Inspection Reports for
Loma Linda Post Acute

The facility was generally well maintained with adequate physical plant conditions and food service. However, deficiencies were cited related to incomplete staff personnel records, missing TB results, insufficient emergency food supplies for 72 hours, and staff not properly associated with the facility through Guardian.

The facility was found deficient in multiple areas including failure to post survey results, incomplete PASARR assessments, failure to notify appropriate authorities of mental health diagnosis changes, inadequate physical therapy services, failure to provide nutritional services for dialysis patients, incomplete pain assessments, expired medications stored, unsanitary kitchen equipment, and failure to properly assess and monitor dialysis access sites.

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 focused on a fall incident involving Resident 1 on April 16, 2025. The fall was unwitnessed, and the resident was found on the floor with no visual injury but required hospital evaluation. The facility's fall prevention policies and interventions were reviewed, and the Director of Nursing confirmed the circumstances and subsequent actions.

The facility failed to provide adequate supervision to prevent avoidable accidents, resulting in Resident 1 falling out of bed and being sent to an acute hospital for evaluation. The investigation included review of the resident's medical records, interviews with the Director of Nursing, and facility policies on fall risk management.

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 MDS for one sampled resident (Resident #22). Interviews with the MDS Coordinator, Director of Nursing, and Administrator confirmed the discharge MDS was missed and not submitted timely.

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 was admitted with multiple diagnoses and later suffered an opioid overdose leading to cardiac arrest and death. The facility acknowledged the late reporting during interviews and review of policies.

The facility failed to timely report a possible narcotic overdose involving Resident 1, which resulted in delayed investigation and reporting. The resident was sent to the hospital for unresponsiveness and later expired due to an opioid overdose, but the facility's report to the state agency was late.

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. This failure had the potential to cause undetected hypoglycemia or hyperglycemia and related medical complications.

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 substantiated that Resident 1 fell during transfer due to improper assistance by CNA 1, resulting in a fractured pelvis. The CNA did not hold the resident with both hands as required by facility policy.

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 falling and sustaining a fractured pelvis. The investigation included interviews, record reviews, and policy review confirming improper transfer technique.

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, was missing for about two hours, and the facility failed to report the incident to required authorities and family as per policy. The resident returned on his own and apologized for not informing staff. The investigation included interviews with the Director of Nursing, Administrator, Licensed Vocational Nurses, and review of progress notes and facility policies.

The facility failed to report a resident's elopement as required by policy, 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 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 complaint investigation found that the licensed nurse failed to transcribe a verbal physician order to wrap the resident's leg with an Ace wrap once daily. The nurse admitted to receiving the order but forgot to transcribe it. The facility policy requires all verbal orders to be recorded immediately by a licensed nurse.

The facility failed to transcribe and follow a physician's verbal treatment order for one of three sampled residents, potentially placing the resident's health and safety at risk. The licensed nurse received the verbal order but forgot to transcribe it into the admission orders.

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 complete advance directive documentation upon admission, incomplete Minimum Data Set (MDS) assessments and submissions, lack of comprehensive care plans for several residents, failure to provide scheduled showers, incomplete wound care documentation, failure to provide ordered orthotic device, improper medication administration through feeding tubes, improper medication storage and labeling, food service safety violations, and failure to timely notify families of COVID-19 positive cases.

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.