Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurel Park Behavioral Health Center during CMS and state inspections, most recent first.
The facility failed to timely complete and transmit annual MDS assessments for two residents and failed to accurately complete and transmit a discharge MDS for another resident. One resident had schizophrenia, anemia, and CKD; another had schizophrenia, HTN, and hyperlipidemia; and a third resident with schizoaffective disorder and HTN was discharged, but the last MDS was submitted as a Quarterly assessment instead of a discharge record. The DON stated the annual assessments were submitted late and that the discharge record needed to reflect the correct resident status.
Failure to Inform Residents of Coffee Social Discontinuation: The facility permanently stopped the daily coffee social, also called the community break, without informing six sampled residents who were documented as alert and cognitively intact or able to make needs known. Residents stated the coffee social relaxed them, made them happy, and supported socialization, while the FSS said it had been part of the routine for years and was removed by admin recommendation. The activity schedule still listed the event as recurring with no cancellation noted, and Resident Council minutes showed residents asked for it back.
Failure to Maintain Dignity During Resident Behavior Outburst: A resident with paranoid schizophrenia, depression, and an LPS conservatorship became agitated and yelled in the hallway near the dining room. A counselor told the resident, "Stop that if you do not want to be restrained," and the resident responded angrily and made a threatening statement. The PD stated staff should have used calm redirection, reassurance, and questions about what was bothering the resident, and that mentioning restraints did not treat the resident with dignity and respect.
Two resident rooms were observed with missing or chipped floor tiles, chipped paint, and a brown/blackish substance along the walls leading to the restroom. A resident stated the room’s appearance lessened the homelike environment and made him feel uncomfortable. The MS and ADM both stated that the conditions were unacceptable and not consistent with a homelike setting, and the facility policy called for a clean, sanitary, and orderly environment.
A resident with schizophrenia and obesity was involved in a resident-to-resident altercation in which hair was pulled and injuries were documented, followed by reports of pain to the head and leg. Pain medication was given on subsequent days, but the MRD and DON confirmed there was no pain care plan in the paper or electronic chart, and the DON stated the resident did not have a care plan addressing pain.
Failure to Administer Omeprazole Before Meals: An LVN gave a resident’s Omeprazole with the morning medication pass instead of 30 to 60 minutes before food as ordered. The resident had GERD without esophagitis and no cognitive impairment, and the MAR, blister pack, and MRR all indicated the PPI should be administered before meals. The LVN acknowledged the medication needed to be given before meals for better absorption and effectiveness.
Resident Rooms Did Not Meet Minimum Square Footage Requirements: The facility failed to ensure 16 of 19 multi-occupancy resident rooms met the minimum 80 sq. ft. per resident requirement. The cited rooms had two or three beds each and were documented in the CAA as being below the required space. Observations found the rooms uncluttered and residents moving freely, and no residents voiced concerns about room size; an LVN also reported no complaints and noted residents had corridors, blinds for privacy, and closets.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
A resident with a history of paranoid schizophrenia and another resident, both cognitively intact and independent, were involved in an incident where one shoved the other in the hallway after a disagreement. Staff and care records indicated a known history of boundary issues between the two, and the facility's policy defined such physical contact as abuse. The event was reported and confirmed by staff interviews, resulting in a deficiency for not protecting residents from physical abuse.
A resident in an LTC facility did not receive orthostatic blood pressure monitoring as ordered by the physician. The resident, with diagnoses including schizophrenia and major depressive disorder, was on antipsychotic medications requiring monitoring for hypotension. On a specified date, only two blood pressure readings were taken, and they were in the wrong sequence, with no standing reading recorded. This was confirmed by interviews with an LVN and the DON, who acknowledged the failure to follow the physician's order.
The facility failed to obtain informed consents for two residents regarding antipsychotic medications. One resident's consent for Clozapine lacked frequency details, while another resident's consent for an increased Olanzapine dose was missing. Staff acknowledged these oversights, which violated facility policies requiring informed consent before administering such medications.
The facility failed to develop and implement individualized care plans for two residents, leading to unmet needs. One resident refused to use a recommended walker after falls, and the facility did not create a care plan to address this refusal. Another resident required supervision during smoking breaks, but no care plan was documented to ensure safety interventions. These deficiencies resulted in unmet needs and potential negative impacts on the residents' well-being.
The facility failed to follow physician orders and medication management policies for two residents. One resident did not have orthostatic blood pressure monitored as ordered, and another missed doses of Propranolol due to a failure to reorder the medication in a timely manner. These deficiencies were due to lapses in following established procedures for physician orders and medication management.
The facility failed to properly dispose of expired medications for three residents, as expired antibiotics were found in the medication cart during an inspection. The medications, including Sulfamethoxazole-Trimethoprim and Amoxicillin, were not disposed of until after their expiration dates, contrary to the facility's policy. This oversight was confirmed through the Medication Disposition Record and staff interviews, highlighting a lapse in procedure adherence.
A facility failed to accurately document a resident's assessment, leading to a discrepancy in the resident's ability to hear and communicate. The resident was incorrectly noted as nonverbal and deaf, despite being able to communicate verbally. This error was due to a mix-up by an NP, potentially affecting the resident's care plan.
A resident with schizophrenia and substance abuse issues experienced a fall, but the facility failed to update the care plan with new interventions as required by policy. Staff interviews confirmed the oversight, which could impact the resident's well-being.
A facility failed to ensure a CNA completed the required annual skills training, which is necessary for maintaining competencies in resident care. The CNA was hired and completed initial training in 2023 but lacked documentation of skills training in 2024. Despite this, the CNA continued to provide direct patient care, as confirmed by timecards and assignment sheets. The Director of Staff Development acknowledged the oversight, noting that the CNA should not have been caring for residents without updated training, contrary to the facility's policy requiring annual in-service training.
The facility did not have a full-time DON, with the role temporarily filled by multiple RNs. The Administrator confirmed the absence of a DON, and an RN highlighted the importance of having a DON for proper oversight of resident care. An employment letter indicated a future start date for a new DON, while facility policy required a full-time DON to oversee nursing standards.
A facility failed to monitor the use of haloperidol for a resident with schizoaffective disorder and anxiety. The PRN order for haloperidol lacked an end date, contrary to the facility's policy of limiting such orders to 14 days. The resident's anxiety behaviors and potential side effects of the medication were not monitored, as required by the facility's policy.
The facility failed to label a bowl of cottage cheese in the kitchen refrigerator with the date of preparation and expiration, violating their food storage policy. This oversight was discovered during a kitchen tour, where a staff member confirmed the labeling requirement. The unlabeled food could potentially lead to foodborne illness if consumed.
The facility did not have an employed Director of Nursing (DON) present at the Quality Assurance Performance Improvement (QAPI) meetings, as required by their policy. The absence of a DON, who oversees nursing services and direct patient care, was confirmed by the Administrator during a review of meeting attendance records.
Two residents were involved in a physical altercation where one punched the other, leading to a retaliatory push. Both residents have mental health diagnoses and were generally calm before the incident. The facility's policy on preventing abuse was not effectively implemented, resulting in the altercation.
The facility failed to meet the minimum space requirements for 15 out of 19 resident rooms, with nine rooms housing two residents each and seven rooms housing three residents each, all below the required 80 square feet per resident. Despite a waiver request indicating adequate space, surveyors noted potential impacts on care provision. Observations showed rooms were uncluttered, and a CNA confirmed sufficient space for care duties.
Two residents were involved in a physical altercation after one elbowed the other, leading to retaliation and a bloody nose. Staff witnessed the incident but did not immediately separate the residents, contrary to the facility's abuse prevention policy. The residents involved had histories of mental health issues, and the incident occurred during a period of agitation for one of them.
The facility failed to appoint a full-time DON after the previous DON resigned, leaving the facility without proper oversight for nursing care in September and October 2024. Interviews and record reviews confirmed the absence of a DON, with staff emphasizing the importance of this role for smooth operations and resident safety. The Acting DON, an LVN, primarily served as an infection control nurse, not fulfilling the DON responsibilities.
A resident was physically assaulted by another in the dining room, resulting in a skin tear and scratch. The incident occurred after one resident accused the other of taking an apple, leading to multiple punches. The assaulted resident had moderate cognitive abilities and was independent in daily activities, while the aggressor had schizophrenia and drug-induced akathisia.
A resident with schizophrenia reported feeling unsafe after another resident placed their hand on his crotch without consent. Both residents were assessed to have intact cognitive status, but the incident was classified as sexual abuse by facility staff. The facility's policies emphasize the right of residents to be free from abuse, which was violated in this case.
A resident in an LTC facility was physically abused by another resident, who intentionally hit them on the arm, knocking a drink from their hand. Both residents had schizophrenia, with the aggressor also having moderate cognitive impairment and a history of physical behavioral symptoms. The facility's policies prohibit such abuse, but the incident was not prevented, resulting in a deficiency.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours on one day, as required by their policy. This was confirmed during a review of the nurse staffing sign-in sheet and interviews with the Administrator and Director of Staff Development (DSD). The absence of an RN on duty was acknowledged as a failure to meet the facility's policy, which mandates RN coverage for at least eight hours every day.
The facility failed to prevent physical and verbal abuse when one resident hit another on the head and verbally abused her. Despite being aware of ongoing tension and previous verbal altercations between the two residents, the facility's measures to keep them apart were insufficient, leading to the incident.
Late and inaccurate MDS submissions
Penalty
Summary
The facility failed to complete and transmit required MDS assessments within the required timeframes for three residents. For Resident 20, the record showed admission on 10/3/2019 with diagnoses including schizophrenia, anemia, and chronic kidney disease. The resident’s H&P dated 1/26/2025 stated the resident was able to make needs known and make decisions, and the annual MDS dated 9/17/2025 showed intact cognition and independence with personal hygiene, dressing, toileting, and bathing. The MDS History Report dated 10/13/2025 showed the annual MDS was export ready with a date of 9/17/2025, but the DON stated the assessment was submitted late on 11/13/2025 and should have been submitted by 9/17/2025. For Resident 43, the record showed admission on 10/2/2024 with diagnoses including schizophrenia, essential HTN, and hyperlipidemia. The H&P dated 1/25/2025 stated the resident could not make own decisions but was able to make needs known, while the annual MDS indicated intact cognition and independence with toileting, bathing, and personal hygiene. The MDS History Report dated 10/13/2025 showed the annual MDS was export ready with a date of 10/8/2025, but the DON stated the assessment was missed and then submitted on 11/13/2025, after the required date. The facility also failed to complete and transmit a discharge MDS accurately and timely for Resident 48. The resident was admitted with schizoaffective disorder and HTN, and the H&P dated 10/22/24 stated the resident could not make decisions but could make needs known. The discharge note dated 7/5/2025 showed the resident was discharged that day, but the MDS submission record showed the last submission dated 7/4/2025 as a Quarterly assessment. LVN 1 stated the latest MDS was submitted under Quarterly as advised by the facility’s consultant, and the DON stated the resident was discharged on 7/5/2025, not 7/4/2025. The DON also stated the MDS needed to be as accurate as possible so the State had the correct information regarding resident status.
Failure to Inform Residents of Permanent Discontinuation of Coffee Social
Penalty
Summary
The facility failed to inform six sampled residents that the daily coffee social, also referred to as the community break, had been permanently discontinued. The affected residents included individuals with diagnoses such as schizophrenia, schizoaffective disorder, diabetes, hypertension, hypothyroidism, constipation, vitamin D deficiency, cannabis dependence, and deafness/non-speaking status. Several of the residents were documented as alert, oriented, and able to recall information, and multiple interviews showed they wanted the coffee social restored or were upset by its removal. During interviews on the unit, residents stated that coffee social relaxed them, made them happy, helped them socialize, or was part of their routine after smoking. One resident said the loss of coffee social made them sad, another said they were mad when it was taken away, and another said it upset them because they wanted coffee after smoking. A resident who was deaf and used sign language was also documented as alert and cognitively intact and stated that coffee calmed them down. These statements showed that the coffee social was a preferred daily activity for the sampled residents. The Food Service Supervisor stated coffee social had been part of the facility for three years, had not been on the regular calendar for two months, and was removed because coffee was not part of the residents’ regular diet and because the administrator recommended stopping it. The DON stated residents had not been happy about the coffee social being taken away and was not aware they wanted it back. The activity schedule still listed the daily community break as a recurring activity from 9:30 to 10:00 a.m. with no notation of cancellation, modification, temporary suspension, or permanent discontinuation. Resident Council minutes showed residents asked for coffee social to return, and the facility responded that socials were not required and would not be reinstated at that time.
Failure to Maintain Dignity During Resident Behavior Outburst
Penalty
Summary
The facility failed to treat one sampled resident with dignity and respect during a behavior outburst. The resident was admitted with diagnoses including paranoid schizophrenia and depression, and the care plan identified a potential for verbal outbursts and aggression toward staff and peers, with interventions directing staff to approach the resident in a calm and reassuring manner and prompt appropriate behavior. The resident’s history and physical also identified the resident as an LPS conservatee. During an observation, the resident was walking in the hallway near the dining room, appeared agitated, and was yelling out. A counselor told the resident, "Stop that if you do not want to be restrained." The resident then appeared angry, walked through the dining room toward rooms 12 to 20, and stated, "Get out of my way or else I will hurt you." In an interview, the Program Director stated staff should redirect an aggressive resident by asking what is bothering them, how they can help, and whether they feel safe, and stated staff should not mention restraints during behavior outbursts because that could worsen agitation. The Program Director stated the comment about restraints did not treat the resident with dignity and respect and that the resident needed praise and reassurance to help calm down.
Unsafe and Unkempt Resident Rooms
Penalty
Summary
The facility failed to maintain resident rooms in a safe, well-kept, and homelike condition. During observation, two resident rooms were found with missing or chipped floor tiles, chipped paint on the walls, and an accumulation of brown/blackish substance along the walls leading into the restroom. The condition of the rooms was identified during survey observation, and the report states that these findings affected two of three resident rooms reviewed. Resident 43 stated during interview that the appearance of the room lessened the homelike environment and made him feel uncomfortable. The Maintenance Supervisor stated that resident rooms with missing tiles, chipped paint, and dirt accumulation were unacceptable, and the Administrator stated that chipped paint and accumulated dirt in resident rooms were not acceptable and did not reflect a homelike environment. The facility policy titled Homelike Environment stated that staff and management maximize characteristics that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Failure to Develop a Pain Care Plan After Resident Altercation
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for pain for Resident 23 after a resident-to-resident altercation. Resident 23 was admitted with diagnoses including schizophrenia and obesity. The history and physical dated 10/22/2024 stated Resident 23 could not make decisions but could make needs known, while the MDS dated 10/15/2025 indicated Resident 23 was cognitively intact, had clear speech, and could understand and be understood by others. The SBAR dated 11/6/2025 documented that another resident pulled Resident 23's hair during an altercation. A later SBAR dated 11/7/2025 documented scratches on the inner left arm and new pain above the left eye and in the left lower leg. The MAR for November 2025 showed pain medication was administered on 11/8/2025 and 11/9/2025. During interview and record review, the MRD and DON stated there was no care plan for pain in either the paper or electronic chart, and the DON stated Resident 23 did not have a care plan that addressed pain.
Failure to Administer Omeprazole Before Meals
Penalty
Summary
Licensed Vocational Nurse 2 failed to follow the ordered administration instructions for Omeprazole for Resident 12. Resident 12 was admitted with diagnoses including paranoid schizophrenia and GERD without esophagitis, and the Minimum Data Set indicated no cognitive impairment and independence with all activities of daily living. During observation, LVN 2 prepared the resident’s 9:00 AM medications, including Omeprazole 20 mg, and the blister pack indicated the medication was to be given 30 to 60 minutes before meals. At 8:59 AM, Resident 12 came to the nursing station window and LVN 2 administered seven medications, including Omeprazole. A concurrent review of the blister pack and Medication Review Report confirmed the order for Omeprazole 20 mg by mouth once daily 30 to 60 minutes before food, while the Medication Administration Record scheduled the medication for 9:00 AM. During interview, LVN 2 stated Omeprazole needed to be administered before meals for the medication to be absorbed and more effective, and stated the time of administration needed to be changed before meals. The facility policy stated medications are administered in accordance with written orders and before- or after-meal orders are based on mealtimes.
Resident Rooms Did Not Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 16 of 19 resident rooms met the minimum requirement of 80 square feet per resident in multiple-occupancy rooms. The rooms identified were 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 16, 17, 20, 21, 22, and 23. Nine of the rooms had two beds each and seven had three beds each. The Client Accommodation Analysis showed that these rooms were below the required square footage per resident, with room sizes ranging from 143 sq. ft. to 235 sq. ft. depending on the number of beds in the room. The facility’s room waiver request letter dated 11/12/2025 stated that there was adequate space for nursing care and that the health and safety of residents in these rooms were not in jeopardy. During observations from 11/12/2025 to 11/14/2025, the cited rooms were uncluttered and residents moved freely in their rooms. No residents expressed concern about room size during interviews or at the Resident Council Meeting. During an interview on 11/14/2025 at 3:20 PM, LVN 4 stated there were no complaints from residents about room size, that residents had their own corridors, could close blinds for privacy, and had their own closets for clothing.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident shoved another in the hallway. Resident 1, who had a diagnosis of paranoid schizophrenia but was cognitively intact and independent in self-care and mobility, reported being shoved by another resident (Resident 2) during a conversation about arcade games. Resident 2, also cognitively intact and independent, admitted to shoving Resident 1 in the chest after becoming upset. Both residents had a documented history of boundary issues and previous play fighting. The incident was reported to staff, and interviews confirmed that the shove was deliberate and caused distress to Resident 1. Facility records, including care plans and interdisciplinary notes, indicated awareness of ongoing boundary issues between the two residents. Staff interviews revealed that the facility's policy defines such physical contact as abuse, regardless of intent to harm. The facility's abuse prohibition policy was reviewed, which states that any willful infliction of injury or physical contact such as hitting or shoving constitutes abuse. The incident was recognized by staff and administration as a violation of this policy, resulting in a deficiency for failing to ensure residents were free from physical abuse.
Failure to Monitor Orthostatic Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with the physician's order for orthostatic blood pressure monitoring. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and general anxiety, was prescribed antipsychotic medications that required monitoring for side effects related to hypotension. The physician's order specified that orthostatic blood pressure readings should be taken in three positions: lying, sitting, and standing, to monitor for orthostatic hypotension. On January 15, 2025, the facility did not perform the orthostatic blood pressure monitoring as ordered. The records showed that only two blood pressure readings were taken, and they were done in the wrong sequence. The sitting blood pressure was recorded at 10:30 a.m., followed by the lying blood pressure at 10:33 a.m., with no standing blood pressure reading taken within minutes of the other two. This failure to follow the physician's order was confirmed during interviews with the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the resident was not monitored for orthostatic hypotension as required. The facility's policy and procedure documents indicated that all physician orders should be complete and accurate, and that treatment orders should include a description of the treatment, frequency, and duration. Despite these guidelines, the facility did not adhere to the physician's order for orthostatic blood pressure monitoring, which could have potentially resulted in adverse effects for the resident, such as hypotension, dizziness, and falls.
Failure to Obtain Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to obtain informed consents for two residents, Resident 7 and Resident 18, regarding the administration of antipsychotic medications. For Resident 7, the informed consent for Clozapine did not include the frequency of administration, which is a required element. The Licensed Psychiatric Technician (LPT) and Registered Nurse (RN) involved acknowledged that the informed consent was incomplete and should have included all necessary information, such as medication, dosage, frequency, diagnosis, and manifestation. This oversight was identified during a review of the resident's Medication Administration Record and informed consent documentation. For Resident 18, the facility did not obtain informed consent before increasing the dose of Olanzapine from 25 mg to 30 mg. The resident's cognition was intact, and they were independent with activities of daily living. Despite this, the required informed consent for the dosage increase was not found in the records. The RN and Health Information Manager (HIM) confirmed that the informed consent was likely not obtained, as it could not be located during the review. The facility's policies and procedures require that informed consent be obtained and verified by a licensed nurse before administering antipsychotic or psychotropic medications. These deficiencies indicate a failure to adhere to the facility's guidelines for informed consent, which are intended to ensure that residents or their conservators are fully informed about the treatments they receive, including the risks, benefits, and alternatives.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents, leading to deficiencies in addressing their specific needs. For Resident 17, the facility did not timely develop a care plan to address the resident's refusal to use a front wheel walker (FWW) after experiencing several falls. Despite a physical therapy evaluation recommending the use of a walker as a fall prevention measure, the resident refused to use it, citing feelings of aging. The facility did not create a care plan to address this refusal, which could have helped in developing strategies to mitigate fall risks while respecting the resident's autonomy. For Resident 24, the facility did not implement a care plan to address the need for supervision during smoking breaks, as required by the facility's policy. The resident's smoking evaluation indicated a need for supervision due to an inability to light a cigarette independently. However, there was no smoking care plan documented in the resident's medical record. This lack of a care plan meant that necessary interventions for the resident's safety, such as proper handling of cigarettes and compliance with smoking policies, were not ensured. The facility's policies require that individualized comprehensive care plans be developed for each resident, including measurable objectives and timetables to meet their medical, physical, mental, and psychosocial needs. The failure to develop and implement these care plans for Residents 17 and 24 resulted in unmet individualized needs and had the potential to negatively affect their physical and psychosocial well-being.
Failure to Follow Physician Orders and Medication Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, Resident 24 and Resident 39, as per the physician's orders and facility policies. For Resident 24, the facility did not follow the physician's order to monitor orthostatic blood pressure (OBP) from February 2024 to December 2024. Despite the order being active since March 2023, the facility's records did not indicate any OBP measurements were taken during this period. Interviews with Registered Nurses (RN) confirmed that the OBPs were not carried out as required, and there was no documentation to suggest otherwise. The failure to follow the physician's order was acknowledged by the nursing staff, who emphasized the importance of adhering to such orders to ensure patient safety and correct treatment. For Resident 39, the facility failed to reorder Propranolol, a medication used to treat severe restlessness and agitation, resulting in the resident missing five doses. The Medication Administration Record (MAR) indicated that the medication was unavailable on several occasions in December 2024. Interviews with nursing staff revealed that the medication should have been reordered when it was first identified as unavailable on December 13, 2024. However, there was no documentation to confirm when the medication was reordered, and the pharmacy records showed that the refill request was only made on December 17, 2024. The lack of timely reordering and documentation was noted as a significant issue by the nursing staff, who highlighted the importance of maintaining an adequate medication supply and proper documentation to ensure effective communication and resident care. The facility's policies and procedures for physician orders and medication management were not followed, leading to these deficiencies. The policy for physician orders required complete and accurate documentation, which was not adhered to in the case of Resident 24. Similarly, the policy for medication ordering and receiving from the pharmacy required medications to be reordered five days in advance, which was not followed for Resident 39. These lapses in following established procedures resulted in incorrect treatment and had the potential to impact the residents' physical and mental well-being.
Failure to Properly Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure the proper disposal of expired medications for three residents, as per their Policy and Procedure on Disposal of Medications and Medication-Related Supplies. During a medication cart inspection, three blister packs of expired antibiotics were found, which included Sulfamethoxazole-Trimethoprim for one resident and Amoxicillin for two other residents. These medications had expiration dates ranging from December 2, 2024, to December 16, 2024, but were not disposed of until December 18, 2024. This oversight had the potential to result in the accidental use of ineffective medications, posing a risk of bacterial growth and physical decline for the residents involved. The facility's Medication Disposition Record/Pass Log confirmed the expiration and delayed disposal of these medications. Interviews with the registered nurse and licensed psychiatric technician revealed that expired medications were supposed to be recorded in a log and disposed of in a locked bin, separate from current medications. However, the expired medications were found in the medication cart, indicating a lapse in following the facility's procedures. The facility's policy stated that discontinued medications should be destroyed within 90 days, but this was not adhered to in this instance.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure accurate documentation in the assessment entry of a resident's History and Physical (H&P) exam, which led to a discrepancy in the resident's ability to hear and communicate. The resident, who was admitted with diagnoses including schizophrenia, moderate intellectual disabilities, and chronic obstructive pulmonary disease, was incorrectly documented as nonverbal, deaf, and using sign language. This error was identified during a review of the resident's Minimum Data Set (MDS), which indicated the resident had adequate hearing and clear speech, and was independent in activities of daily living and mobility. An observation confirmed the resident was able to verbally communicate without difficulty. The error was attributed to Nurse Practitioner 1, who admitted to mixing up the resident's information with another patient during documentation. The facility's policy and procedure guidelines emphasize the importance of concise, accurate, and complete charting and documentation. The inaccurate assessment had the potential to negatively affect the resident's plan of care and delivery of necessary services, as it provided the foundation for proper diagnosis and treatment. Interviews with facility staff highlighted the critical nature of accurate assessments in ensuring appropriate care and avoiding potentially harmful consequences.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for Resident 36 after the resident experienced a fall on October 30, 2024. Resident 36, who was admitted on March 26, 2024, with diagnoses including schizophrenia and psychoactive substance abuse, had a care plan initiated on May 3, 2024, for being at risk for falls. The care plan included interventions such as obtaining orthostatic blood pressure and providing verbal cues for safety. However, after the fall on October 30, 2024, the care plan was not updated to include new interventions, despite the facility's policy requiring such updates after a fall. Interviews with staff, including a Licensed Psychiatric Technician and a Registered Nurse, confirmed that the care plan was not revised following the fall. The staff acknowledged that care plans should be updated after each fall to address specific risk factors and prevent future incidents. The facility's policies on care plan comprehensive and fall management also indicated that care plans should be reviewed and revised when there is a significant change in a resident's condition, such as a fall. The failure to update the care plan had the potential to result in unmet individualized needs for Resident 36 and affect the resident's physical and psychosocial well-being.
Failure to Ensure Annual Skills Training for CNA
Penalty
Summary
The facility failed to ensure that one of four Certified Nursing Assistants (CNA 3) had completed the required annual skills training, which is necessary to maintain competencies for safe resident care. CNA 3 was hired on 5/2/2023 and completed initial trainings on 5/2/2023, 5/3/2023, and 5/5/2023. However, there was no documentation indicating that CNA 3 completed any skills training in 2024. Despite this, CNA 3 continued to provide direct patient care, as evidenced by timecards and assignment sheets showing work on 12/7/2024 and 12/8/2024. The Director of Staff Development acknowledged the lack of updated skills training and stated that CNA 3 should not have been caring for residents without it. The facility's policy requires all staff to participate in initial orientation and annual in-service training, which was not adhered to in this case.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a full-time Director of Nursing (DON) was employed, which is a requirement for proper oversight of nursing practices. During an interview, the Administrator confirmed that the facility currently had no DON, and the role was being filled by multiple Registered Nurses (RNs). This was corroborated by an interview with an RN who emphasized the importance of having a DON onsite due to their greater knowledge, training, and experience in handling resident treatments and medications. A review of the facility's employment letter indicated that a full-time DON position was offered and accepted, with a start date set for a future date. The facility's policy and procedure document stated that the DON should be employed full-time and responsible for overseeing nursing practice standards.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor the use of psychotropic medication, specifically haloperidol, for one resident. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar type, and anxiety disorder, was prescribed haloperidol on a PRN basis for anxiety. However, the facility did not adhere to its policy of limiting PRN orders for psychotropic drugs to 14 days. The medication administration record lacked an end date for the haloperidol order, which could lead to its administration beyond the intended period. Additionally, the facility did not monitor the resident's anxious behaviors or the side effects of haloperidol, as required by their policy. Interviews with nursing staff revealed that the resident's anxiety manifested through pacing, fidgeting, and verbalization of anxiety, but these behaviors were not documented or monitored. The staff acknowledged that the order should have included the manifestation of anxiety and the duration of the order to ensure proper understanding and management of the resident's condition. The facility's policy required monitoring for efficacy, risks, benefits, and adverse consequences of psychotropic medications, but this was not done for the resident in question.
Failure to Label Food in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling of food items in the kitchen, which is a violation of their food storage policy. During a kitchen tour, a Styrofoam bowl wrapped in plastic was found in the reach-in refrigerator without a date label. The bowl contained a white substance, later identified as cottage cheese, intended for a resident's breakfast. However, the resident did not consume it. The staff member acknowledged that all food in the refrigerator should be labeled with the name of the item, the date of preparation, and the date of expiration. The facility's policy, titled Healthcare Services Group (HCSG) Policy 019: Food Storage - Cold Foods, mandates that all Time/Temperature Control for Safety (TCS) foods must be stored in accordance with the U.S. Food and Drug Administration (FDA) Food Code. This includes being wrapped or in covered containers, labeled, dated, and arranged to prevent cross-contamination. The failure to label the bowl with the date of preparation and expiration could potentially lead to foodborne illness if consumed, as stated by the staff member.
Lack of Director of Nursing in QAPI Meetings
Penalty
Summary
The facility failed to have all required members of the Quality Assessment and Assurance committee present, specifically lacking an employed Director of Nursing (DON). During a review of the Quality Assurance Performance Improvement (QAPI) Meeting attendance records for meetings held on 9/20/2024 and 10/24/2024, it was found that the DON was not present. The Administrator confirmed that the facility did not have a DON employed at the time, which is crucial as the DON oversees nursing services and the direct care provided to patients. The facility's policy and procedure document, revised in March 2020, specifies that the Director of Nursing Services is a required member of the committee.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect two residents, Resident 2 and Resident 15, from physical abuse, as outlined in their Abuse Prohibition Policy and Procedure. On December 11, 2024, an altercation occurred between the two residents, where Resident 2 punched Resident 15 in the chest after being called a name, and Resident 15 retaliated by pushing Resident 2 to the ground. This incident was documented in Resident 2's progress notes and was reported in the Confidential Adverse Incident Initial Reporting Form. Resident 2, who has a history of schizophrenia, moderate intellectual disabilities, and chronic obstructive pulmonary disease, was admitted to the facility in 2011 and readmitted in 2014. The Minimum Data Set (MDS) for Resident 2 indicated that their cognition was moderately intact, and they were independent in activities of daily living and mobility. Resident 15, admitted in 2020, has diagnoses including schizoaffective disorder, hypertension, and anemia, with their MDS also indicating moderately intact cognition and independence in daily activities and mobility. Interviews with staff and residents revealed that the altercation was not witnessed from the beginning, but CNA 1 and Resident 8 provided accounts of the incident. CNA 1 noted that neither resident showed signs of aggression prior to the altercation, and both residents were generally calm. The facility's policy emphasizes the need for adequate supervision to prevent resident-to-resident altercations, which was not effectively implemented in this case, leading to the physical abuse incident.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 15 out of 19 resident rooms met the minimum requirement of 80 square feet per resident in rooms with more than one resident. Specifically, nine rooms housed two residents each, and seven rooms housed three residents each, all of which were below the required space per resident. This deficiency was identified through a review of the facility's Client Accommodation Analysis (CAA) and was confirmed during an observation and walk-through of the facility. The rooms in question were found to be uncluttered, and residents were able to move freely without expressing concerns about the room sizes. Despite the facility's room waiver request letter indicating that there was adequate space for nursing care and that the health and safety of residents were not in jeopardy, the surveyors noted the potential for insufficient space to impact the ability of nursing staff to provide resident hygiene care and for residents to reside comfortably. During an interview, a Certified Nursing Assistant (CNA) stated that there was enough space in each resident's room to perform care duties, such as helping residents and changing bed sheets. However, the facility's failure to meet the minimum space requirements for resident rooms was documented as a deficiency.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in an altercation between them. Resident 1, who has a history of schizophrenia, autism, and hypertension, was involved in an incident where they elbowed Resident 2, who has paranoid schizophrenia and other conditions. This led to Resident 2 retaliating by hitting Resident 1, causing a bloody nose and pain rated 5 out of 10. The incident was witnessed by staff, but they did not immediately separate the residents, which could have prevented the escalation. Resident 1's cognitive status was moderately impaired, and they exhibited behaviors such as hallucinations and delusions. On the day of the incident, Resident 1 was reportedly agitated and had a history of striking out when frustrated. Resident 2, whose cognitive status was intact, reacted to being elbowed by Resident 1 by hitting them back. Interviews with staff and residents confirmed the sequence of events, and it was noted that Resident 1 had been cycling through a period of agitation. The facility's policy on abuse prevention requires staff to immediately separate residents upon witnessing abuse to ensure their safety. However, in this case, the staff did not act quickly enough to prevent the physical altercation. The facility's administrator acknowledged that staff should have redirected Resident 1 and separated the residents to prevent the incident from escalating. The deficiency highlights a failure to adhere to the facility's abuse prevention policy, resulting in harm to Resident 1.
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as a full-time Director of Nursing (DON) to oversee nursing service personnel for the months of September and October 2024. This deficiency was identified through interviews and record reviews, which revealed that the facility had been without a DON since the resignation of the former Director of Nursing in May 2024. The facility's RN schedules for September and October 2024 did not indicate the presence of a DON, although several RNs were scheduled to work. Interviews with staff, including a Licensed Psychiatric Technician and an RN, confirmed the absence of a DON and highlighted the importance of having a DON for smooth operations, resident assessments, and staff oversight. The Acting Director of Nursing, who was a Licensed Vocational Nurse, primarily served as an infection control nurse and did not fulfill the role of a DON. The facility's policy and procedure indicated that the nursing services department should be under the direct supervision of a registered nurse employed full-time, which was not adhered to, leaving the facility without proper clinical oversight for resident care.
Resident Assault in Dining Room
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in an incident where one resident was physically assaulted by another. On 9/12/24, Resident 1 was hit by Resident 2, leading to a skin tear on the left hand and a scratch on the right lower leg of Resident 1. The incident occurred in the dining room after dinner, where Resident 2 accused Resident 1 of taking an apple from Resident 2's drawer and subsequently punched Resident 1 multiple times. Resident 1, who was admitted to the facility with a history of myopia and COVID-19, was found to have moderate cognitive abilities and was independent in all activities of daily living. Resident 2, who was admitted with schizophrenia and drug-induced akathisia, was involved in the altercation. The facility's policy on abuse prohibition defines abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. The policy specifies that physical abuse includes actions such as hitting and slapping. During interviews, Resident 1 confirmed the details of the incident, showing the surveyor the injuries sustained, while Resident 2 admitted to hitting Resident 1 but did not provide further details. The facility's failure to prevent this altercation highlights a deficiency in protecting residents from physical abuse.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. Resident 1, who has multiple diagnoses including schizophrenia and hypothyroidism, reported feeling unsafe after Resident 2 placed Resident 1's hand on Resident 2's crotch without consent. Resident 1's medical records indicated a history of hallucinations and delusions, and the resident expressed feeling bad and unsafe following the incident. Resident 2, who also has a diagnosis of schizophrenia, was reported to have engaged in non-consensual acts with Resident 1. According to the facility's records, Resident 2 admitted to placing Resident 1's hand on his groin and acknowledged that the act was not consensual. Both residents were assessed to have intact cognitive status, but Resident 1 reported feeling threatened and unsafe around Resident 2. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that the incident was classified as sexual abuse. The facility's policies and procedures clearly state that residents have the right to be free from abuse, and the incident violated these rights. The facility's Abuse Prohibition Policy emphasizes the importance of providing a safe and secure environment for all residents, which was not upheld in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident where one resident hit another on the arm. The incident involved two residents, both with schizophrenia and other diagnoses. The resident who was hit had no cognitive impairments and was independent in daily activities, while the resident who hit was moderately impaired in cognitive skills and exhibited physical behavioral symptoms. The incident occurred when the two residents were walking past each other, and one resident intentionally hit the other, knocking a drink from their hand. The facility's policies and procedures prohibit abuse, including physical abuse such as hitting or slapping. Despite this, the incident was not prevented, and the resident experienced physical aggression from a peer. Interviews and record reviews confirmed that the resident who hit admitted to doing so intentionally after being bumped into. The facility's documentation, including progress notes and care plans, reflected the occurrence of the physical aggression, but the facility failed to prevent the abuse as required by their policies.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least eight consecutive hours on one day, specifically on 4/29/2024. This deficiency was identified during an interview and record review conducted on 5/9/2024 with the Administrator and the Director of Staff Development (DSD). The nurse staffing sign-in sheet for 4/29/2024 confirmed the absence of an RN on duty for the required duration. Both the Administrator and the DSD acknowledged the importance of having an RN on duty to oversee the safety and care of residents, as well as to conduct resident assessments and care. The facility's policy and procedure, revised in August 2022, mandates that an RN must provide services for at least eight consecutive hours every 24 hours, seven days a week.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to ensure that Resident 1 was free from physical and verbal abuse when Resident 2 hit the back of Resident 1's head and verbally abused her. Both residents had a history of verbal altercations, and the facility staff were aware of the tension between them. Despite this knowledge, the facility's measures to keep the residents apart were insufficient, leading to the incident where Resident 2 physically and verbally abused Resident 1. Resident 1 was admitted to the facility with multiple diagnoses, including schizophrenia and psychoactive substance dependence, and was cognitively intact and independent in daily activities. Resident 2, who also had schizophrenia and diabetes, was similarly cognitively intact and independent. On the day of the incident, Resident 2 admitted to intentionally hitting Resident 1 and throwing water at her due to ongoing verbal provocations from Resident 1. Interviews with various staff members, including the Primary Counselor, Licensed Vocational Nurse, Administrator/Abuse Coordinator, Director of Nursing, and a Certified Nurse Assistant, revealed that the facility was aware of the ongoing tension and had instructed staff to monitor and separate the residents. However, these measures were not effectively implemented, resulting in the physical and verbal abuse of Resident 1 by Resident 2. The facility's policies and procedures on abuse prohibition and resident rights were not adequately followed to prevent this incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,881 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pomona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pomona Vista Care Center | 1.1 mi | ★★★★★ | 4 | 0 |
| Country Oaks Care Center | 1.1 mi | ★★★★★ | 20 | 0 |
| Park Avenue Healthcare & Wellness Center | 1.4 mi | ★★★★★ | 8 | 0 |
| Inland Valley Care And Rehabilitation Center | 1.5 mi | ★★★★★ | 64 | 0 |
| Landmark Medical Center | 1.8 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Laurel Park Behavioral Health Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.