Laguna Honda Hospital & Rehabilitation Ctr D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of two sampled residents (Resident 1) had a safe and clean environment. This deficient practice resulted in placing Resident 1 at risk for accidents and unsafe conditions. During a review of MD Assessment for Resident 1, dated 02/27/2026, the MD Assessment indicated Resident 1 has the following active diagnoses that requires a clean, safe and hazard-free environment that is calm and predictable for Resident 1: blindness, schizoaffective disorder, bipolar type, and human immunodeficiency virus (HIV) infection. During an observation conducted on 04/22/2026 at 2:47 PM, Resident 1's room was found to be cluttered with excessive items stored on surfaces, furniture, and the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' rights to be free from physical abuse by a resident for one of three sampled residents (Resident 11) when Resident 12 struck Resident 11 on the left side of her face. This failure resulted in Resident 11 sustaining a left Zygomatic Arch (cheek bone area) fracture , Left Orbital (bone area around eye) wall fracture, and contusion (swelling) on the left side of her face.

Inspectors wroteBased on interview and record review, the facility failed to report four allegations of abuse, within two hours, to the California Department of Public Health (the Department). This failure had the potential to leave residents vulnerable to further abuse.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one, full, outside refuse (garbage) container lid was closed, and that outside recycle and compost bins were cleaned. This failure had the potential to attract pests such as rodents and insects resulting in the spread of disease to all residents for a facility census of 506.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the kitchen was free from flies. The failure to ensure the kitchen was free from flies had the potential to contaminate food, equipment, and utensils and result in pest transmitted disease for 467 residents who received food from the kitchen out of a census of 506.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure resident rights to choose treatment options was honored for one of three residents (Resident 290) when, urine sample was sent for urine toxicology (also known as drug screen, a test that analyzes a urine sample to detect the presence of drugs or other chemicals) and completed on 4/16/25, which the resident refused. This deficient practice violated residents' rights to make medical decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately administer medication when one of 35 sampled residents (Resident 414) was self-administering medication without being appropriately assessed and approved for self-administration. This failure had the potential for Resident 414 to aspirate (choking, the accidental inhalation of food, liquid, or other material into the lungs) from improperly administered medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan was developed within 48 hours of admission for one of 35 sampled residents (Resident 879) on ADL (Activities of Daily Living) for oral care. This failure had the potential to result in inadequate care and services rendered to Resident 879.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to meet professional standards of quality when: 1. One out of two sampled residents (Resident 183) received oxygen therapy outside the prescriber's order. This failure could potentially result in negative outcomes for Resident 183 like shortness of breath, fatigue and confusion. 2. Two residents out of 42 sampled residents reviewed for medication administration (Resident 44 and Resident 155) received medication outside the prescriber's order and parameters. These failures resulted in Resident 44 receiving prescription medication Glipizide (a medication to treat high blood sugar) 10 mg tablet for type 2 diabetes mellitus (high blood sugar) outside prescribing parameters and Resident 155 receiving incorrect application of Lidocaine 5% patch for pain outside the prescriber's order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately dispose of and record disposal of controlled drugs for one of one sampled resident reviewed for safe and secure disposal and recording methods for controlled medications (Resident 332). This failure could result in Resident 332 receiving an inaccurate dose or diversion of the controlled medication.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure that one out of one kitchen staff was competent when testing sanitizer (a substance or product that reduces or eliminates microorganisms such as bacteria on surfaces to a safe level) strength used to sanitize food contact surfaces. This failure had the potential to result in compromising infection control and resident safety.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure that food stored in a resident refrigerator located in a great room (great room is the large resident dining area on each unit/floor) were stored according to professional standards for food service safety when: 1. Lunch meat was not discarded according to manufacturer's instructions; and 2. Food items intended to be stored frozen were not stored frozen. The failure to store food according to the manufacturer's instructions for two residents (Resident 1 and Resident 420) out of 506 residents had the potential to result in food borne illness his practice poses a risk to residents' health and safety by potentially compromising food quality and safety.

Inspectors wrote5. During an observation on 11/4/24 at 10:18 AM, in Resident 569's room, an egg salad sandwich was on the overbed table. The label on the sandwich indicated, 11/3/24 Dinner. During a concurrent interview, Resident 569 confirmed the sandwich was served for dinner on 11/3/24. Resident 569 stated, Yes, it was for last night's dinner. During an interview on 11/4/24 at 10:43 AM, Nurse Supervisor (NS) 1 validated the sandwich was served for dinner on 11/3/24. NS 1 stated, He can have food poisoning. According to the 2022 Federal Food Code, a Time Temperature Control for Safety (TCS; foods designated to maintain specific temperature ranges within designated time frames to prevent the growth of harmful bacteria) food is to be discarded when within four hours from the point in time when the food is removed from temperature control. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the kitchen was free of pests when fruit flies were consistently present. This failure had the potential for contamination of food and food contact-surfaces leading to the transmission of disease to 385 residents who received food from the kitchen out of a census of 417.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one out of 35 sampled residents (Resident 62) when Resident 62's comfort care was not care planned. This failure has the potential for Resident 62 to not receive person-centered services.

Inspectors wroteBased on interview and record review, the facility failed to follow the speech language pathologist's (SLP, a health care professional who assesses, diagnoses, and treats speech, language, and swallowing disorders in people) recommendations in one out of 6 sampled residents (Resident 78) when SLP 1 recommended a special diet for Resident 78 until reassessment of Resident 78's swallowing ability after esophageal dilation (a procedure that widens the tube connecting the mouth to the stomach to make it easier to swallow), but Resident 78 was continued onto a regular diet without reassessment by a SLP. This failure has the potential for Resident 78's swallowing ability to be inaccurately assessed leading to a high risk of aspiration (the accidental inhalation of food, liquid, or other material into the lungs) or choking.

Inspectors wroteBased on interview and record review, the facility failed to give a clinical rationale (specific reason a medication or procedure is done) for a PRN (given as needed or requested) medication order beyond 14 days of a psychotropic drug (any drug that affects brain activities associated with mental processes and behavior) in one of five sampled residents (Resident 1) when Resident 1 was prescribed Ativan (a sedating medication) for 90 days. This failure has the potential for Resident 1 to be continued on psychotropic medications that may be unnecessary for their care or physical, mental, functional, and psycho-social well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent. During the medication pass on 11/05/24 and 11/06/24, two medication errors were observed out of thirty-two opportunities for two out of seven residents, resulting in an error rate of 6%. This failure had the potential to result in harm in the health and safety of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care to one of two sampled residents (Resident 1), when Resident 1's toenails were long, crooked, and jagged. Resident had not had foot care or hand care for more than three months. This failure caused the resident pain, discomfort, and feelings of neglect.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse when Resident 2 climbed into Resident 1's bed and kissed him on the lips. This failure resulted in Resident 1 not being able to sleep well due to feeling unsafe at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of one sampled Resident (Resident 1) from abuse when Resident 1 was verbally abused by a Security Guard (SG). The facility's failure resulted in Resident 1 1. thinking and reliving the incident, 2. feeling sad 3. having low self-esteem 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of verbal abuse (a type of psychological/mental abuse that involves the use of oral, gestured, and written language directed to a victim. Verbal abuse can include the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) was reported to the State Survey Agency (SSA) within the required timeframe of two hours for one sampled resident (Resident 1) when Resident 1 reported a verbal altercation with Security Guard (SG) 2. This failure resulted in a delayed investigation by the SSA of allegation of abuse. Furthermore, this failure had the potential to compromise the safety of all residents in the facility from unreported and uninvestigated allegations of abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) when Resident 1 was ambulating (walking) in the facility independently without any assistive devices (objects used to help stabilize someone for safer movement). This failure resulted in Resident 1 sustaining a left femoral neck fracture (a break in the long upper leg bone near where it touches the hip bone) requiring a left hemiarthroplasty (surgery necessary to replace part of the hip joint).

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1's fall care plan interventions were updated and implemented to prevent or minimize fall-related injuries for one of 20 sampled residents (Resident 1) when Resident 1 was assessed as total dependent with activities of daily living, including repositioning when in bed. The care plan interventions did not reflect the two person physical assist required by Resident 1 when repositioning and the facility did not implement effective interventions to prevent falls after identifying Resident 1 with limited Range of Motion (ROM) on bilateral upper and lower extremities, diagnosis of Seizure Disorder (a medical condition that can cause sudden, uncontrollable movements and change in level of consciousness) and poor safety awareness due to diagnosis of Dementia (impaired ability to remember, think, or make decisions). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice, comprehensive person-centered care plan to enable residents to maintain their highest practicable level when Resident 1 who was assessed as a high risk for fall, total dependent with activities of daily living, including repositioning when in bed sustained a fall on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for six of 70 sampled residents (Residents 1153, 1151, 1253, 56, 859, and 1303) when: 1. For Resident 1153, there was no CP addressing the diagnosis of Hepatic Encephalopathy (a medical condition caused by a buildup of toxins in the brain that can happen with advanced liver disease), and the use of rifAXIMin antibiotic for Hepatic Encephalopathy. 2. For Resident 1151, there was no CP addressing the use of Calamine Zinc Ointment (medication used to relieve pain, itching and discomfort from minor skin irritations) for itching. 3. For Resident 1253, CP intervention for Passive Range of Motion (PROM: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for 3 of 70 sampled residents (Residents, 61, 1302, 805) when: 1. Patient Care Assistants failed to document the placement and function of Aero Scout (a device used to monitor wandering patients in unauthorized areas) for Residents 61 and 32 and; 2. Staff failed to utilize two staff people when providing care to a dependent resident per the plan of care for Resident 805. These failures resulted in the potential for Resident 61 and 1302 to elope from the facility and for Resident 805 to fall out of bed and be sent to the hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the infection prevention and control program (IPCP) included a facility-wide program for the surveillance, prevention, and control of healthcare-associated infections (HAIs-infections acquired during the process of receiving healthcare that was not present during the time of admission) and other infectious diseases for nine of nine sampled residents (Residents 355, 404, 451, 460, 461, 462, 463, 553, and 1303) when: 1. For Resident 1303, the facility did not follow their policy and procedure on contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) and encouraged group activities. 2. [...]

Inspectors wroteBased on dietetic services observations, dietetic and facility services interview and departmental document review, the facility failed to ensure equipment and physical environmental maintenance when 1) one of two dish machines had water leaking from underneath as well as from the top of the machine and the temperatuare dial for the final rinse was non-operational; 2) there were greater than 10 tiles in the hot and cold food production areas that had missing grout and resulting in a build-up of moisture and food particles; and 3) the flush drain for the ice machine filter was inserted directly into a soiled floor sink. Failure to ensure an effective maintenance program of spaces and equipment may result in practices that promote the harborage of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to visually monitor one of 70 sampled Residents (Resident 1301) physical restraint device (device attached to the resident body that cannot be easily removed which restricts freedom of movement). This failure had the potential to result in injury and limited mobility.

Inspectors wroteBased on interview and record review, the facility failed to report within 2 hours one of five allegations of abuse to the California Department of Public Health (the Department). This failure could have delayed the Department's investigation of the allegation of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility did not revise the care plan related to the denture care, when a resident received a new upper and partial denture on July 21, 2023, for one of one resident reviewed (Resident 62). This failure resulted in Resident 62, not being compliant of wearing his new dentures, and Patient Care Assistant (PCA) were not able to implement the specific care of Resident 62's new dentures. In addition this failure had the potential to affect the necessary care specific for Resident 62's new dentures and potential for the developmental of complications for not wearing his new dentures that will create adverse effect on dental health.

Inspectors wroteBased on observation, interview, and record review, the facility did not document the specific dental care instruction when a resident received his new dentures on July 21, 2023, on the facility's worklist tasks section of resident's Electronic Health Record (EHR) for one of one resident reviewed (Resident 62). This failure resulted in Resident 62, not being compliant of wearing his new dentures, and Patient Care Assistant (PCA) were not able to implement the specific care of Resident 62's new dentures. In addition this failure had the potential to affect the necessary care specific for Resident 62's new dentures and potential for the developmental of complications for not wearing his new dentures that will create adverse effect on dental health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of 70 sampled residents (Resident 451), that necessary assistance was provided during mealtime. This failure had the potential to impact the health and well-being of the resident.

Inspectors wroteBased on interview and record review, the skilled nursing facility did not monitor wound progression for one of 70 sampled residents (Resident 351). Resident 351 had developed an infection on his left lower leg. Staff did not document in the medical record the continued status of the infection. This failure resuled in the potential for staff to not be aware of the lack of wound healing.

Inspectors wroteBased on interview and record review, the facility failed to provide Passive Range of Motion (PROM: outside force causing movement to a joint for restorative purposes) to one of 70 sampled residents, when PROM was not charted as performed according to the active orders. This failure had the potential for Resident 1251's mobility and functional status to decline.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, five medication errors were observed out of fifty-five opportunities, resulting in an error rate of 9%.

Inspectors wroteBased on the interview and document review, the facility failed to: 1. Respond to refrigerated temperature excursions for medications when the continuous temperature monitoring system Temptrak alarmed. There was no evidence of a response in accordance with facility policy. 2. Monitor temperature of the medication room located in the Pavilion Mezzanine skill nursing area. These failures could have resulted in medications not being stored in accordance with manufacturers recommendations.

Inspectors wroteBased on observation, dietary staff interview and administrative document review, the facility failed to ensure ready to eat foods, obtained from Vendor 1, met current standards for food safety when facility did not verify whether the vendor completed corrective actions identified by the Food and Drug Administration.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure on influenza immunizations when the medical record did not include influenza immunization information or the refusal of the vaccine for one of five sampled residents (Resident 1303). This failure resulted in an incomplete medical record which did not reflect Resident 1303's preferences or care needs.