a lower number is better; the vaccination measures are the exception and are marked. A star means the measure counts toward the quality star rating.
This home State average National average
Long-stay residents (14) [7]
Residents who live in the home. From their regular health assessments (the Minimum Data Set), averaged over four quarters. Period: 2025Q3-2026Q2.
- Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Higher is better
- 99.3
≈ About the state average. State 98.7 · National 93.7
- Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Higher is better
- 98.3
≈ About the state average. State 97.9 · National 95.3
- Percentage of long-stay residents experiencing one or more falls with major injury ★ Lower is better
- 0.9
✓ Better than the state average. State 1.6 · National 3.2
- Percentage of long-stay residents who have depressive symptoms Lower is better
- 10.5
✗ Worse than the state average. State 7.6 · National 13.5
- Percentage of long-stay residents who lose too much weight Lower is better
- 3.5
✓ Better than the state average. State 4.1 · National 5.1
- Percentage of long-stay residents who received an antianxiety or hypnotic medication Lower is better
- 17.9
✗ Worse than the state average. State 13.7 · National 19.5
- Percentage of long-stay residents who received an antipsychotic medication ★ Lower is better
- 10.0
✓ Better than the state average. State 12.3 · National 15.4
- Percentage of long-stay residents who were physically restrained Lower is better
- 0.0
✓ Better than the state average. State 0.3 · National 0.1
- Percentage of long-stay residents whose ability to walk independently worsened ★ Lower is better
- 6.8
✓ Better than the state average. State 8.9 · National 12.7
- Percentage of long-stay residents whose need for help with daily activities has increased ★ Lower is better
- 6.2
✓ Better than the state average. State 10.2 · National 13.5
- Percentage of long-stay residents with a catheter inserted and left in their bladder ★ Lower is better
- 0.1
✓ Better than the state average. State 0.7 · National 0.7
- Percentage of long-stay residents with a urinary tract infection ★ Lower is better
- 2.4
✗ Worse than the state average. State 1.2 · National 1.5
- Percentage of long-stay residents with new or worsened bowel or bladder incontinence Lower is better
- 17.1
✗ Worse than the state average. State 9.8 · National 18.3
- Percentage of long-stay residents with pressure ulcers ★ Lower is better
- 6.0
✗ Worse than the state average. State 4.3 · National 4.5
Short-stay residents (3) [7]
Residents staying for rehab or recovery. From their health assessments, averaged over four quarters. Period: 2025Q3-2026Q2.
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Higher is better
- 94.0
≈ About the state average. State 94.6 · National 82.3
- Percentage of short-stay residents who newly received an antipsychotic medication ★ Lower is better
- 0.0
✓ Better than the state average. State 1.3 · National 1.5
- Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Higher is better
- 94.6
≈ About the state average. State 93.1 · National 80.1
Long-stay residents: hospital use (2) [8]
Hospital stays and emergency visits found in Medicare claims, adjusted for how sick residents were. Period: 20250401-20260331.
- Number of hospitalizations per 1000 long-stay resident days ★ Lower is better · Expected for these residents: 2.1
- 4.9
✗ Worse than the state average. State 2.2 · National 1.8
- Number of outpatient emergency department visits per 1000 long-stay resident days ★ Lower is better · Expected for these residents: 1.5
- 2.1
✗ Worse than the state average. State 1.5 · National 1.7
Short-stay residents: hospital use (2) [8]
Rehospitalizations and emergency visits after admission, found in Medicare claims and adjusted for how sick residents were. Period: 20250401-20260331.
- Percentage of short-stay residents who had an outpatient emergency department visit ★ Lower is better · Expected for these residents: 11.0
- 2.3
✓ Better than the state average. State 11.1 · National 11.8
- Percentage of short-stay residents who were rehospitalized after a nursing home admission ★ Lower is better · Expected for these residents: 22.4
- 20.1
✓ Better than the state average. State 22.6 · National 23.4
Sources: Nursing Home MDS Quality Measures [7] ; Nursing Home Medicare Claims Quality Measures [8] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Ownership & operator
Who owns and runs a home can matter: for-profit, non-profit and chain-owned homes tend to differ on staffing and inspection results.
- Ownership type
- For profit - Limited Liability company
- Legal business name
- MACLAY HEALTHCARE LLC
- Certified for
- Medicare and Medicaid
- Certified beds
- 141
- Residents per day (average)
- 128
- In Medicare/Medicaid since
- Dec 1, 1993
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
- County
- Los Angeles
- Located in a hospital
- No
Company profiles: Serrano Group (11 homes, average 2.1 stars)
Part of SERRANO GROUP
One of 11 homes in this chain. Average star ratings across the chain (1 to 5):
- Overall
- 2.1
- Health inspections
- 1.6
- Staffing
- 3.2
- Quality
- 4.3
Owners, officers and managers (8) [6]
Operational/Managerial Control
- DONOHOE, MARK (individual, NOT APPLICABLE, since 11/01/2015)
5% Or Greater Indirect Ownership Interest
- FENSTERMAN, HOWARD (individual, 17%, since 11/01/2015)
- TAUB, JUDAH (individual, 17%, since 11/01/2015)
5% Or Greater Direct Ownership Interest
- JACOBS, DOV (individual, 20%, since 11/01/2015)
- LORY LYNN LLC (organization, 17%, since 11/01/2015)
- MACLAY PARTNERS LLC (organization, 17%, since 11/01/2015)
Corporate Officer
- JACOBS, DOV (individual, NOT APPLICABLE, since 11/01/2015)
- LANDA, BENJAMIN (individual, NOT APPLICABLE, since 11/01/2015)
Sources: Nursing Home Provider Information [1] ; Nursing Home Ownership [6]
Sources
All figures on this page come from the U.S. government's published nursing home data, as of October 1, 2026. We reproduce them without change except for rounding and layout; ratings, scores and flags are CMS's, not ours. Averages and comparisons use the state and national figures CMS publishes in the same release.
- 1. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Provider Information. Star ratings, staffing, turnover, inspection scores, fines, chain and flag data. https://data.cms.gov/provider-data/dataset/4pq5-n9py
- 2. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Health Deficiencies. Each health deficiency cited, with scope and severity. https://data.cms.gov/provider-data/dataset/r5ix-sfxw
- 3. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Fire Safety Deficiencies. Each fire-safety deficiency cited. https://data.cms.gov/provider-data/dataset/ifjz-ge4w
- 4. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Survey Summary. Deficiency totals by inspection cycle and category. https://data.cms.gov/provider-data/dataset/tbry-pc2d
- 5. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Penalties. Fines and payment denials. https://data.cms.gov/provider-data/dataset/g6vv-u9sr
- 6. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Ownership. Owners, officers, directors and managers. https://data.cms.gov/provider-data/dataset/y2hd-n93e
- 7. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home MDS Quality Measures. Quarterly quality measure scores from resident assessments. https://data.cms.gov/provider-data/dataset/djen-97ju
- 8. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Medicare Claims Quality Measures. Risk-adjusted quality measures from Medicare claims. https://data.cms.gov/provider-data/dataset/ijh5-nb2v
- 9. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home State & National Averages. State and national averages used for comparison. https://data.cms.gov/provider-data/dataset/xcdc-v8bm
- 10. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Health Inspection Cut Points. Score ranges that earn each health inspection star in a state. https://data.cms.gov/provider-data/dataset/hicp-9999
- 11. Centers for Medicare & Medicaid Services. Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide. How the star ratings, scope and severity points, and abuse and Special Focus flags are defined. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf
- 12. Centers for Medicare & Medicaid Services. Medicare Care Compare. CMS's own consumer site, with the latest figures. https://www.medicare.gov/care-compare/
Attendant Homes is not affiliated with or endorsed by CMS. The data describes past inspections and reported figures and can be out of date or contain errors; it is not a recommendation. Confirm current information with the facility and on Medicare Care Compare [12] .
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