Loma Linda Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was protected from financial exploitation (the illegal or improper use of a person's money, property, or assets) for one of three residents (Resident 1) reviewed for allegations of financial abuse when Certified Nursing Assistant 1 (CNA 1) attempted to add Resident 1's debit card to the CNA's Apple Pay account. This failure had the potential to placed Resident 1 at risk for financial loss and misappropriation of personal property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dishwashing equipment and food serving utensils were kept in a sanitary condition when:1. The dish drying racks were found to be unsanitary.2. Three scoops stored in a clean storage drawer were found to have dry food particles sticking on the inside part of the scoops.3. Four (4) bags of wheat tortilla were found in the refrigerator past expiration date of June 25, 2025. These failures had the potential to cause cross-contamination of food prepared in the kitchen which can cause severe illness and even be fatal for the 77 vulnerable residents who resided at the facility.

Inspectors wroteBased on interview, and record review, the facility failed to update Resident 30's Pre-admission Screening and Resident Review (PASARR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness [SMI], intellectual or developmental disability [I/DD] are not inappropriately placed in skilled nursing facilities for long term care) when Resident 30 did not have his diagnoses of major depressive disorder, and anxiety disorder included in the PASARR assessment used to admit Resident 30 into the skilled nursing facility. This failure had the potential to result in Resident 30 being not accurately assessed regarding the need for supplemental treatment and services to better suite the needs of Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the State Mental Health authority or the State Intellectual Disability authority of a resident's new mental illness diagnosis, when on December 3, 2024, Resident 31 was newly diagnosed with Paranoid Schizophrenia ( a mental disorder that affects a person's ability to think, feel, and behave clearly). This failure had the potential to prevent Resident 31 to receive specialized care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physical therapy services were provided to one of two residents (Resident 35) sampled for rehabilitative and restorative services when Resident 35 did not receive physical therapy four times a week as ordered by the physician. This failure had the potential to contribute to a delay in Resident 35's ability to reach his highest level of physical functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided nutritional services to one of one sampled residents (Resident 49) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when Resident 49 was not provided a sack lunch on multiple days in May 2025, and June 2025. This failure had the potential for Resident 49 to experience undesirable weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff provide a complete pain assessment when a Licensed Vocational Nurse 3 (LVN 3) and a Registered Nurse Supervisor 1 (RNS 1) were observed not performing a complete pain assessment during an emergency for Resident 278 who was experiencing chest pain. This failure had the potential to cause Resident 278 to experience a decline in health status and function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one of one sampled residents (Resident 49) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when there was no documented evidence staff assessed Resident 49's dialysis access site (the location where a dialysis machine is connected to a patient) after Resident 49 dialysis procedure on June 14, 2025, and June 17, 2025. This failure had the potential for a delay in the staff identification and subsequent treatment of possible dialysis associated complications such as symptoms of infection, bleeding or dislodgement of the dialysis access site for Resident 49.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals stored in the facility were not expired when on July 2, 2025, three over-the-counter bottles of medications were found to be stored in the medication storage room past their expiration date. This failure had the potential for the expired medications to be accessed and administered to a vulnerable population of 77 residents, potentially resulting in altered effectiveness of the medication and worsening of the residents' symptoms, requiring medical intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the results of the facility's most recent recertification survey when it was discovered the survey results were not posted anywhere in the facility. This failure resulted in residents and visitors inability to read the survey results and assess facility's compliance with regulations which directly impacts their well-being and quality of life within the skilled nursing facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of bed. This failure contributed to Resident 1 being sent out to acute hospital for evaluation.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) for 1 (Resident #22) 1 sampled residents reviewed for resident assessment.

Inspectors wroteBased on interview and record review, the facility failed to report a possible overdose of narcotics for one of three sampled residents (Resident 1) per the facility policy of within 24 hours to the state agency. This failure had the potential for the possible overdose of narcotics to go uninvestigated and unreported thereby increasing the chances of potential harm to (Resident 1).

Inspectors wroteBased on interview, and record review, the facility failed to follow the physician ' s order for blood glucose level (the amount of sugar in the blood) monitoring for one of three sampled diabetic (residents with diagnosis of diabetes mellitus [DM- a health condition that affects how your body turns food into energy]) residents (Resident 1). This failure had the potential to cause conditions related to DM such as hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level) to remain undetected and cause medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from injury when the Certified Nurse Assistant 1 (CNA 1) was assisting Resident 1 from a standing position and held Resident 1 with one hand, while reaching for the wheelchair with the other hand during transfer from bed to wheelchair. Resident 1's knees lost postural stability while standing. This failure resulted in Resident 1 falling and sustaining a fractured pelvis (hip bone).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow the menu when: 1. The incorrect portion of the alternate starch was served to seven residents on a renal (special diet for those with kidney failure) diet and three residents who preferred mashed potatoes instead of rice. They were served with a #12 scoop (2.8 ounces) but should have been served with a #8 scoop (4 ounces), for lunch on January 3, 2023. 2. The cook used a slotted spoon (large plastic or metal spoon with holes in it) instead of a standardized portion server or scoop (Level scoops, ladles, and portion servers provide more accurate portion control than serving spoons that are not volume-standardized measure) to portion the ground meatballs and vegetables (zucchini) according to the Daily Spreadsheet (document that indicates what foods are being served and how much to serve). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain professional standards for food service safety when: 1. The walk-in freezer floor had food crumbs and trash under the shelves and under the crates that were storing food. This had the potential for microorganism growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 2. The microwave had yellow food crumbs and build-up on the inside, this had the potential to contaminate food heated in the microwave. 3. The stainless-steel wall behind the food preparation area, where the microwave was, had yellow food stains on the wall. This had the potential to attract pests and for microorganism growth that could be inadvertently transferred to food. 4. The floor under the convection oven had black grime, food crumbs and trash. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately reflect the resident's status in the Minimum Data Set (MDS - computerized resident assessment completed by a licensed nurse) Assessments for 12 sampled residents when: 1. The facility did not complete MDS Discharge Assessments for 11 residents (Residents 79, 88, 84, 89, 58, 85, 6, 42, 87, 86, and 77) who were reviewed for MDS data completion. 2. The facility did not accurately code Section N: Medications of the MDS for antibiotics (medication given to treat bacterial infections) for Resident 83. This failure to notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents has the potential for monies to continue to be paid to the facility after a resident has been discharged , and for services not rendered to the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store medications when: 1. One bottle of liquid oral Pantoprazole (a medication given to reduce acidity in the stomach and esophagus) was left unsupervised on top of a medication cart and was accessible to others. This failure had to potential to allow medication access to residents, staff, and others passing by who do not have the authority to handle medications. 2. One bottle of liquid oral Gabapentin (a medication given for nerve pain) which required refrigeration was found stored in the bottom drawer of a medication cart. This failure had the potential to negatively affect the medication's effectiveness when administered. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff discussed with two residents (Residents 12 and 164) upon admission whether or not they had an existing advanced directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) or wanted to establish a new advance directive. This failure had the potential for both Residents 12 and 164 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the residents wanted.

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS) (a computerized clinical assessment) Significant Change Assessment (SCA) within 14 days for two sampled residents (Resident 93 and 83), who were reviewed for hospice (a program providing services for the care of terminally ill residents and their family) services as evidenced by: 1. The facility did not complete a MDS SCA for Resident 93 within 14 days of admission to hospice services. 2. The facility did not complete a MDS SCA for Resident 83 within 14 days of discharge from hospice services. This failure had the potential to delay identification and implementation of necessary interventions to address the resident's care and support needs.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit two Minimum Data Set (MDS - a computerized assessment completed by a licensed nurse) Assessments within 14 days of completion, for two residents (Residents 90 and 55) who were reviewed for MDS data completion. This failure to notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents has the potential for monies to continue to be paid to the facility after a resident has been discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for five sampled residents (Resident 36, 93, 41, 83, and 12) when: 1. The facility did not develop a comprehensive care plan for pain, for Resident 36. 2. The facility did not develop a comprehensive care plan for hospice for Residents 36, 93, 41, and 83 within seven days of a comprehensive Minimum Data Set (MDS - a computerized resident assessment) Assessment. 3. The facility did not develop a comprehensive care plan for dialysis (a process of filtering out the blood through a machine, when the kidneys are unable to do it by themselves), for Resident 12. These failures had the potential to prevent the resident's medical, physical well-being, and psychosocial needs from being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide evidence that one resident (Resident 164) was provided assistance with a shower or bath in accordance with the shower schedule and policy and procedure when the resident stated he had not had a shower for 20 days from the date he was admitted into the facility (December 14th, 2022) to the date of interview on January 3, 2023. This failure had the potential to result in resident 164 to have poor personal hygiene and cleanliness and experience a decline in his functional ability to maintain performance of activities of daily living (ADLs - i.e. bathing, grooming etc).

Inspectors wroteBased on interview, and record review, the facility failed to provide evidence wound care was provided to one resident (Resident 165) as ordered by the physician for the month of December 2022 when: a. Resident 165's clinical record did not indicate treatment was provided for six out of 21 days for the treatment of the resident's coccyx (tailbone) region for a stage two pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin. In stage two, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) between December 8, 2022, and December 28, 2022. b. Resident 165's clinical record did not indicate treatment was provided for six out of 14 days for the treatment of redness to the residents left great toe between December 8, 2022, through December 21, 2022. c. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a Right Ankle Foot Orthosis (AFO - device to correct alignment or provide support for weak muscles of the ankle and foot) Brace as ordered by the physician for Resident 91. This finding had the potential to impede the resident's rehabilitation success due to necessary devices not being available for foot mobility management and comfortability.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff followed facility policy for flushing (to clear by using a prescribed amount of water) G-tube (gastrostomy tube-a tube inserted through the abdominal wall that brings liquid nutrition or medications directly to the stomach) in-between medication administration for one Resident (Resident 14). This failure had the potential to cause an interaction between medications resulting in a reduced drug effect, or drug toxicity, as well as clogging the G-tube.

Inspectors wroteBased on interview and record review, the facility failed to inform resident representatives and families of identified positive COVID-19 (an illness caused by a virus) cases by five PM the following day. This had the potential for resident representatives and families to not be informed of current positive cases occurring within the facility of which their family resided.