Laurel Park Behavioral Health Center

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans (CP), for two of 20 sampled residents (Resident 6 and Resident 10), were updated and revised quarterly (occurring, done, once every three months, or four times a year) in accordance with the facility's policy and procedure (P&P) titled, Care Plan Comprehensive. These failures had the potential to result in unmet individualized needs for Resident 6 and Resident 10 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure, five of twenty sampled residents (Resident 5, 6, 7, 8, and 9), were evaluated quarterly for smoking in accordance with the facility's policy and procedure (P&P) titled, Smoking. This failure resulted in compromised safety and the potential to result in harm to Resident's 5, 6, 7, 8, and 9.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the discharge minimum data set (MDS, a standardized assessment and care-screening tool) assessment in a timely manner for one of one sampled residents (Resident 48) and failed to complete and transmit the annual MDS assessment in a timely manner for two of two sampled residents (Resident 20 and Resident 43) as required by the Centers for Medicare & Medicaid Services (CMS is a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to inform six of six sampled residents (Residents 10, Resident 22, Resident 28, Resident 33, Resident 35, and Resident 42) regarding the permanent discontinuation of coffee social during daily community breaks. This deficient practice resulted in limiting residents' ability to exercise choice in the residents' daily routine and ability to participate in preferred social activity which had the potential for psychosocial harm to the residents, and violation of the residents' right to determine their preferred activities.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to treat one of one sampled resident (Resident 1) with dignity and respect during a behavior outburst on 11/14/2025. This deficient practice had the potential to result in escalation of Resident 1's behavior and the potential for a psychosocial decline to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' rooms in a safe, well-kept, and homelike condition when two of three resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with missing or chipped floor tiles, chipped paint and an accumulation of brown/blackish substance along the walls leading into the restroom. This deficient practice had the potential to exposing residents to an environment that was unclean, and negatively impacting residents' comfort, safety, and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized person-centered care plan for pain for one of one sampled resident (Resident 23) who had a resident-to-resident altercation and experienced pain on 11/12/2025. This failure had the potential for Resident 23 not to receive the necessary care and services for Resident 23's pain and the had the potential to affect the resident's physical and mental well-being.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse 2 (LVN 2) failed to follow instructions for administering Omeprazole (medication to treat certain conditions where there is too much acid in the stomach) before meals as ordered for one of six sampled residents (Resident 12). This deficient practice had the potential to affect the effectiveness of the medication for Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 16 out of 19 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 10,12, 14, 16, 17, 20, 21, 22, 23) met the minimum requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms. Nine rooms had two beds per room and seven rooms had three beds per room. This deficient practice had the potential to impact on residents' safety and the ability of staff to provide safe nursing care and privacy to the residents

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1), who was on a [NAME]-Petris-Short (LPS, a California law enacted in 1969 that regulates the involuntary commitment of individuals with mental health disorders) conservatorship (a legal process where a court appoints a person to make certain decisions for an individual who was deemed gravely disabled [unable to provide for basic needs] due to a mental health disorder), did not elope (the act of leaving a facility unsupervised and without prior authorization) from a secure facility (a building, institution, or location designed and operated with features that physically restrict unauthorized access or the movement of individuals to prevent people from leaving or others from entering) on 7/28/2025 at 9:27 PM by failing to ensure,1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) was free from physical abuse when on 6/14/2025 Resident 2 shoved Resident 1. This failure resulted in physical abuse to Resident 1 and had the potential to result in psychosocial harm and injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received treatment and care in accordance with the physician's order for orthostatic blood pressure monitoring (involves measuring blood pressure while sitting, standing, and lying down to assess changes) by failing to ensure Resident 1 was monitored for orthostatic hypotension (condition in which the blood pressure quickly drops upon standing up after sitting or lying down) with three blood pressure (BP) readings on 1/15/25 and observed for adverse side effects. This deficient practice had the potential to result in hypotension (very low blood pressure) with dizziness and fainting and can lead to falls and injuries for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consents from the resident or the resident's responsible party for two of six sampled residents (Resident 7 and Resident 18) by failing to: A. Ensure the frequency (how many times per day and how often a medication is to be administered) of Clozapine (an antipsychotic medication [a drug used to treat serious mental health conditions]) was indicated in Resident 7's informed consent. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care (care plan, CP) that included measurable objectives, timeframes, and interventions that met resident needs for two of two sampled residents (Resident 17 and Resident 24) by failing to: A. Develop a CP for Resident 17 in a timely manner to address Resident 17's refusal of the front wheel walker (FWW, a mobility device with two wheels in the front and two glide caps in the back that's used to help people with limited mobility walk and transfer) after several falls. B. Implement goals and care interventions in a timely manner to address Resident 24's need for supervision during smoking breaks. [...]

Inspectors wroteBased on interview and record review, the facility failed treatments and services were provided for two of two sampled residents (Resident 24 and Resident 39) as indicated in the facility policy and procedure (P&P) titled, Physician Order, and Medication Ordering and Receiving from Pharmacy, when, A. The facility failed to follow a physician's order from 2/2024 to 12/2024 for Resident 24, that indicated orthostatic blood pressure ([OBP], the measurement of BP taken when a person stands up from a lying or sitting position. The person lies down for at least five minutes, the BP and pulse are measured while lying or sitting, then the person stands up and the measurement is repeated after one and three minutes. The purpose is to compare the BPs taken in both positions and look for a significant drop in BP upon standing which would indicate orthostatic hypotension [low BP]) was to be taken . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal (discarding of medications) of drugs (medications), for three of three sampled residents (Residents 7, 8, and 13), as indicated in the facility's Policy and Procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, when, 1. On 12/18/2024, three blister packs (a tamper-evident packaging where individually sealed tablets are pushed through foil to dispense the medication) of expired antibiotic (medications that fight bacterial infections) medications were found in the medication cart. This deficient practice had the potential to result in the accidental use of ineffective antibiotic medications and the potential to result in bacterial growth and physical declines to Residents 7, 8, and 13.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 2 and Resident 15) were free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, when on 12/11/2024 Resident 2 punched Resident 15 on the chest and Resident 15 pushed Resident 2 to the ground. This deficient practice resulted in physical abuse and had the potential to result in injury and harm to Resident 15 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entry in the general (refers to the initial observation of the patient's overall appearance, including their level of comfort, posture, hygiene, skin color, and any noticeable physical characteristics) section on a physical and history (H&P) exam was accurately documented to reflect the Resident's ability to hear and verbalize with others for one of one sampled resident (Resident 2). This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to update a care plan (CP) and include new interventions, for one of two sampled residents (Resident 36), after Resident 36 sustained a fall on10/30/2024 and as indicated in the facility's policy and procedure titled, Care Plan Comprehensive, and Fall Management. This deficient practice had the potential to result in unmet individualized needs for Resident 36 and the potential to affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to evaluate and ensure one of four Certified Nursing Assistants (CNA 3) had completed annual skills training. This failure had the potential to result in unsafe resident care.

Inspectors wroteBased on interview and record review, one of one facility (the facility) failed to ensure a full-time Director of Nursing (DON) was employed by the facility. This failure had the potential to lead to a lack of oversight of the facility's nursing practices and effect the care provide to the residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor one of five sampled resident's (Resident 40) use of psychotropic (drug or substance that changes mood, awareness, thoughts feelings or behavior) medication haloperidol (medication used to treat nervous, emotional, and mental conditions) as evidenced by failure to limit PRN (as needed) haloperidol to 14 days per the facility's policy and procedure (P&P) and failure to monitor Resident 40's anxious behavior and side effects of haloperidol. This failure had the potential to result in Resident 40 to experience adverse (unwanted) effects of haloperidol.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were labeled in one of one kitchen (Kitchen 1) when: 1. A bowl, wrapped in plastic, was observed in the reach-in refrigerator, and the bowl was not dated. This deficient practice had the potential to result in foodborne illness (illness caused by food contaminated with bacteria) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever for the residents residing at the facility.

Inspectors wroteBased on interview and record review, one of one facility (the facility) failed to have all required members of the Quality Assessment and Assurance committee present by not having an employed Director of Nursing (DON). This failure had the potential to lead to areas of deficiency in nursing without correction or oversight at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 15 out of 19 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 16, 20, 21, 22, 23) met the minimum requirement of 80 square feet (sq. ft., unit of measure) per resident in rooms with more than one resident. Nine rooms had two residents per room and seven rooms had three beds per room. This deficient practice had the potential to result in not having enough space for nursing staff to provide resident hygiene care, or the ability of residents to reside in their room comfortably.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2), were free from physical abuse (willful infliction of injury, deliberately aggressive or violent behavior with the intention to cause harm) in accordance with the facility's policy and procedure (P&P) titled Abuse Prohibition Policy and Procedure when on 11/19/24 Resident 1 pushed Resident 2 and Resident 2 reacted by hitting Resident 1 back. This deficient practice resulted in physical abuse, pain, and a bloody nose to Resident 1.

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse (RN, a nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) to serve as a full-time Director of Nursing (DON, an RN who leads and supervises the care of all patients at a health care facility) to oversee nursing service personnel that included six of six Registered Nurses (RNs) for September and October 2024. This deficient practice left the facility without oversight for nursing care provided for all residents residing at facility. This failure placed the residents at risk for harm due to lack of clinical oversight.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of two sampled residents (Resident 1). On 9/12/24, Resident 1 was hit by Resident 2. This deficient practice resulted in a skin tear/abrasion to Resident 1's anterior left hand and a scratch to Resident 1's right lower leg.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1), was free from sexual (non-consensual sexual contact of any type with a resident) abuse in accordance with the facility's policies and procedures (P&P). Resident 2 placed Resident 1's hand on Resident 2's crotch (the part of the body that includes the groin and genitals [the sexual organs located on the outside of the body]) without Resident 1's consent (permission for something to happen or agreement to do something). This deficient practice violated Resident 1's right and resulted in Resident 1 feeling bad and unsafe in the facility around Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility's policies and procedure (P&P), when Resident 2 hit Resident 1 on Resident 1's arm. This deficient practice resulted in Residents 1 to experience physical abuse while in the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week on 4/29/2024 for one of 35 days. This deficient practice had the potential to affect the quality of nursing care provided to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical and verbal abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility's policies and procedure (P&P), when Resident 1 hit the back of Resident 2's head. This deficient practice resulted in Resident 1 experiencing verbal and physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one of seven sampled residents (Resident 2). This deficient practice had the potential to cause a negative impact on Resident 2's psychosocial well-being related to possible recollection of past trauma or reluctance to reach out to staff when feeling distressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary dietary services were provided to 43 of 43 residents in the facility in accordance with the facility's Policy and Procedure (P&P) titled Menus, by failing to: A. Ensure the facility's Registered Dietitian (RD) reviewed and approved the menus for nutritional adequacy prior to the implementation of the menu changes on 12/11/23. B. Ensure the facility menus were followed, prepared in advance, and met the nutritional needs of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Residents 16, 24, and 41) and/or their representatives were provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) by failing to: 1. Ensure Resident 16's conservator (CON 1, court appointed person to act or make decisions for another person)/Family Member (FM) 1 was notified regarding Resident 16's AD. 2. Ensure Resident 24's conservator was notified regarding Resident 24's AD. 3. Ensure Resident 41's conservator was notified regarding Resident 41's AD. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all services provided by the facility for two of two sampled residents met professional standards of quality. A. For Resident 36, the facility failed to ensure all licensed staff were aware of the facility's policy and procedures (P&P) and national standards regarding the treatment of hypoglycemia (blood sugar levels below 70 milligrams per deciliter [mg/dl, a unit of measure that shows the concentration of a substance in a specific amount of fluid] that could prevent bodily functions to continue). B. For Resident 34, Licensed Psychiatric Technician 1 (LPT 1) did not check Resident 34's heart rate (heartbeats per minute) as ordered by the physician prior to administering the blood pressure medication. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the facility had a Registered Nurse at least 8 consecutive hours a day for 7 days a week for five of 30 days in the month of June 2023 (6/10/2023, 6/13/2023, 6/15/2023, 6/18/2023, and 6/30/2023) from staffing assignments and payroll-based data reviewed. This failure had the potential to cause a decline in the residents' physical and/or psychosocial well-being related to insufficient supervision, monitoring, and coordination of care and services by the registered nurse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's food was held at a safe temperature in two of two facility freezers, during a scheduled power outage. This deficient practice had the potential to result in unsafe consumption of food served to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum required member, the Medical Director (MD, physician who provides guidance and leadership in a healthcare organization), was present for two of two quarterly Quality Assurance Performance Improvement (QAPI, data driven and proactive approach to quality improvement) meetings. This deficient practice had the potential to impact facility residents as the Medical Director was not involved in identifying and responding to quality deficiencies within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the infection prevention and control practices by failing to implement interventions to prevent and control the spread of infections in the facility in accordance with their own policies and procedures and national health guidelines. A. One (1) of two (2) staff members was not wearing a mask while serving food to the residents. B. One (1) of three (3) staff members did not perform hand hygiene upon entering the kitchen. C. Ensure personal belonging was not kept in food storage area. These failures had the potential to result in an increased spread of infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to ensure one of two sampled resident (Resident 8) was informed in advance, of the risks and benefits of taking psychotherapeutic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). This deficient practice violated the resident's right to make an informed decision regarding the use of psychotherapeutic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive plan of care for one of one sampled resident (Resident 41) who was observed to have yellow-colored teeth (change in the color of the teeth, looking less bright and white) and yellow plaque (sticky film of bacteria that constantly forms on your teeth) buildup. This failure resulted in Resident 41 not receiving individualized care and/or treatment for activities of daily living (ADL, activities related to personal care) and did not maintain the residents' highest practical physical and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain proper footwear to prevent falls by failing to follow up with the Orthopedics (Ortho, medical specialty focusing on treating injuries and diseases of the musculoskeletal system) consultation, ordered by the primary care provider 1 (PCP 1) after a fall incident for one of 12 sampled residents (Resident 36). This failure had the potential to increase Resident 36's risks for injury and repeated falls.

Inspectors wroteBased on interview and record review, the facility failed to schedule a neurologist (a doctor who treats and diagnoses conditions in the brain and nervous system) consultation for one of one resident (Resident 8). This failure resulted in Resident 8 not being examined by a neurologist.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 16) was free from unnecessary medications. Resident 16 was prescribed and received Erythromycin (an antibiotic used to treat infections) ointment to both eyes since 4/8/21 without adequate monitoring. This deficient practice had the potential for Resident 16 to receive unnecessary medication for an excessive period of time and could result in antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to monitor the antibiotic use for one (1) of one (1) sampled residents (Resident 16). This failure had the potential for the resident to develop an antibiotic resistance (when germs like bacteria and fungi develop the ability to defeat the drugs designated to kill them).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 16 of 19 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 16, 17, 20, 21, 22, and 23) meet the minimum requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. Nine resident rooms (Rooms 3, 4, 5, 6, 9, 20, 21, 22, and 23) had two beds inside each room and seven resident rooms (Rooms 7, 8, 10, 12, 14, 16, and 17) had three beds inside the room. These rooms had the potential to result in inadequate space needed to provide nursing care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one of four sampled resident (Resident 1) regarding the development of an eye contusion (black eye-deep bruise of the eye) after a physical altercation with another resident. This deficient practice may have resulted in Resident 1 delay treatment for an eye injury and having to be transferred to a general acute care hospital's emergency room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 4) was free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility ' s policies and procedure (P&P), when Resident 5 punched Resident 4 in his eye. This deficient practice resulted in Residents 4 to experience physical abuse.