Meadowbrook Behavioral Health Center

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a physical and mental status assessment prior to one of three residents (Resident 1) leaving the facility out on pass (OOP - a temporary, physician-approved leave from a facility) for therapeutic leave on 7/10/2026 according to the facility's policy and procedures (P&P) titled Out on Pass, last reviewed by the facility on 1/21/2026. As a result, on 7/10/2026 Resident 1 eloped (when a resident leaves the facility without the knowledge or permission of the staff) from a restaurant while out on pass, placing Resident 1 at increased risk for falls, injuries, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place and develop a policy on how to supervise and monitor one of one resident (Resident 1) who was transported by court personnel to attend in person court proceedings on 6/22/2026. The facility was aware Resident 1 was a high risk for elopement and had repeated verbalized wanting to leave/elope (is when a patient leaves a healthcare facility against medical advice, when doing so poses an imminent threat to the patient's health or safety) the facility. As a result, on 6/22/2026 at approximately 3 P.M., Resident 1 eloped from the court during the resident's court proceedings and has not been located.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 28) participated in care plan meetings to discuss his psychotropic (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications according to the facility's policy and procedures (P&P), Care Planning - Interdisciplinary Team, reviewed 1/21/2026. This deficient practice had the potential to violate Resident 28's right to be an active participant in his own care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses notify the physician for orders for blood glucose monitoring twice daily as indicated in the plan of care under the physician's progress notes for one of the three residents (Resident 1). This deficient practice of failing to notify the physician for orders as indicated in the physician's plan of care had the potential to cause adverse effects of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) for Resident 1.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the facility's policy and procedure (P&P) titled, Smoking, by not performing quarterly smoking assessments for two of two sampled residents (Resident 35 and Resident 71). This deficient practice placed Resident 35 and Resident 71 at increased risk for injury related to smoking. a. A review of Resident 35's admission record indicated the facility admitted the resident, on 11/18/2025 with diagnoses that included paranoid schizophrenia (type of schizophrenia associated with feelings of being persecuted or plotted against), Syphilis (a common, curable sexually transmitted infection (STI) caused by bacteria (tiny, single-celled living organisms found everywhere in the world). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely nutritional intervention/s to prevent continuous significant weight loss for one of two sampled residents (Resident 51) who had weight loss, by failing to: 1. Initiate a change of condition (COC- refers to a significant alteration in a person's physical, mental, or functional health status compared to their previous baseline, often requiring new interventions) form for an 18 pounds (Ibs - unit of measurement) weight loss documented on 3/3/2026.2. Conduct a weight variance Interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) when Resident 51 experienced weight loss.3. Revise the interventions on Nutritional Risk Weight Loss care plans. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform a physician of an abnormal laboratory (lab) result for one of four sampled residents (Resident 61) according to the facility's policy and procedures (P&P) titled Change in Condition: Notification of reviewed 1/21/2026. This deficient practice placed the resident at risk for not having appropriate treatment for abnormal laboratory results and as a result on 11/13/2025, Resident 61 was transferred to a general acute hospital (GACH) from a doctor's appointment for chronic anemia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 27 resident rooms (rooms [ROOM NUMBER]) accommodated no more than 4 residents per room. Rooms 3, and 4 had six residents, and 5 had five residents. This deficient practice had the potential to affect the delivery of care and safety of the residents, especially during an emergency.

Inspectors wroteAmendedBased on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in 17 out of 27 resident rooms (Rooms 1, 3, 5, 7, 8, 9, 13, 15, 17, 18, 20, 21, 23, 24, 25, 26, and 27) did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate usable living space for resident Rooms 1, 3, 5, 7, 8, 9, 13, 15, 17, 18, 20, 21, 23, 24, 25, 26, and 27.

Inspectors wroteCross Reference F742 Based on interview and record review, the facility failed to protect one of four residents (Resident 3) from inappropriate touching by Resident 4 according to facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Abuse Prohibition, with a review date of 2/23/2021. The facility was aware that Resident 3 was unable to defend himself from Resident 4 and that Resident 4 had a behavior of poor personal boundaries and inappropriate physical contact with residents and staff. This deficient practice caused Resident 3 to experience psychological stress and emotional distress by stating that Resident 4 should not be touching him (Resident 3). [...]

Inspectors wroteCross Reference F600 Based on interview and record review, the facility failed to notify the psychologist (PSY - a mental health professional with advanced education [usually a doctorate] who studies the mind, emotions, and behavior, using talk therapy, assessment, and interventions to help individuals cope with life issues, mental disorders, or improve overall wellness, focusing on psychological strategies rather than medication) for one of four residents (Resident 4) who had several documented incidents of repeated inappropriate behaviors of touching Resident 3, other residents, and staff. This deficient practice caused Resident 3 to experience psychological stress and emotional distress by stating that Resident 4 should not be touching him (Resident 3). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff that was having signs and symptoms of respiratory infection (an illness caused by germs, like viruses or bacteria, that get into your breathing system -nose, throat, lungs, and airways and cause problems) stay home according to the facility's policy and procedures (P&P) titled Oxygen Therapy revised 1/27/2025. This deficient practice resulted in four out of 77 residents being positive for covid (COVID 19-A highly contagious respiratory disease).

Inspectors wroteFindings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension (when a person has abnormally high blood pressure that's not the result of a medical condition), paranoid schizophrenia (Persistent, false beliefs, often centered around persecution, where the individual believes they are being harmed or negatively affected by others). During a review of Resident 1's History and Physical (H&P) dated 10/30/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions, however, he can make needs known. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/4/2025, the resident's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) was intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's Administrator (ADM) failed to ensure to provide a safe environment and oversee the safety of one of two sampled residents (Resident 10) by failing to: -Ensure Resident 10 who could not make her own decisions and Resident 9 who could not make his own decisions had a safe environment to engage in sexual activities that occurred in the facility. -Ensure all staff including Registered Nurse 1 (RN1) were aware Resident 9 and Resident 10 had sexual activities. These failures resulted for Resident 10 to feel unsafe, have emotional distress (mental suffering), and alleged Resident 9 was sexually and physically aggressive with her (Resident 10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from sexual abuse (non-consensual sexual contact of any type or sexual harassment) from Resident 2 who had a history of exchanging money for sex while residing at the facility. On [DATE] at approximately 8:13 PM Resident 2 went inside Resident 1's room while Resident 1 (who did not have the capacity to consent for sexual activities) was laying down and Resident 2 pulled out his genitals. Resident 1 told Resident 2 to stop, and Resident 2 was masturbating in front of Resident 1 and got on top of Resident 1 while Resident 1 laying down. Resident 2 touched and sucked on Resident 1's breasts. Resident 1 told Resident 2 to stop, and Resident 2 did not stop. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Abuse Prohibition Policy and Procedure (P&P) to prohibit, prevent, and investigate allegations of sexual abuse (non-consensual contact of any type or sexual harassment), for two of six sampled residents (Resident 1 and Resident 2) by failing to ensure Resident 1 was free from sexual abuse from Resident 2 who had a history of exchanging money for sex while residing at the facility. On [DATE] at approximately 8:13 PM Resident 2 went inside Resident 1's room while Resident 1 (who did not have the capacity to consent for sexual activities) was laying down and Resident 2 pulled out his genitals. Resident 1 told Resident 2 to stop, and Resident 2 was masturbating in front of Resident 1 and got on top of Resident 1 while Resident 1 laying down. Resident 2 touched and sucked on Resident 1's breasts. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an infection prevention and control program (prevents or stops the spread of infections in healthcare settings) designed to provide a safe, sanitary (clean), and comfortable environment, and to help prevent the development and transmission of communicable diseases (illnesses that can spread from person to person) and infections for three of three sampled residents (Resident 4, Resident 5, and Resident 7) and infections by failing to: Ensure the facility implement appropriate precautions to prevent transmission of sexually transmitted infection (STI) among residents. Resident 7 who had a diagnosis of sexually transmitted diseases had unprotected sex (Sexual intercourse without a condom) with Resident 4. Resident 4 had also unprotected sex with Resident 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect two of six sampled residents'(Resident 1 and Resident 4) right to be free from physical abuse when: - On 3/21/2025, Primary Counselor (PC) 1 physically fought Resident 1 inside Resident 1's assigned room and - On 4/2/2025 Resident 5 hit Resident 4 in the nose These deficient practices resulted in Resident 1 and Resident 4 being subjected to abuse and requiring x-rays after the assault and had the potential for all residents (77) to feel powerless and unprotected in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow its' policy and procedures (P&P) by not allowing one of three sampled residents (Resident 1) to return to the facility. Resident 1 was admitted to General Acute Care Hospital (GACH) on [DATE] and was had an order to dicharge back to the facility on [DATE]. This deficient practice resulted in Resident 1 remaining at the hospital longer than necessary (24 days as of [DATE]) and had the potential to affect the resident ' s psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's right to examine the results of the most recent survey (an annual inspection of the facility by State or Federal surveyors) and any plan of correction in effect with respect to the facility by not posting the information in a readily accessible place for four of four sampled residents (Residents 68, 22, 74, and 29). This failure resulted in the denial of the resident's rights to information regarding there care while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Container of cooked leftover chicken was noted in the refrigerator without a date on it. 2. Opened and unboxed bags of meatballs, egg rolls, and some type of meat were not labeled or dated in the kitchen's freezer. 3. A pan of uncooked chicken stored on top of raw vegetables in the refrigerator. These deficiencies had the potential to result in harmful bacteria growth that could place the residents at risk for food borne illness or contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Used a quality cleaning agent to prevent the spread of infection. 2. Maintain adequate supply of N95 Masks (a personal protective equipment used to protect the wearer from particles or from liquid). These failures had the potential to result in the spread of infection to residents, staff, and guests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Repair leaking pipe under kitchen sink. 2. Repair entire wall panel from the sink that was completely separated from the wall. These deficient practices could result in: 1. Growth in mold and become a breeding ground for bacteria due to the damp environment it creates. 2. Rodents entering in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Accurately code the Minimum Data Set (MDS - a resident assessment tool) for the section relating to Antipsychotic Medication (a class of medications that treat mental illness) use for one of four sampled residents (Resident 48). 2. Transmit the quarterly and annual assessments within 14 days after completion for two of four residents sampled (Residents 45 and (52). These deficient practices had the potential to incorrectly reflect Resident 48's plan of care, care, and services received Residents 45, 48, and 52.

Inspectors wroteBased on interview and record review, the facility failed to develop/create and implement a person-centered comprehensive care plan plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) that addressed: 1. The psychotropic medication (a medication that affects behavior, mood, thoughts, or perception) medications and or medications and or medical needs and for one of six sampled residents (Resident 14). 2. The medical needs and goals for one of six sampled residents (Resident 16). These deficient practices had the potential to result in increased risks for Residents 14 and 16 to receive suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure staff are competent on what cleaning agents is effective to clean the facility to prevent the spread on viruses, bacteria, and infections. 2. Staff completed infection control skills competencies. These failure can cause or have the potential to cause a resident to contract an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to the residents and guests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 27 resident rooms (rooms [ROOM NUMBER]) accommodated no more than 4 residents per room. room [ROOM NUMBER] and room [ROOM NUMBER] had seven residents. room [ROOM NUMBER] had five residents. This deficient practice had the potential to affect the delivery of care and safety of the residents especially during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in six out of 27 resident rooms (Rooms 1, 3, 4, 5, 7, 8 and 9) in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate usable living space for the residence Rooms 1, 3, 5, 7, 8, 9 and working space for the healthcare staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate non-consensual (without permission) sexual abuse allegation by Licensed Vocational Nurse (LVN) 2 for one of three sampled residents (Resident 1). This failure resulted in Resident 1 feeling afraid to remain in the facility because the resident felt LVN 2 would touch her and kiss her again.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the nursing staff met the skills and staff competency evaluation requirements and place them in the employee files for for out of four staff. This deficient practice had the potential for a knowledge, training, and certification deficit among the nursing staff, leading to inadequate or delay resident care.

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to follow its policy and procedures (P&P) titled, Abuse Prohibition Policy and Procedure dated 2/23/21. By failing to supervise Residents 1 and 2 while the resident were in the facility ' s staircase on 5/10/24. As a result, on 5/10/2024 at 10:40 AM Resident 2 pushed Resident 1 in the staircase, placing Resident 1 at risk for serious injury, harm, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to the rights for one of two residents (Resident 1), to be free from physical abuse from Resident 2. This deficient practice resulted in Resident 1 sustaining injuries to his face.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to designate a registered nurse (RN) to serve as full-time Director of Nursing (DON) from 10/13/2023 until 12/26/2023. This deficient practice had the potential to result in the facility's inability to establish nursing standard of practices, compliance with the Stated and Federal agencies, handle emergencies in the facility, complete incident reports, initiate investigations on incidents, manage the entire nursing department and assume the responsibility for resident care in the absence of a physician, and the assume the responsibility of an Administrator in the absence of an Administrator. Placing all 77 residents at risk for harm due to lack of clinical oversight.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label food in accordance with professional standards and facility policy to ensure food service safety. By failing to: 1. Label food with expiration dates. 2. Discard expired food stored in the resident's refrigerator. 3. Ensure the resident's snack refrigerator had a functional thermometer. This deficient practice placed all 77 residents with compromised health status at risk for foodborne illnesses.

Inspectors wroteBased on interview, and record review the facility failed to follow its policy on Advanced Directives by failing to inform and documented notification to 4 of 6 sampled residents (Residents 67, 70, 51, and 40) and/or their representatives of their rights to formulate and advanced directive advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission to the facility. This deficient practice had the potential to deny the residents their rights to request or refuse medical care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a water management program was in place to test the facilities water supply for disease causing pathogens (organisms that can cause disease) as part of the facility's infection control program. This deficient practice had the potential to place residents at risk for water borne diseases including pneumonia (lung infection), which could lead to hospitalization of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (3) of 27 resident rooms (Rooms 3,4, and 5) were accommodated no more than four residents in each room. rooms [ROOM NUMBERS] had six (6) residents in each room while five (5) residents occupied room [ROOM NUMBER]. This deficient practice had the potential to affect the delivery of care and safety of the residents especially during an emergency.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure three out of six shower rooms (shower room near room [ROOM NUMBER], shower room near room [ROOM NUMBER], and the shower room near the activities room) were in safe operating condition free form safety and fire hazards. This deficient practice placed the residents at risk for falls, cuts, and other illnesses caused by unhygienic conditions, which could lead to serious injury and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of five (5) sampled residents lived in a homelike environment by providing comfortable and safe temperatures. This deficient practice resulted in the residents living under comfortable and safe temperatures, which could cause the residents to lose body heat leading to hypothermia (dangerously low body temperature).

Inspectors wroteBased on record review and interview, the director of nursing (DON) failed to demonstrate knowledge of facility residents by incorrectly completing the Matrix for Providers (used to identify pertinent care categories for all residents) during a Recertification Survey (conducted to ascertain whether a provider/supplier meets applicable requirements for participation in the Medicare and/or Medicaid programs) for 77 of 77 sampled residents. This deficient practice had a potential not to meet the residents' needs due to lack of knowledge of residents' health conditions. Findings On 1/9/2024 at 7:30 a.m., the California Department of Public Health (CDPH) entered the facility to conduct a recertification survey. During an interview on 1/9/2024 at 10:30 a.m., the administrator (Adm) stated the total in-house census (number of residents physically in the building) was 77. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure seven (7) of 27 resident rooms (1,3,5,7,8,9, and 16) met the requirement of 80 square feet (sf) per resident. These seven (7) rooms consisted of five two-bed rooms, one five-bed and one six-bed room. This deficient practice had the potential to result in inadequate useable living space for the residents in Rooms 1,3,5,7,8,9 and 16 and working space for the healthcare staff.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for five of 12 sampled residents (Resident 1, 3, 5, 6, and 10) when Resident 1, 5, 6, and 10 refused pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination in accordance with the facility's policy and procedures (P&P) titled, Care Plan Comprehensive, reviewed on 1/24/2023. Resident 3, who is high risk for PNA, was not offered a PNA vaccine. This deficient practice had the potential to result negative impact on Resident 1, 3, 5, 6, and 10's quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccine was offered and/or re-offered to four of 12 sampled residents (Resident 3, 5, 6 and 10) in accordance with the facility's policy and procedures (P&P) titled, Pneumococcal (PNA) Vaccine, reviewed on 1/24/2023. This deficient practice placed Residents 2, 4 and 5 at a higher risk of acquiring and transmitting pneumonia infection to other residents in the facility.