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Complaint Investigation

Laurel Park Behavioral Health Center

August 13, 2025 · Pomona, CA · 1425 Laurel Avenue
Citations 1
CMS Rating 3/5
Beds 43
Provider ID 05A137
Healthcare Facility
Laurel Park Behavioral Health Center
Pomona, CA  ·  View full profile →
Inspection Summary

LAUREL PARK BEHAVIORAL HEALTH CENTER in POMONA, CA — inspection on August 13, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

P&P's purpose indicated, To provide a safe environment for residents.Upon admission, residents will be monitored for behavioral triggers including, but not limited to:.Increased pacing or wandering.Response to unsafe behavior: If a resident's behavior becomes.unmanageable in a way that compromises his or her safety. the Charge Nurse and the [Director of Nursing Services] DNS are notified immediately.

The Charge Nurse will: .Maintain 1-1 supervision of the resident until the behavior has subsided.During a review of the facility's P&P titled, Elopements, revised 2/21/2025, the P&P indicated, The residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.

Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless.

Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so.The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.The effectiveness of interventions will be evaluated, and changes will be made as needed.During a review of the facility's undated Protocol titled, Supervision Level Protocol and Guidelines, the protocol indicated, When residents are under general supervision, they are expected to stay in the building except when following standard policies for leaving (e.g. therapeutic pass (authorized outing), outings, appointments, and hospital stays). A staff member entering/exiting a secured resident area is responsible for detecting any resident who attempts to leave without permission.

The staff member should verbally redirect the resident away from the area and alert other staff members for assistance so they can intervene to keep the residents safe.

The protocol indicated, Increased supervision is provided to.residents whose .behavior .indicated an increased level of risk.

The protocol indicated residents required 1-1 supervision when residents were actively seeking to elope or required constant observation.

The protocol indicated 1-1 supervision is an emergency intervention that may be implemented by charge nurses or RNs with a doctor's order.

The protocol indicated that a resident on 1-1 supervision will have dedicated staff assigned to have visual contact with the resident at all times, the assigned staff will have no other duties besides the 1 to 1 observation of the resident.

The protocol's guidelines indicated a resident will be placed 1 to 1 supervision per doctor's orders for a maximum of 72 hours.

The protocol indicated the IDT will reevaluate the necessity of continuing this level of supervision.

Facility ID:

05A137

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in POMONA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAUREL PARK BEHAVIORAL HEALTH CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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