Meadowbrook Behavioral: COVID Outbreak After Sick Staff - CA
The nursing assistant began feeling unwell on Saturday, August 16, experiencing body aches, throat pain, and congestion. She continued working Monday while suffering from a runny nose and coughing. On Tuesday, August 19, she still felt sick but finally took a COVID test at the facility. The test came back positive.
Two residents contracted COVID-19 during this period. Resident 8, who was cognitively intact and independent with daily activities, tested positive on August 19 at 10:19 PM. Resident 9, admitted in March with schizoaffective disorder, hypertension, and high cholesterol, also tested positive that evening at 7:03 PM.
Resident 9's condition made the outbreak particularly concerning. The resident suffered from schizoaffective disorder, a mental health condition combining symptoms of schizophrenia with mood disorders like bipolar disorder or depression. Federal inspectors noted this resident was cognitively impaired, making them especially vulnerable to infection complications.
During the inspection, the nursing assistant acknowledged her mistake. She admitted she "was not supposed to come into work feeling sick" and that she "did not make the right decision." She recognized she "should have stayed home to prevent spreading the infection in the facility."
The facility's infection prevention nurse was blunt about the policy violation. Staff members experiencing symptoms including runny nose, sore throat, coughing, sneezing, headache, or red eyes must stay home. "If they come into the building with these symptoms it may cause the symptoms to go around the building and we need to keep the resident safe as the resident in the facility are vulnerable," the nurse explained.
The infection prevention nurse directly confronted the assistant about her decision to work while sick, asking why she came to work when experiencing symptoms.
A registered nurse supervisor reinforced the policy during the inspection, stating that staff must stay away from work when exhibiting any signs of respiratory infection, including sneezing, runny nose, or fever, specifically "to prevent them from passing the infection to the residents."
The facility's own policies, updated in September 2024, explicitly addressed this situation. The infection prevention and control program was designed "to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections."
The policy specifically covered situations when employees should avoid the facility, including during "respiratory infections with considerable coughing and sneezing."
Federal inspectors found the facility violated infection control standards by failing to prevent a staff member with obvious respiratory symptoms from working and potentially exposing residents to COVID-19.
The outbreak occurred at a behavioral health facility serving particularly vulnerable residents. These patients often struggle with serious mental health conditions that can complicate their ability to understand or respond appropriately to illness. Resident 9's combination of schizoaffective disorder and cognitive impairment exemplified this vulnerability.
The timing proved especially problematic. The nursing assistant worked three full days while symptomatic before testing, providing multiple opportunities for virus transmission throughout the facility. Both infected residents tested positive on the same evening the staff member finally confirmed her COVID status.
The incident highlighted ongoing challenges in healthcare facilities where staff may feel pressure to work despite illness, potentially due to staffing shortages or other workplace factors. However, inspectors found the facility's own policies clearly prohibited such behavior.
The nursing assistant's admission that she knew she shouldn't have worked while sick suggested the facility had communicated its policies but failed to ensure compliance. Her acknowledgment that she "did not make the right decision" indicated awareness of the rules she violated.
The infection prevention nurse's emphasis on protecting vulnerable residents underscored the heightened risks in behavioral health settings. Patients with psychiatric conditions often have compromised immune systems or other health complications that make them particularly susceptible to severe COVID outcomes.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents, though the two confirmed COVID cases demonstrated actual transmission occurred. The facility now faces scrutiny over its infection control practices and staff oversight procedures.
The outbreak serves as a reminder of the ongoing risks posed by COVID-19 in congregate care settings, particularly when basic prevention protocols fail. Two vulnerable residents contracted a potentially serious infection because one staff member made what she herself called the wrong decision to work while sick.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowbrook Behavioral Health Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
MEADOWBROOK BEHAVIORAL HEALTH CENTER in LOS ANGELES, CA was cited for violations during a health inspection on August 20, 2025.
The nursing assistant began feeling unwell on Saturday, August 16, experiencing body aches, throat pain, and congestion.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.