Maclay Healthcare Center

In the surveyor’s words

From the most serious findings on record at Maclay Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF805Jan 16, 2026

  Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs (requirements for a person's well-being, such as food) for:1. Three (3) of eight (8) sampled residents (Resident 14, Resident 96, and Resident 24) on pureed diet (a texture modified diet that consist of smooth, pudding-like consistencies that are easy to swallow) by not following the recipe for puree oatmeal and in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks) when on 1/13/2026, Resident 14, Resident 96, and Resident 24 were served regular oatmeal with lumps, grains, and was not pureed.2. […]

• Immediate jeopardy, isolatedF600Mar 22, 2025

  Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. […]

• Immediate jeopardy, isolatedF689Mar 22, 2025

  Based on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of residents) for two of four residents (Resident 1 and Resident 2) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. […]

• Immediate jeopardy, isolatedF806Oct 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 135) was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when on 10/8/2024, Resident 135, who was allergic to onions, was served baked beans containing onions for lunch. This deficient practice resulted in Resident 135 being served baked beans containing onions which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and… […]

• Immediate jeopardy, isolatedF600Jun 7, 2024

  Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was cognitively (mental action or process of acquiring knowledge and understanding) intact and had a history of right-sided weakness following a cerebral infarction (stroke-a loss of blood flow to part of the brain, which damages brain tissue), was free from sexual abuse (sexual behavior or a sexual act forced upon a woman, man, or child without their consent). On 5/26/2024 at 8:45 p.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3, after hearing Resident 1 yelling for help, went to Resident 1 ' s room. CNA 2 and CNA 3 witnessed Resident 2, Resident 1 ' s roommate, on top of Resident 1 and was kissing Resident 1 ' s neck area. […]