Inspection Reports for
Loma Linda Post Acute

The facility was found deficient in multiple areas including failure to post the most recent survey results, inaccurate PASARR assessments, failure to notify appropriate authorities of new mental health diagnoses, inadequate physical therapy services, insufficient nutritional support for dialysis patients, incomplete pain assessments during emergencies, failure to assess dialysis access sites post-treatment, storage of expired medications, and unsanitary kitchen conditions including expired food and contaminated dish drying racks.

The complaint investigation found that the resident fell out of bed on April 16, 2025, despite being identified as high risk for falls and having a care plan in place. The Director of Nursing confirmed the incident and described interventions including placing the resident near the nurse station and medication review. The fall was substantiated as the resident was sent to the hospital for evaluation.

The facility failed to ensure adequate supervision to prevent avoidable accidents for one of three sampled residents, resulting in a fall incident. The resident was assessed as high risk for falls, and despite care plans and interventions, the resident fell and required hospital evaluation. The facility's policies on fall risk management and clinical protocols were reviewed and found to be in place.

The facility failed to complete and transmit a discharge Minimum Data Set (MDS) for one sampled resident (Resident #22) discharged on 03/13/2024, despite policy requirements and regulatory guidelines. Interviews with the MDS Coordinator, Director of Nursing, and Administrator confirmed the discharge MDS was missed and expected to be completed timely.

The complaint investigation found the facility did not report the overdose incident within the required 24 hours. The incident involved Resident 1 who suffered an opioid overdose and subsequent cardiac arrest. The facility reported the incident late after receiving information from the hospital social worker. The investigation concluded the reporting was delayed contrary to facility policy.

The facility failed to timely report a possible narcotic overdose involving Resident 1, who was sent to the hospital unresponsive with an opioid overdose diagnosis. The delay in reporting increased the risk of uninvestigated harm. The facility's policy requires reporting unusual occurrences within 24 hours, which was not followed in this case.

The facility failed to follow the physician's order for blood glucose monitoring prior to insulin administration for one diabetic resident, which had the potential to cause undetected hypoglycemia or hyperglycemia and related medical complications.

The complaint investigation was substantiated by evidence including interviews with Resident 1, CNA 1, Director of Nursing, Physical Therapist, and Director of Staff Development, as well as medical records confirming the fall and injury.

The facility failed to protect Resident 1 from injury when a Certified Nurse Assistant assisted the resident with one hand while reaching for the wheelchair with the other, resulting in Resident 1 losing stability and falling, sustaining a fractured pelvis. The investigation included interviews, record reviews, and policy evaluation, confirming the fall and identifying improper transfer technique.

The complaint investigation found that Resident 1 eloped from the facility on June 25, 2023, walking home approximately 3 miles away to get his hat and returned after about two hours. Staff did not report the incident as required by policy. The sheriff's department and police were involved in searching for the resident. The facility's policies on elopements and unusual occurrence reporting were reviewed and found not to have been followed.

The facility failed to report a resident's elopement in accordance with its policies, despite the resident leaving the facility without notifying staff and being missing for approximately two hours. The resident returned on his own, but the failure to report had the potential to cause serious health and psychosocial harm.

The facility failed to follow its policy when a licensed nurse did not transcribe a verbal physician order to wrap a resident's leg with an Ace wrap daily. This failure had the potential to place the resident's health and safety at risk. The facility's policy requires all verbal orders to be recorded immediately by a licensed nurse.

The facility was found deficient in multiple areas including failure to discuss advance directives with residents upon admission, incomplete or inaccurate Minimum Data Set (MDS) assessments, lack of comprehensive care plans for dialysis and hospice residents, failure to assist a resident with bathing as scheduled, inadequate wound care documentation, failure to provide ordered orthotic device, improper medication administration through G-tube, improper medication storage and labeling, failure to follow menu portion sizes, and poor food service sanitation and cleaning practices. Additionally, the facility failed to timely notify families of COVID-19 positive cases.